Clinical Governance Practice Self Assessment Tool

Public Health Wales / Clinical Governance Practice Self Assessment Tool 2010/11
Primary Care Quality and Information Service (PCQIS)
All Wales Clinical Governance Practice Self Assessment Tool 2010/11
Proposed 11 Questions to be completed by 31st March 2011
Author:PCQIS Team
Date:1 November 2010 / Version:1
Publication/ Distribution:

Public Health Wales (Internet)
NHS Wales (Intranet)
Public Health Wales (Intranet)

Review Date: 1 April 2012
Purpose and Summary of Document:
This document shows the 11 questions that the Primary Care Quality and Information Service (PCQIS) are suggesting practices to complete by 11th March 2011; completion of practices answers should be carried out in the on-lineAll Wales Clinical Governance Self Assessment Tool (CGPSAT) for General Medical Practices.
Practices should read ‘the All Wales Clinical Governance Practice Self Assessment Tool - Tutorial’ and have been provided with a username and password to complete the on-line version, accessed via the Public Health Wales intranet site.
This document is intended to enable interested parties to view the content of the tool without having to log in. Please note that this document shows the content only and the layout is different from the on-line version. Practices should complete the on-line version
© 2010 Public Health Wales. Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement of Public Health Wales is to be stated
Date: 1 November 2010 / Version: 1 / Page: 1 of 46
Public Health Wales / Clinical Governance Practice Self Assessment Tool 2010/11

Clinical Governance Practice Self Assessment Tool 2010/12

Proposed 11 questions to be completed by practices by 31st March 2011

PCQIS is mindful that as practices have to start afresh due to the change in format, there will not be time this year to complete the whole or even half the full set of questions within the CGPSAT. Therefore we are suggesting that practices complete their practice details and 11 questions by the end of March 2011. It is up to you as a practice if you want to complete more questions; you will need to check with your local contact in your LHB as they may wish you to complete a question/section set before the end of March.

Please also add in you ‘PDP’and ‘constraints’ this will assist practices in preparing a practice ‘action plan’ – see the CGPSAT tutorial for further information

Section / Question/Matrix
1. Introduction, Acknowledgements and Practice details / Please scroll down and complete your Practice details
2. Care Planning and Provision / 2.1 Availability of consultations
3. Equality, Diversity and Human Rights / 3.1 Equity of Access
4. Patient Information and Consent / 4.1 Consent for clinical examination and treatment
5. Dignity and Respect / 5.1 Chaperone
10. Safeguarding children and vulnerable adults / 10.1 Safeguarding Children
13. Infection Prevention, Control and Decontamination / 13.1 Waste Management
13.2 Infection Control
14. Safe and Clinically Effective Care / 14.1 Patient Safety alerts and reporting
17. Communicating Effectively / 17.1 Communication systems
22. Managing Risk and Health and Safety / 22.1 Risk Assessment
23. Dealing with Concerns and Managing Incidents / 23.1 Raising concerns
28. Feedback your comments / Please provide suggestions on how the tool should be improved (compliments also welcome)

References, Guidance and Web-links

The link below will take you to the Public Health Wales, Primary Care Quality and Information Service internet site where you will find a downloadable Excel workbook with links to all the references and guidance used in the All Wales Clinical Governance Practice Self Assessment Tool for 2010/11, Risk Assessment Tool, Infection Control Toolkit and other Quality Improvement Toolkits for General Medical Practices.

Note:

Sessional GPs include doctors working on the retainer scheme, salaried GPs and locum GPs. Some are peripatetic and work in a number of practices whilst others work only in a small number of practices on a regular basis. ref: 'Clinical Governance for Sessional GPs.' Department of Postgraduate Education for General Practice. WalesCollege of Medicine. Nov 20075

Please note that throughout the CGPSAT, 'staff' refers to all people working in the practice, both employed, including sessional GPs, and partners

1. Practice Details

There are particular features of our practice or patient population that we wish to comment on. (eg Age distribution/ethnic issues/drug abuse/housing, branch surgery provision etc)
Our Practice offers work experience/education/training to other individuals - Y/N -
We have a designated prescribing lead GP who undertakes regular work on prescribing issues - Y/N -
Our Clinical Governance Lead is – name -
We have - number - independent prescribers at our practice
The definition of independent prescribing is “prescribing by a practitioner (eg doctor, nurse or pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing” Ref: Royal Pharmaceutical Society of Great Britain.
We have - number - supplementary prescribers at our practice
The definition of supplementary prescribing is "a voluntary partnership between an independent prescriber (doctor or dentist) and a supplementary prescriber to implement an agreed patient-specific clinical management plan with the patient's agreement". Ref: Royal Pharmaceutical Society of Great Britain. Supplementary prescribers may be Nurses or Pharmacists. A supplementary prescriber may prescribe all medicines including controlled drugs, medicines for unlicensed indications and unlicensed medicines, by agreement with the independent prescriber.
We employ sessional GPs - Y/N -

2. Care Planning and Provision

This section contains 6 matrices. Other matrixes containing elements relevant to the Standards for Health Services in Wales, Care Planning and Provision are to be found under: Citizen Engagement and Feedback, Communicating Effectively, Workforce Planning, Health Promotion, Protection and Improvement and Medicines Management

2.1 Availability of Consultations

This matrix makes reference to elements of the GMS Dispensary Services Quality Scheme (DSQS)6

Level / Description / Supporting Information / Additional Information ‘Help’
Level 0 / We have not achieved level 1
Level 1 / We offer consultations with an appropriate health professional to meet the reasonable needs of patients (this includes telephone consultations) /

Copy of appointments policy
Copy of appointments schedule/timetable showing pre-book able appointments available
Information in Practice leaflet
Notices in waiting room
Practice website
Staff can explain how patients are asked who is their usual doctor and how an appointment with that doctor is arranged whenever possible.
Training/ induction records for reception staff

/ Consider whether:

Patients are provided with information about opening hours and availability of appointments:
A system to ensure that a named healthcare professional can be contacted promptly in the case of an emergency.

QOF Management 5:The practice offers a range of appointment times to patients which as a minimum should include morning and afternoon appointments 5 mornings and 4 afternoons per week except where agreed with the LHB
Dispensing Practices: DSQS Minimum level of staff hours 2.2.2: The contractor must assure a level of staffing that reflects the practice’s dispensary configuration and hours of opening as agreed with the LHB
Dispensing Practices: DSQS Information 1.2.2: The contractor must inform the LHB (who will advise NHS Direct as for pharmacies)The contractor must ensure that opening times are displayed prominently on the premises from which they carry out dispensing and that they are legible from outside the premises when they are shut.
Level 2 / We offer a range of consultations of at least 10 minutes long. For practices with only an open surgery system the practice should ensure that the average face to face consultation with the patient is at least 8 minutes long. /

Appointment/access audit reports
Blank appointments template

/ Consider:

Audit of appointment lengths
Whether appointments are offered with a doctor or nurse outside 9am to 5pm

QOF PE1: The length of routine booked appointments with the doctors in the practice is not less than 10 minutes. If the practice routinely sees extras during booked surgeries then the average booked consultation length should allow for the average number of extras seen in a surgery session. If the extras are seen at the end then it is not necessary to make this adjustment. For practices with only an open surgery system the practice should ensure that the average face to face time spent by the GP with the patient is at least 8 minutes. Practices that routinely operate a mixed economy of booked and open surgeries should report on both criteria.
Level 3 / We have a system for spotting when we are running late and inform patients /

Staff can explain how waiting times and reasons for delay are communicated to patients
Workload schedule/rota

/ Consider:

Whether waiting times and reasons for delay are communicated to patients
A system for day to day operational management of appointments:
A timetable
A workload schedule/rota

Level 4 / We monitor access to consultations so that we are responsive to patients’ needs and as part of this we encourage continuity of care /

Agenda and minutes of meetings when appointment systems were discussed
Copy of Patient questionnaire / complaints / compliments
Agenda and minutes of meetings when complaints were discussed
Copy of DNA policy
All clinicians can demonstrate how they access patient’s case records, summaries and prescribing data. This includes sessional GPs
Copy of Sessional GP policy
LocumPak or equivalent

Copy/demonstration of the procedure for handling of messages to OOH services eg palliative care
Copy/demonstration of the procedure for home visits
message book

e-mail messaging
Audit of record-keeping
Timetable/schedule of chronic disease clinics

/ Consider whether:

All clinicians have access to the patient’s case records, summaries and prescribing data
Sessional GPs are informed (LocumPak)
Patients are asked who is their usual doctor and offered an appointment with that doctor whenever possible
you include comments made about dispensing services if provided

QOFPE 7: the percentage of patients who, in the appropriate national survey, indicate that they were able to obtain a consultation with a GP or appropriate health care professional within 24 hours
QOFPE 8: The percentage of patients who in the appropriate national survey indicate that they were able to book an appointment with a GP more than 2 days ahead
Level 5 / We ensure that changes are made as a result of our reviews and that our system is updated /

Evidence of changes/staff explanation of changes made to the appointment system as a result of complaints / audit /survey
Training records
Evidence of communication of DNAs to patients eg: copies of letters sent to patients, monthly DNA rate posters etc

/ Consider examples of best practice eg: the Practice opening and Appointments sections of ‘Developing General Practice, Listening to Patients’ BMA 20097

Equality, Diversity and Human Rights

This section contains 1 matrix. Other matrixes containing elements relevant to the healthcare standard Equality and Diversity and Human Rights are to be found under Dignity and Respect, Safeguarding Children and Vulnerable Adults, Environment, Patient Information and Consent and Workforce Recruitment and Employment practices.

3.1Equity of Access

This matrix makes reference to the social model of disability11and EquIP Cymru Disability Access Self Assessment Audit Toolkit12

Level / Description / Supporting Information / Additional Information
Level 0 / We have not achieved Level 1
Level 1 / Most patients can readily access our premises and services /

Disability Discrimination Act compliance checklist / template

/ GMS contract Annex B: Where patients are requesting to join the practice list, the practice does not discriminate on the grounds of race, gender, social class, religion, sexual orientation, appearance, disability or medical condition
This includes equity of access to dispensing services if provided
Consider:

Practice self assessment of premises with regard to disability access

Level 2 / All patients can readily access our premises and services /

Appointment/access audit reports
Copy of appointments schedule/timetable
Workload schedule/rota
large print practice leaflets,
RNID recommended communication tools
Welsh speakers available
interpreter services
translated literature
Staff training schedules

/ Consider:

The needs of patients with differing abilities and whether appropriate adjustments have been made
Arrangements to help patients with sensory impairments:
Arrangements to help patients with long term mental health impairments
Arrangements to help patients with long term physical impairments
Assistance with communication for patients whose first language is not English,

The 'Social Model of Disability' 11uses the following definitions: Impairment: an injury, illness or congenital condition that causes or is likely to cause a long term effect on physical appearance and/or limitation of function within the individual that differs from the commonplace. Disability: The loss or limitation of opportunities to take part in society on an equal level with others due to institutional, environmental and attitudinal barriers.
Level 3 / We are aware of when and which patients have difficulty with access
We encourage patient feedback on access /

Copy of EquIP Cymru Disability Access Self Assessment Audit Toolkit 12or a similar tool
Copy of registration policy
Copy of carers policy
Copy of policy for highlighting in the patient recordeg: ‘Major Alert’ on the practice system
Summarisation policy
Patient questionnaires
Patient Participation Group agenda, minutes / feedback
Complaints / compliments
Report from CHC visit if undertaken locally

/ Consider:

Completion of the EquIP Cymru Disability Access Self Assessment Audit Toolkit12or a similar tool
External assessment of DDA compliance by CHC if offered or undertaken locally

Level 4 / We have an access policy /

Copy of access policy

/ Please see the PCQIS References andResources webpage for the CGPSAT tutorial with details of what should be included in a good Practice policy
Level 5 / As a result of review we have considered the needs of patients and updated our access policy accordingly /

Agenda and minutes of practice meetings when policy and action plan discussed with staff
Updated access policy

/ Consider

examples of best practice eg: the Premises, Facilities and Waiting rooms section of ‘Developing General Practice, Listening to Patients’ BMA 20097

Whether the practice has an action plan arising from completion of the EquIP12 or similar tool (An action plan template is provided in appendix 1 of the EquIP12 tool)

Whether the action plan has been implemented universally, reviewed annually, updated and embedded.

4. Patient Information and Consent

This section contains 3 matrices. Other matrixes containing elements relevant to the Standards for Health Services in WalesPatient Information and Consent are to be found under Equality, diversity and human rights, Citizen engagement and feedback, Research development and innovation, Safeguarding children and vulnerable adults, Dignity and respect and Medicines management.

4.1. Consent for clinical examination and treatment

Level / Description / Supporting Information / Additional Information
Level 0 / We have not achieved Level 1
Level 1 / Wehave regard for the need to obtain valid consent for clinical procedures and treatments /

Completed consent forms
Staff training records
Patients are provided with information to help them make informed decisions
Clinicians record patient decisions/consent in the patient record (this may only be verbal consent)

/ Patient consent is required on every occasion the doctor wishes to initiate an examination or treatment or any other intervention, except in emergencies or where the law prescribes otherwise (such as where compulsory treatment is authorised by mental health legislation). Consent may be:

Explicit or express - when a person actively agrees, either orally or in writing.
Consent can also be implied - signalled by the behaviour of an informed patient. Implied consent is not a lesser form of consent but it only has validity if the patient genuinely knows and understands what is being proposed.

The provision of sufficient accurate information is an essential part of seeking consent. Acquiescence when a patient does not know what the intervention entails, or is unaware that he or she can refuse, is not ‘consent’. Consent is a process, not a one-off event, and it is important that there is continuing discussion to reflect the evolving nature of treatment. Ref: BMA Consent Toolkit 2009 Card 113 Guidance and seeking informed consent.
Consider

A Sessional GP Booking form which specifies the procedures Sessional GPs are expected to perform that are outside normal consultations.
systems for obtaining consent for immunisations and vaccinations and those who lack capacity and documentation of competence for minors >16

Mental capacity act guidance
using All Wales Consent Reference Guide & model consent forms14
GMS contract Annex B: The practice has a policy for consent to the treatment of children that conforms to the current Children’s Act or equivalent legislation

GMS contract annex B: For minor surgery, patients’ consent to any surgical procedures including wart cautery and joint injections, is recorded
GMS contract Annex B: For vaccination and immunisation, consent to immunisation, or contraindications if they exist are recorded in the records
Level 2 / We ensure valid consent is obtained for clinical procedures and treatments as appropriate /

Staff are aware of their responsibilities in obtaining relevant and valid consent
Consent checklist
Record that issues considered and discussed
Copy of policy for chaperone

/ See also matrix 5.1 ’Chaperone’
Level 3 / We ensure valid consent obtained and recorded in the case record for all invasive procedures /

A note or READ code in the patient notes that consent was obtained

/ You need to obtain verbal consent before undertaking any intimate examination. It is recommended that you obtain written consent for invasive procedures such as vaccinations and blood tests. There should be a record in the case notes that consent was obtained either in text or a READ code.
Consider using the PCQIS Minor surgery audit tool
Level 4 / We have a written up to date consent policy for clinical procedures and treatments in line with national guidance / good practice which all staff understand and follow /

Copy of consent policy
Agenda and minutes of meetings where consent policy discussed

/ Consider using Health Board resources eg: Policy and consent forms
Level 5 / Wereview use of consent procedures /

Audits and reports
Copies of Significant Event Analyses
Patient complaints
Patient surveys
Audit case notes

/ Check if all clinicians are compliant with procedures. Is appropriate use made of consent forms? How often is consent recorded in the notes? Is your consent policy still in line with national guidance?

Dignity and Respect

This section contains 1 matrix. Other matrixes containing elements relevant to the Standards for Health Services in WalesDignity and Respect are to be found under Equality, diversity and human rights, Environment, Dealing with concerns and managing incidents, Patient information and consent and Safeguarding children and vulnerable adults.