Leading change

Nurses within the Quality Team in South Nottinghamshire Clinical Commissioning Group (CCG) led the development and implementation of a new quality assurance process for their 44 GP practices. This has resulted in a consistent quality assurance approach being established which is driving improvements and enhancing safety within the practices.

Where to look

In April 2016 South Nottinghamshire CCG took over commissioning responsibility for primary care services in their locality. Nurses within the Quality Team identified unwarranted variation within primary care practices in the broad areas of quality, safety, clinical effectiveness and patient experience, where there was no uniformed process to review effectiveness and safety across GP practices across the CCG area. The implementation of a quality assurance and improvement framework enabled the CCG nurses to target resources and support towards GP practices that needed greater support to achieve effective and safe practice.

What to change

The CCG nurses alongside their commissioning and clinical colleagues identified the need to develop fit-for-purpose tools and procedures used by all practices in order to address the unwarranted variation and to create a standardised, uniformed assurance process. The result was a framework incorporating a quality dashboard, risk matrix and escalation process – enabling practices to monitor sustained quality, safety and improvement.

How to change

The CCGs’ Quality Team, headed by the Director of Nursing and Quality, led implementation of the quality assurance framework by:

• Visiting practices to explain the framework and gain feedback.
• Reviewing existing frameworks from other healthcare sectors to identify what would and wouldn’t be transferable to primary care.
• Identifying a General Practice clinician to champion the work.
• Collaborating with Informatics colleagues to develop the dashboard, using existing information streams to limit inaccurate data and overwhelming practices with burdensome data collection.

The resulting primary care quality dashboard has a range of metrics across the three domains of quality safety, clinical effectiveness and patient experience. Data sources include immunisation and vaccinations, screening, prescribing, the Friends and Family Test, other surveys, and safeguarding are all included.

Using this data each practice is rated under each quality domain using a RAG (red, amber, green) system, which in turn goes on to calculate a suggested overall rating of red, amber or green so that appropriate levels of communication and support are provided. This includes support to address unwarranted variation they are seeing in practice and demonstrate sustained safe and effective care.

The primary aim was to develop a mechanism for commissioners to gain assurance of quality and safety in general practice and also for practices, in turn, to have a tool for collating and having an awareness of their own individual performance in relation to safety and quality

To support oversight a multi-disciplinary Primary Care Quality Group (including representatives from infection control and community nursing) has been established. Within this forum performance can be reviewed as part of the CCG’s governance structures. The dashboard is a key tool, supplemented by audits, CQC reports, patient and staff feedback, incidents and data from the Quality Outcomes Framework (QOF).

Adding value

Better outcomes – The CCGs now have a robust system for gaining assurance about the quality and safety of services being provided by GP practices. Practices are developing a ‘safety first’ culture, actively reporting incidents or concerns – as well as sharing best practice (for example, consistent carer signposting and more accessible information for patients about chaperoning or how to complain). Where trends are seen such as in cervical screening rates across practices action has been taken to support system wide improvement.

Better experience – The quality dashboard has been adopted into GP practices internal governance systems and is supporting them to prepare for CQC inspections and take actions following inspections by demonstrating their ongoing commitment to quality and safety. More collaborative working between practices is being seen. There is more transparency between practices and patients, particularly Patient Participation Groups, where the quality dashboard and any improvement actions are now discussed and shared.

Better use of resources – Increased awareness, trust and maturity around incident reporting has been invaluable in ensuring lessons learnt from incidents are reported and disseminated. Practices are sharing best practices as a result, including sharing policies, procedure and protocols to reduce unwarranted variation further.

Challenges and lessons learnt for implementation

Establishing the framework has helped to identify areas of improvement and where support is required. The dashboard has also strengthened collaboration between both individual practices and multi-disciplinary members of the Primary Care Quality Groups.

Find out more

For more information contact:

• Esther Gaskill, Head of Quality, Patient Safety and Experience, Esther.gaskill@nhs.net