Section C:
Clinical practice systems
Section Contents Page Number
Indicator Group 7: Screening (early detection), surveillance and
audit of clinical systems and implementation of clinical practice
guidelines (for the identification and management of patients at
risk for preventable diseases, with chronic diseases, with cancers,
and with mental health problems)
Indicator C.7.1C5
The practice has agreed policies for screening, surveillance and audit
Indicator C.7.2C8
The practice has an effective database of registered patients for screening,
surveillance and audit
Indicator C.7.3C10
The practice uses evidence-based clinical practice guidelines to ensure
consistent high quality health care
Indicator C.7.4C13
The practice has a regular appropriate review of prescription medications
Indicator Group 8: Applying surveillance and audit to outcome
indicators
Indicator C.8.1 C15
Smoking cessation
Indicator C.8.2 C18
Diabetes mellitus
Indicator C.8.3 C21
Hypertension
Indicator C.8.4 C24
Stroke or transient ischaemic attacks (TIAs)
Indicator C.8.5 C27
Secondary prevention in coronary heart disease (CHD)
Indicator C.8.6 C30
Anticoagulation medication
Indicator C.8.7 C32
Mental health
Section Contents Page Number
Indicator C.8.8 C35
Benzodiazepines for older patients
Indicator C.8.9 C37
Postmenopausal bleeding
Indicator C.8.10 C39
Asthma care (patients diagnosed with asthma - defined as those who had one
repeat prescription of a beta 2-agonist in the past year, who filled a prescription
for long-term control of asthma)
Indicator C.8.11C42
Chronic obstructive pulmonary disease (COPD)
Indicator C.8.12 C45
Epilepsy
Indicator C.8.13 C48
Hypothyroidism
Indicator C.8.14 C50
Cancer
Indicator C.8.15 C52
Sore throat
Indicator Group 9: Clinical practice systems and life cycle issues
Indicator C.9.1 C54
The practice provides comprehensive care for children
Indicator C.9.2C56
The practice has an effective system to identify and record childhood and
adolescent immunisations
Indicator C.9.3C59
The practice has an effective system to identify and record adult immunisations,
including flu vaccine
Indicator C.9.4C61
The practice provides comprehensive care for cervical screening
Indicator C.9.5C63
The practice provides comprehensive care for chlamydia
Indicator C.9.6C65
The practice provides comprehensive care for breast cancer screening
Section Contents Page Number
Indicator C.9.7C67
The practice provides comprehensive care for family planning
Indicator C.9.8C69
The practice provides comprehensive care for maternity services
Indicator C.9.9C71
The practice provides comprehensive care for adult patients
Indicator C.9.10C73
The practice provides palliative end of life care to patients
Section C
Clinical practice systems
This section is designed to assess quality clinical outcomes through screening, surveillance and audit of clinical systems and implementation of clinical practice guidelines. At this time, Ontario does not have identified clinical outcome priorities for family practices. For the purpose of the QIFP project, the following approach has been developed for identification of clinical outcomes:
- Clinical outcomes where clinical practice guidelines reviewed by the Guidelines Advisory Committee in Ontario and guidelines developed by the Canadian Task Force on Preventive Health Care are published.
- Clinical outcomes as defined by contracts between the MOH and PCNs, FHNs,FHGs, and others: pap smears, mammograms, flu vaccine and childhood immunisations.
- Clinical outcomes proposed by Cancer Care Ontario as priorities: breast cancer, cervical cancer and colon cancer as priorities.
- Clinical outcomes as outlined in the Mandatory Health Programs and Services Guidelines (December 1997) which includes chronic disease and injuries, family health and infectious disease categories.
- Mental health outcomes as defined by Canadian Collaborative Mental Health Initiative and other key stakeholders.
The QIFP has developed a number of indicators (but not all) which can be used as a framework for assessing clinical outcomes. Some of the clinical outcomes that could be assessed include:
- Substance abuse prevention: smoking, alcohol
- Physical activity and healthy eating
- Injuries: road safety, impaired driving, bicycle helmet use, correct use of car restraints, falls in the elderly
- Chronic diseases: heart disease, stroke, cancer, chronic lung disease, high blood pressure, diabetes, osteoporosis, and many others
- Early detection of cancer: breast, cervical, colon
- Family health: improving planned pregnancy rates, contraception access, sexual assault and abuse, sexual orientation, prevention of sexually transmitted diseases
- Reproductive health: preventing low birth weight, decreasing neural tube defects, pregnancy assessments
- Child health promotion: childhood immunisation, injury prevention, parenting, developmental assessments
- Infectious disease: HIV/AIDS, STDs, tuberculosis, SARS, rabies, vaccine preventable diseases through adult immunisation programs
- Mental health: suicide, depression, schizophrenia, personality disorders
- Prescription medication surveillance and monitoring
Section C: Clinical practice systems
Indicator Group 7 Screening (early detection), surveillance
and audit of clinical systems and
implementation of clinical practice
guidelines (for the identification and
management of patients at risk for preventable diseases, with chronic diseases, with cancers, and with mental health problems)
Indicator C.7.1The practice has agreed policies for screening,
surveillance and audit
Criteria C.7.1.1There is a practice screening (early detection), surveillance and
audit programme
Section C – Clinical practice systems
Indicator Group 7 – Screening (early detection), surveillance and audit of clinical systems and implementation of clinical practice guidelines (for the identification and management of patients at risk forpreventable diseases, with chronic diseases, with cancers, and with mental health problems)
Indicator C.7.1
The practice has agreed policies for screening, surveillance and audit
The purpose of this indicator is to demonstrate that there is an effective system in place for screening, surveillance and audit of the practice
Criteria
C.7.1.1There is a practice screening (early detection), surveillance and audit
programme
Interpretation
- The practice describes its screening, surveillance and audit policy (includes process - how patients are identified when they visit the practice, opportunistic screening, case alerts; and outcomes - rates of screening for cancers, high blood pressure, BMI, etc.)
- The practice describes how it chooses priorities for screening, surveillance and audit
- The practice describes how its team approach to screening, surveillance and audit
- The roles of each team member in screening, surveillance and auditare clear (who is responsible, processes used, actions taken as a result, preparation of reports, etc.)
- The practice describes the audits that have taken place in the last two years
- The practice describes how it has addressed and plans to address challenges associated with screening, surveillance and audit
- The practice describes how it captures changing information regarding personal and family history for screening, surveillance and audit
Further information
GAC Guidelines
Cancer Care Ontario and the Canadian Cancer Society - Call to Action: Cancer 2020 Summary Report
Cancer Care Ontario – Ontario Breast Screening Program
Cancer Care Ontario – Ontario Cervical Screening Program
Cancer Care Ontario - Colorectal Pilot Project
Pap Screening for Life – Guide to Screening by Nurses
Foundation for Medical Practice Education
Canadian Task Force on Preventive Health Care – Evidence-Based Clinical Prevention and Evidence-Based Resource Sheets
Section C: Clinical practice systems
Indicator Group 7 Screening (early detection), surveillance
and audit of clinical systems and
implementation of clinical practice
guidelines (for the identification and
management of patients at risk forpreventable diseases, with chronic diseases, with cancers, and with mental health problems)
Indicator C.7.2The practice has an effective database of registered
patients for screening,surveillance and audit
Criteria C.7.2.1The practice has an effective system for maintaining an accurate
patient database
C.7.2.2The practice uses a disease identifying coding system which is
compatible with other commonly used data transfer systems
Section C – Clinical practice systems
Indicator Group 7 – Screening (early detection), surveillance and audit of clinical systems and implementation of clinical practice guidelines (for the identification and management of patients at risk forpreventable diseases, with chronic diseases, with cancers, and with mental health problems)
Indicator C.7.2
The practice has an effective database of registered patients for screening, surveillance and audit
The purpose of this indicator is to ensure that the practice is aware of the demographics of the population it serves and can access this information easily for screening, surveillance and audit purposes
Criteria
C.7.2.1The practice has an effective system for maintaining an accurate patient
database
Interpretation
- The practice describes its patient database(includes age/sex register, patient profile, disease database) and how it ensures maintenance and accuracy of the database
C.7.2.2The practice uses a disease identifying coding system which is compatible
with other commonly used data transfer systems
Interpretation
- Disease coding system (also OHIP coding and coding for incentives for prevention and chronic disease management, IHA has interesting layout for this)
Further information
From NZ
The advantage of Read Coding – recording data consistently, retrieving data more easily, data analysis, common clinical language, includes a range of diseases
Physician IT Program
Section C: Clinical practice systems
Indicator Group 7 Screening (early detection), surveillance
and audit of clinical systems and
implementation of clinical practice
guidelines (for the identification and
management of patients at risk forpreventable diseases, with chronic diseases, with cancers, and with mental health problems)
Indicator C.7.3The practice uses evidence-based clinical practice
guidelines to ensure consistent high quality health care
Criteria C.7.3.1The practice uses evidence-based guidelines in its clinical
practice systems
C.7.3.2The practice has links with community resources to enhance
implementation of guidelines
C.7.3.3The practice has links with family resources to enhance
implementation of guidelines
Section C – Clinical practice systems
Indicator Group 7 – Screening (early detection), surveillance and audit of clinical systems and implementation of clinical practice guidelines (for the identification and management of patients at risk forpreventable diseases, with chronic diseases, with cancers, and with mental health problems)
Indicator C.7.3
The practice uses evidence-based clinical practice guidelines to ensure consistent high quality health care
The purpose of this indicator is to ensure that evidence-based clinical practices guidelines are applied consistently in the practice
Criteria
C.7.3.1The practice uses evidence-based guidelines in its clinical practice systems
Interpretation
- The practice describes how it chooses to implement evidence-based guidelines (GAC, ICES, PBSG)
- The practice describes how it keeps up to date with evidence-based guidelines
- Patient audit process and outcomes are able to be assessed against the expected rates for the province (e.g. CCO, FHN contract, international standards)
- The practice describes its clinical decision making and review process
- The practice uses evidence-based guidelines for practice team education
- The practice describes the processes used by the team to improve the use and uptake of guidelines in the practice
C.7.3.2The practice has links with community resources to enhance
implementation of guidelines
Interpretation
- The practice describes its links with community resources to enhance implementation of guidelines
- The practice describes how unique partnerships are developed with other organisations to enhance implementation of clinical practice guidelines
C.7.3.3The practice has links with family resources to enhance implementation of
guidelines
Interpretation
- The practice describes how it utilises family resources in the management of diseases to enhance implementation
Further Information
GAC Guidelines
Institute for Clinical Evaluative Services (ICES)
Practice Based Small Group Learning Program
Canadian Task Force on Preventive Health Care
The Society of Obstetricians and Gynaecologists of Canada – Clinical Practice Guidelines
Canadian Medical Association (CMA) Infobase Clinical Practice Guidelines- the Canadian access to evidence-based clinical practice guidelines including patient guides and health professional summaries. These guidelines are produced or endorsed in Canada by a national, provincial/territorial or regional medical or health organization, professional society, government agency or expert panel.
Section C: Clinical practice systems
Indicator Group 7 Screening (early detection), surveillance
and audit of clinical systems and
implementation of clinical practice
guidelines (for the identification and
management of patients at risk for preventable diseases, with chronic diseases, with cancers, and with mental health problems)
Indicator C.7.4The practice has a regular appropriate review of
prescription medications
Criteria C.7.4.1There is a system in place for reviewing prescription medications
regularly
C.7.4.2There is an audit of medication reviews
C.7.4.3There is a policy on reporting adverse drug reactions
Section C – Clinical practice systems
Indicator Group 7 – Screening (early detection), surveillance and audit of clinical systems and implementation of clinical practice guidelines (for the identification and management of patients at risk for preventable diseases, with chronic diseases, with cancers and with mental health problems)
Indicator C.7.4
The practice has a regular appropriate review of prescription medications
The purpose of this indicator is to demonstrate that the practice reviews its prescription medications regularly
Criteria
C.7.4.1There is a system in place for reviewing prescription medications regularly
Interpretation
- The practice describes the system for medication review for all patients being prescribed four or more repeat medicines (excluding over-the-counter or topical medications)
- The practice describes how drug-related problems are identified and resolved
- The practice describes how correspondence with pharmacists regarding drug recommendations and concerns are documented and addressed
C.7.4.2There is an audit of medication reviews
Interpretation
- The practice describes its audit of medication reviews
C.7.4.3There is a policy on reporting adverse drug reactions
- The practice describes its policy on reporting adverse reactions
Further information
CPSO Policy of Prescribing Practices
Health Canada- Adverse Reaction Information
Health Canada- Adverse Reaction Reporting Forms
Section C: Clinical practice systems
Indicator Group 8Applying surveillance and audit to outcome
indicators
Indicator C.8.1 Smoking cessation
Criteria C.8.1.1The practice has reviewed the evidence-based clinical practice
guidelines for smoking cessation
C.8.1.2There is a register of patients’ smoking status
C.8.1.3The practice actively promotes smoking cessation strategies and
provides educational intervention programme information to
patients
C.8.1.4The practice has access to specific programmes that assist
patients with smoking cessation
C.8.1.5There is an audit of policy and charts
C.8.1.6There is a follow-up ofpatients involved in smoking cessation
intervention programmes
Section C – Clinical practice systems
Indicator Group 8 – Applying surveillance and audit to outcome indicators
Indicator C.8.1
Smoking cessation
The purpose of this indicator is to describe how the practice applies surveillance and audittosmoking cessation. The framework can be adapted and applied by practices to any clinical problem/issue priority.
Criteria
C.8.1.1The practice has reviewed the evidence-based clinical practice guidelines
for smoking cessation
Interpretation
- The practice describes its review of the clinical practice guidelines for smoking cessation
C.8.1.2There is a register of patients’ smoking status
Interpretation
- There is a patient register for smoking status
- Smoking status is recorded and inserted into the medical record
- There is a system to update the smoking status ofpatients, e.g. warning flags on computer system, practice policy, etc.
- Smoking status is recorded in the records of patients over the age of 17
C.8.1.3The practice actively promotes smoking cessation strategies and provides
educational intervention programme information to patients
Interpretation
- Educational materials are provided for patients (in the waiting room)
- The practice describes how it promotes smoking cessation programmes and relevant information to patients (e.g. opportunistically, as part of ongoing care, other screening opportunities)
- Smoking cessation advice/counselling is recorded for patients who use tobacco products
C.8.1.4The practice has access to specific programmes that assist patients with
smoking cessation
Interpretation
- Knowledge of local programmes, how to access (e.g. website, pamphlets, 1-800 numbers, self-care, etc.) and link patients to existing programmes or people for support
C.8.1.5There is an audit of policy and charts
Interpretation
- The practice describes its audit of smoking cessation
C.8.1.6There is a follow-up of patients involved in smoking cessation intervention
programmes
Interpretation
- The practice describes how it follows up on patients involved in smoking cessation intervention programmes
- The practice describes how it follows up on prescription and non-prescription medication use
Further information
Ontario – OMA Clinical Tobacco Intervention
GAC Guidelines
Section C: Clinical practice systems
Indicator Group 8 Applying surveillance and audit to outcome
indicators
Indicator C.8.2 Diabetes mellitus
Criteria C.8.2.1The practice has reviewed the evidence-based clinical practice
guidelines for diabetes mellitus
C.8.2.2The practice can produce a register of patients with diabetes
mellitus
C.8.2.3The practice actively promotes lifestyle modification to reduce
the risk of type 2 diabetes
C.8.2.4The practice has access to specific programmes that assist
patients with diabetesmellitus
C.8.2.5There is an audit of policy and charts
C.8.2.6There is a follow-up programme for diabetic patients
Section C – Clinical practice systems
Indicator Group 8 – Applying surveillance and audit to outcome indicators
Indicator C.8.2
Diabetes mellitus
The purpose of this indicator is to describe how the practice applies surveillance and audit to diabetes mellitus. The framework can be adapted and applied by practices to any clinical problem/issue priority.
Criteria
C.8.2.1 The practice has reviewed the evidence-based clinical practice guidelines