QOF

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Organisational domain

1. Format

Organisational indicators are split into five domains:

For each indicator (x), four descriptions are given unless it is reported electronically:

X.1 Practice guidance

This section contains a number of things, dependent on the indicator, including:

X.2 Written evidence

This specifies the written evidence which a practice would be expected to produce for an assessment visit. The evidence generally should be available in the practice and need not be submitted in advance. However, some written evidence will be required in advance and this is indicated in the document. In some instances no written evidence will be required but may be requested if there is an appeal.

In summary, written evidence is categorised as follows:

Grade A – to be submitted in advance of a visit.

Grade B – to be available in the practice at the visit.

Grade C – optional or used in the event of an appeal.

X.3 Assessment visit

This section describes how a visiting assessment team will verify the written evidence.

X.4 Assessors’ guidance

This section contains more detailed guidance for assessors to use during practice assessment visits. This guidance has been produced to ensure that practices are being judged to the same standard across the UK.

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Records

Records indicator 3

The practice has a system for transferring and acting on information about patients seen by other doctors out of hours

Records 3.1 Practice guidance

Good medical practice for general practitioners (2008) states that the excellent GP “can demonstrate an effective system for transferring and acting on information from other doctors about patients.” Out-of-hours reviews in England and Scotland have emphasised the importance of the effective transfer of information.

If the practice undertakes its own out-of-hours cover, there needs to be a system to ensure that out-of-hours contacts are entered in the patient’s clinical record.

If out-of-hours cover is provided by another organisation, for example a co-operative, deputising service, PCO-provided service or shared rota, there needs to be a system for:

Records 3.2 Written evidence

There must be a written procedure for the transfer of information. (Grade B)

Records 3.3 Assessment visit

Inspection of the procedure for the transfer of information may be carried out on an assessment visit.

Records 3.4 Assessors’ guidance

Receptionists and doctors will be questioned on the system for the transfer of information.

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Records indicator 8

There is a designated place for the recording of drug allergies and adverse reactions in the notes and these are clearly recorded

Records 8.1 Practice guidance

It is important that a clinician avoids prescribing a drug to which the patient is known to be allergic. Not all patients can recall this information and hence records of allergies are important.

All prescribing clinicians should know where such information is recorded. Ideally, the place where this information is recorded should be limited to one place and not more than two places.

Records 8.2 Written evidence

There should be a statement as to where drug allergies are recorded. (Grade C)

Records 8.3 Assessment visit

The practice should be able to demonstrate where drug allergies are recorded.

Records 8.4 Assessors’ guidance

The place where drug allergies are recorded can be on the computer or in the paper records. This information should be easily available to the prescribing clinician at the time of consultation.

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Records indicator 9

For repeat medicines, an indication for the drug can be identified in the records (for drugs added to the repeat prescription with effect from 1 April 2004)

Minimum standard 80%

Records 9.1 Practice guidance

When reviewing medication, it is important to know why a drug was started. This information in the past has often been difficult to identify in GP records, particularly if a patient has been on a medication for a long time or has transferred between practices. It is proposed that this information needs to be recorded clearly in the clinical records.

It is recognised that most practices utilise computer systems for repeat prescriptions and it is intended that an IT solution will be available to assist practices in meeting this indicator.

In practices where the computer is not utilised for repeat prescriptions, the clinician should write clearly in the patient record the diagnosis relating to the prescription. This need only be done once when the medication is initiated.

The survey to show compliance should be a minimum of 50 patients who have been commenced on a new repeat prescription from 1 April 2004.

Records 9.2 Written evidence

A survey of the drugs used should be carried out. The survey should show an indication can be identified for at least 80% of repeat medications commenced after 1 April 2004. (Grade A)

Records 9.3 Assessment visit

The records should be inspected.

Records 9.4 Assessors’ guidance

As part of the inspection of records those drugs which have been added to the repeat prescription from 1 April 2004 should be identified and an indication for starting them should be clear. The help of practice staff may be required to achieve this. The records of 20 patients for whom repeat medication has been started since that date should be surveyed. If the standard is not achieved then a further 20 clinical records should be surveyed and the cumulative total should be used.

The minimum standard is that 80% of the indications for repeat medication drugs can be identified.

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Records indicator 11

The blood pressure of patients aged 45 years and over is recorded in the preceding five years for at least 65% of patients

Records 11.1 Practice guidance

Detecting elevated blood pressure and treating it is known to be an effective health intervention. The limit to patients aged 45 and over has been pragmatically chosen as the vast majority of patients develop hypertension after this age. It is anticipated that practices will opportunistically check blood pressures in all adult patients.

Depending on whether practices record blood pressure in the computer or manual record, the survey can be undertaken by computer search or a survey of the written records.

A similar indicator is proposed as Records Indicator 17 but a higher standard must be achieved.

Records 11.2 Written evidence

A survey of the records of patients aged 45 and over (a minimum of 50 records) or a report from a computer search should be carried out, showing that blood pressure has been recorded in the previous five years. (Grade A)

Records 11.3 Assessment visit

A random sample of 20 notes or computerised records of patients aged 45 and over should be inspected, to confirm that blood pressure has been recorded in the previous five years.

Records 11.4 Assessors’ guidance

The practice’s own survey may be verified by inspecting 20 clinical records of patients aged 45 and over at the visit. If the result differs from the practice survey, then a further 20 records need to be checked.

Note: A logical query and dataset (business rule) is available to support this indicator.

The Practice reports the percentage of patients aged 45 years and over in whom there is a record of blood pressure having been recorded in the preceding five years

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Records indicator 13

There is a system to alert the out-of-hours service or duty doctor to patients dying at home

Records 13.1 Practice guidance

Good medical practice (2008) states that when off duty the doctor ensures there are arrangements which “include effective hand-over procedures and clear communication between doctors”. It is especially important for patients who are terminally ill and likely to die in the near future at home or where clinical management is proving difficult or challenging.

The practice should have developed a system with their out-of-hours care provider to transfer information from the practice to that provider about patients that the attending doctor anticipates may die from a terminal illness in the next few days and hence may require medical services in the out-of-hours period. If a practice does its own on-call duties then a system should ensure that all doctors in the practice are aware of these patients. A single-handed doctor who usually covers his or her own patients out of hours should have a similar system in place when he or she is absent from the practice, e.g. on holiday.

Records 13.2 Written evidence

The system for alerting the out-of-hours service or duty doctor to patients dying at home should be described. (Grade C)

Records 13.3 Assessment visit

The doctors in the practice should be questioned on the system that is in place.

Records 13.4 Assessors’ guidance

The team should be questioned on their system by asking for recent examples of patients who have been terminally ill and/or dying at home and what information was passed to the out-of-hours service or duty doctor.

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Records indicator 15

The practice has up-to-date clinical summaries in at least 60% of patient records

Records 15.1 Practice guidance

Good medical practice for general practitioners (2008) states: “Important information in records should be easily accessible, for example, as part of a summary.”

If a system for producing summaries is not in place then this will involve a great deal of work. The practice will need to decide which conditions it will include in the summary. The practice would be expected to have a policy on what is included in the summary. All significant past and continuing problems should be included.

If a computer is used the practice will need to decide which Read codes to use for common conditions. It is best to use a set of codes that has been agreed within a PCO or nationally to allow comparison and exchange of data. Practices should adhere to the joint RCGP/GPC guidance on record keeping. This can be found at: www.connectingforhealth.nhs.uk/systemsandservices/gpsupport/gp2gp/docs/good_practice_guidelines.pdf/view

Similar indicators are proposed as Records 18 and Records 20 but higher standards must be achieved.

Records 15.2 Written evidence

A survey of patient records (minimum 50) should be carried out, recording the percentage that have clinical summaries and the percentage which are up to date. (Grade A)

Records 15.3 Assessment visit

A random sample of 20 patient records should be examined to confirm the percentage that have clinical summaries and the percentage which are up to date.

Records 15.4 Assessors’ guidance

The practice’s own survey is verified by inspecting 20 clinical records. If the result differs from the practice survey then a further 20 records need to be checked. Assessors may need to clarify with the practice what information they would normally include in a clinical summary ensuring that they do not assess this indicator based on their own experience and beliefs.

Note: A logical query and dataset (business rule) is available to support this indicator.

In Scotland, manual submission of achievement continues and is reviewed by the Scottish Government and Scottish General Practitioners Committee of the BMA annually. Please refer to your PCO for current information.

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Records indicator 17

The blood pressure of patients aged 45 years and over is recorded in the previous five years for at least 80% of patients

Records 17.1 Practice guidance

See Records 11.1

Records 17.2Written evidence

See Records 11.2 (Grade A)

Records 17.3 Assessment visit

See Records 11.3 Records

17.4 Assessors’ guidance

See Records 11.4

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Records indicator 18

The practice has up-to-date clinical summaries in at least 80% of patient records

Records 18.1 Practice guidance

See Records 15.1

Records 18.2 Written evidence

See Records 15.2 (Grade A)

Records 18.3 Assessment visit

See Records 15.3

Records 18.4 Assessors’ guidance

See Records 15.4

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Records indicator 19

80% of newly registered patients have had their notes summarised within eight weeks of receipt by the practice

Records 19.1 Practice guidance

The criterion refers to the time the notes have been received by the practice and not the time of registration. For some practices that take on many patients at a set time of year, achievement of the indicator will require some forward planning.

Read codes may be utilised to record this information and can then be searched for on the practice computer system.

Records 19.2 Written evidence

A survey should be carried out of the records of newly-registered patients whose notes have been received between eight and 26 weeks previously (either a sample of 30 or all patients if there have been fewer than 30 such registrations), noting if the records have been received and summarised.

Alternatively, a computer print-out should be examined, showing the patients registered where the records have been received between eight and 26 weeks previously, to confirm whether the computer record contains a clinical summary. (Grade A)

Records 19.3 Assessment visit

A sample of 20 records of patients whose records were sent to the practice between nine and 26 weeks ago should be examined, to ascertain if the records have arrived and have been summarised.

Records 19.4 Assessors’ guidance

A list of patients registered in the past 12 months and whose records have been forwarded between nine and 26 weeks ago to the practice will be obtained from the PCO. A sample of 20 records, or all if there have been fewer of these patients, will be checked. If the result differs significantly (at least 10%) from the practice survey a further 20 records will be checked if appropriate.

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Records indicator 20

The practice has up to date clinical summaries in at least 70% of patient records

Records 20.1 Practice guidance

See Records 15.1

Records 20.2 Written evidence

See Records 15.2 (Grade A)

Records 20.3 Assessment visit

See Records 15.3

Records 20.4 Assessors guidance

See Records 15.4

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Information

Information indicator 5

The practice supports smokers in stopping smoking by a strategy which includes providing literature and offering appropriate therapy

Information 5.1 Practice guidance

There is good evidence about the effectiveness of healthcare professionals in assisting patients to stop smoking.

A number of studies have recently shown benefits from the prescription of nicotine replacement therapy or buproprion in patients who have indicated a wish to quit smoking.

The strategy does not need to be written by the practice team. A local or national protocol could be adapted for use specifically by the practice and implemented. The provision of dedicated smoking cessation services remains the responsibility of the PCO.

Information 5.2 Written evidence

There should be a practice protocol concerning smoking cessation. (Grade A)

Information 5.3 Assessment visit

Prescribing data should be reviewed, and literature available for patients who wish to quit should be examined.

Information 5.4 Assessors’ guidance

The strategy should take into account current evidence in this area. Signs of implementation may be evident in the practice’s prescribing data or in the patient leaflets that are used by the practice.

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Education & Training

Education indicator 11

There is a record of all practice-employed clinical staff and clinical partners having attended training/updating in basic life support skills in the preceding 18 months

Education 11.1 Practice guidance

The primary care team members, including GPs, deal with cardio-pulmonary collapse relatively rarely, but require up-to-date skills to deal with an emergency. This is best undertaken at regular intervals through practical skills-based training sessions, as it is known that these skills diminish after a relatively short time. The timescale has been set pragmatically at 18 months, although many practices offer training on a more frequent basis.

This training may be available from a variety of providers including your local accident and emergency department, BASICS, the PCO, out-of-hours co-operative, Red Cross, St John’s Ambulance or equivalent. It may be sufficient for one individual in the team to attend for external training and then cascade this within the team.

Further information:

Cardiopulmonary resuscitation guidance for clinical practice and training in primary care (2001) www.resus.org.uk/pages/cpatpc.htm#contents

Resuscitation Guidelines 2005 (Resuscitation Council UK).
www.resus.org.uk/pages/guide.htm

Education 11.2 Written evidence

Attendance at Basic Lives Saving, BLS, training should be listed. (Grade B)

Education 11.3 Assessment visit

Staff should be questioned on the date of their last BLS training.

Education 11.4 Assessors’ guidance

Assessors should confirm by checking the BLS attendance list that practice-employed clinical staff have attended.

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Education indicator 5

There is a record of all practice-employed staff having attended training/updating in basic life support skills in the preceding 36 months

Education 5.1 Practice guidance

Although it is rare for practice non-clinical staff to have to deal with a cardio-pulmonary collapse, the situation may arise within or outwith the practice premises.

See Education 11.

The interval for training is pragmatically set at three years although many practices offer training on a more frequent basis.

Education 5.2 Written evidence

Attendance at BLS training should be listed. (Grade B)

Education 5.3 Assessment visit

Staff should be questioned on the date of their last BLS training.

Education 5.4 Assessors’ guidance

Confirmation that practice non-clinical staff have attended training should be obtained by checking the BLS attendance list.

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Education indicator 6

The practice conducts an annual review of patient complaints and suggestions to ascertain general learning points which are shared with the team

Education 6.1 Practice guidance

Practices and clinicians generally find complaints stressful. It is important that the practice view complaints as a potential source for learning and for change and development.

Reports should include a summary of each complaint or suggestion and an identification of any learning points which came out of the review. It may be useful to agree at the time of each review how the learning points or areas for change will be communicated to the team; it is likely that not all team members will be involved in every review meeting for various reasons. It may also be useful to identify an individual responsible for implementing the change and monitoring its progress.

These reports may form part of the written evidence for the indicators on significant event analysis (Education 7 and Education 10).

Education 6.2 Written evidence

Reports/minutes of team meetings where learning points have been discussed should be made, with a note of the changes made as a result. (Grade A)

Education 6.3 Assessment visit

The issue of learning from complaints should be discussed with staff and GPs.

Education 6.4 Assessors’ guidance

Assessors should discuss with team members their involvement in reviews of patient complaints and suggestions and how the learning points are shared with the team.

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Education indicator 7

The practice has undertaken a minimum of 12 significant event reviews in the past three years which could include:

Education 7.1 Practice guidance

Detail of methodology on significant event analysis is given in indicator Education 10.

This indicator is more prescriptive in the requirement to report on specific occurrences in the practice. Clearly if certain of these events have not occurred, e.g. patient suicide, then this should be stated in the evidence.

Education 7.2 Written evidence

Each review case report must consist of a short commentary setting out the relevant history, the circumstances of the episode and an analysis of the conclusions to be drawn.

Evidence should be presented of any clinical and organisational changes resulting from the analysis of these cases. (Grade A)

Education 7.3 Assessment visit

The reviews should be discussed.

Education 7.4 Assessors’ guidance

The practice should report on its analyses in a form consistent with either of the two methods described in Education 10.

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Education indicator 8

All practice-employed nurses have personal learning plans which have been reviewed at annual appraisal

Education 8.1 Practice guidance

The production of a personal learning plan should be one of the outcomes of the appraisal system and the points allocated to this indicator have been increased to reflect this. The plan should record the agreement between appraiser(s) and appraisee on areas for further learning, how they will be achieved, who is responsible for organising them, within what timescale, and how progress will be reviewed. It may also include learning areas which have been identified as an organisational need but which have been agreed at the appraisal as an individual development area for the appraisee to take forward. This information should be recorded.

An annual appraisal can reasonably be extended to employed members of the nursing team e.g. Health Care Assistants (HCAs) who have direct patient contact. This supports good practice arrangements.

Education 8.2 Written evidence

The staff appraisal system should be described. (Grade C)

Education 8.3 Assessment visit

A discussion should be held with practice employed nursing staff (including employed members of the nursing team e.g. HCAs who have direct patient contact) about their personal learning plans and the appraisal system.

Education 8.4 Assessors’ guidance

Personal learning plans and the appraisal system should be discussed with practice employed nursing staff (including employed members of the nursing team e.g. HCAs who have direct patient contact) and the person responsible for managing the appraisal system.

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Education indicator 9

All practice-employed non-clinical team members have an annual appraisal

Education 9.1 Practice guidance

Appraisal is a constructive opportunity to review performance objectives, progress and skills and identify learning needs in a protected environment. The learning needs identified may be personal to the appraisee and/or organisational learning needs which the appraisee has agreed to fulfil. The outcome of the appraisal should be a written action plan agreed between appraiser and appraisee which could include a personal learning plan for the appraisee. In addition the opportunity could be taken to review and update the appraisee’s job description.

Education 9.2 Written evidence

The staff appraisal system should be described. (Grade C)

Education 9.3 Assessment visit

A discussion should be held with practice-employed non-clinical staff about their experience of appraisal.

Education 9.4 Assessors’ guidance

It may be useful to discuss the appraisal system with the non-clinical staff themselves, the practice manager and the GPs.

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Education indicator 10

The practice has undertaken a minimum of three significant event reviews within the preceding year

Education 10.1 Practice guidance

Significant event review is a recognised methodology for reflecting on important events within a practice and is an accepted process as evidence for GMC revalidation.

Significant event analysis is not new, although its terminology may have changed. It was first known as critical event monitoring. It provides structure to an activity which anyway happens informally between health care professionals. It is the discussion of cases and events and the learning obtained through reflection and is an extension of audit activity. Discussion of specific events can provoke emotions that can be harnessed to achieve change. For it to be effective, it needs to be practised in a culture that avoids allocating blame and involves all disciplines within the practice.

The following steps are useful in introducing significant event analysis to a practice:

  1. A multidisciplinary meeting to explain the concept.
  2. Consideration of events which should be important to the practice but need not imply criticism of the practice or of individuals. The practice can construct a core list as a basis to stimulate discussion or it can use the one published in the RCGP Occasional Paper (see reference at end of this section). Some of the examples from this are below.

    Preventative care:

The events are then discussed, first highlighting the aspects of high standard and then those standards that can be improved. A decision about the case needs to be reached.

This could be:

Follow-up of these decisions should be arranged and this may occur at the next significant event analysis meeting.

These reports should be laid out in a form consistent with either of the two following suggested formats:

A.

B.

Further Information

A description of significant event audit is also available in: Robinson et al. How to do it: Use facilitated case discussions for significant event auditing. BMJ 1995; 311: 315-318.

NPSA/RCGP October 2008. SEA guidance for Primary Care Teams: .
www.npsa.nhs.uk/nrls/improvingpatientsafety/primarycare/significant-event-audit/

Education 10.2 Written evidence

Each case report should consist of a short commentary setting out the relevant history, the circumstances of the episode and an analysis of the conclusions to be drawn.

Evidence should be presented of any clinical and organisational changes resulting from the analysis of these cases. (Grade A)

Education 10.3 Assessment visit

The reviews should be discussed.

Education 10.4 Assessors guidance

The practice should report their analyses in a form consistent with either of the two following methods:

A. Statement of the problem or event, learning outcome and action plan

OR

B. What happened? Why did it happen? Was insight demonstrated? Was change implemented?

The practice should involve, if possible, all team members who were stakeholders in the event in the case discussion.

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Practice Management

Management indicator 1

Individual healthcare professionals have access to information on local procedures relating to child protection

Management 1.1 Practice guidance

Awareness of the existence of local child protection procedures is mandatory and all healthcare professionals should be able to access a copy.

Management 1.2 Written evidence

There should be a description of how local procedures are accessed. (Grade C)

Management 1.3 Assessment visit

Access to local procedures should be demonstrated.

Management 1.4 Assessors’ guidance

The assessors should check with team members what action they would take if they had reason to suspect that a child might be being abused, including which local procedures they would refer to and how.

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Management indicator 2

There are clearly defined arrangements for backing up computer data, back-up verification, safe storage of back-up tapes and authorisation for loading programmes where a computer is used

Management 2.1 Practice guidance

The practice should have a written policy which defines who is responsible for backing up data, how it is done and how often it is done. It is good practice to keep weekly and monthly backups as well as daily backups using a rotation of back-up tapes or their equivalent. It is good practice to keep a log. Tapes should be renewed at specified intervals. Verification of backups should also be carried out at regular specified intervals, especially in paper-light or paperless practices. Tapes should be stored in a fireproof safe, with a procedure in place for back-up tapes being stored off site in order to ensure confidentiality. The policy should also define the individuals who are authorised to load new software programmes.

Management 2.2 Written evidence

There should be written policy regarding:

Management 2.3 Assessment visit

The back-up and loading arrangements should be demonstrated.

Management 2.4 Assessors’ guidance

The arrangements for back-up, verification and storage procedures should be checked with the responsible staff member. It is important to ascertain that staff are aware of the procedure for authorisation for loading new software.

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Management indicator 3

The hepatitis B status of all doctors and relevant practice employed staff is recorded and immunisation recommended if required in accordance with national guidance

Management 3.1 Practice guidance

Useful guidance on hepatitis B risks and immunisation is contained in the UK Health Departments’ publication Guidance for clinical health care workers: protection against infection with blood borne viruses – recommendations of the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis (www.dh.gov.uk/assetRoot/04/01/44/74/04014474.pdf)

Under the Health and Safety at Work etc Act (1974) (HSWA), GPs are legally obliged to make sure that all employees receive appropriate training and know the procedures for working safely. They must also carry out risk assessments and these could include assessing procedures under the Control of Substances Hazardous to Health Regulations 1994 (COSHH). These regulations would cover employees who have direct contact with patients’ blood, other potentially infectious bodily fluids or tissues. Immunisation of doctors and staff that have direct contact with these substances is recommended in the above regulations.

The DH guidance Protecting health care workers and patients from hepatitis B and the 1996 and 2004 addenda (see above reference to the website, Annex 1) states that all healthcare workers who perform exposure prone procedures (EPPs) should be immunised. They should have their response to the vaccine checked and non-responders to vaccination should be investigated for infection in order to minimise risk to patients. This guidance also states that workers whose hepatitis B status is unknown should be tested before carrying out EPPs.

Immunisation provides protection in up to 90% of patients vaccinated, but is not a substitute for good infection control procedures.

The BMA website provides a specimen hepatitis B immunisation policy in the general practice staff (non medical) specimen handbook. Advice on suitable immunisation policies can also be obtained from the Occupational Health Service, which works with reference to guidelines published in Immunisation against infectious disease (see annex 1 in the above website).

In relation to confidentiality, it is extremely important that hepatitis B infected healthcare workers have the same right of confidentiality as any patient seeking or receiving medical care.

Occupational health notes are separate from other hospital notes and occupational health physicians are ethically and professionally obliged not to release information without the consent of the individual. There are occasions when an employer may need to be advised that a change of duties should take place, but hepatitis B status itself will not normally be disclosed without the healthcare worker’s consent. However, where patients are, or have been, at risk of exposure to hepatitis B from an infected healthcare worker, it may be necessary in the public interest for the employer to have access to confidential information.

Management 3.2 Written evidence

There should be evidence that the hepatitis B status of all staff is known. (Grade C)

Management 3.3 Assessment visit

Questioning should take place on the system to check hepatitis B status.

Management 3.4 Assessors’ guidance

It should be confirmed that evidence is available that the hepatitis B status of all doctors and relevant practice-employed staff has been recorded and that there is a mechanism for recommending (and recording any recommendation) regarding vaccination to the doctor or staff member, including checking response to vaccination.

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Management indicator 5

The practice offers a range of appointment times to patients, which as a minimum should include morning and afternoon appointments five mornings and four afternoons per week, except where agreed by the PCO

Management 5.1 Practice guidance

In practices which operate with open surgeries, this would mean that the practice should have a range of times of availability equivalent to the appointment range in the indicator. Patients should be offered a reasonable range of appointment times, which are advertised to them. The practice’s appointment system should normally offer as a minimum the range of appointments described in the practice leaflet. In remote and rural areas, for example, or in some single-handed practices, the range of appointment availability described in the indicator will not be appropriate. In these circumstances, the practice should agree its availability with the PCO and this should be advertised in the practice leaflet. Evidence that this has been agreed should be made available to the assessor.

Management 5.2 Written evidence

The practice leaflet should be scrutinised for evidence of appointment times. (Grade A)

Management 5.3 Assessment visit

The practice leaflet and appointment book should be checked.

Management 5.4 Assessors’ guidance

The assessor should check that the practice advertises in the practice leaflet a range of appointment times which corresponds to the indicator. The availability of such appointments should be confirmed by looking at a randomly selected week in the appointment book/appointment system. In practices offering a more limited range of appointment availability, the practice should provide evidence that the PCO has agreed the range on offer.

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Management indicator 7

The practice has systems in place to ensure regular and appropriate inspection, calibration, maintenance and replacement of equipment, including:

Management 7.1 Practice guidance

The evidence for this criterion may form part of the statutory risk assessment activity which takes place under the Health and Safety at Work Regulations 1999 (Management Regulations). Comprehensive guidance on risk assessment can be found in the Health and Safety Executive’s website at www.hse.gov.uk. The website provides a free booklet, "Five steps to risk assessment."

This website also contains a free leaflet, "Maintaining portable electrical equipment in offices and other low risk environments." This contains guidance on the appropriate person to inspect and maintain equipment in relation to the equipment’s associated risks as well as suggested intervals between inspections and maintenance. For example, a printer may be inspected and maintained by a “competent” person with enough knowledge and training, who need not be an electrician. This is only one of several free leaflets available on the website, others may also be relevant to the individual practice’s circumstances.

The schedule should clearly identify who has overall responsibility, who is the appropriate individual to inspect/maintain/calibrate each piece of equipment, the intervals between inspections and the system for reporting faults.

Management 7.2 Written evidence

Details should be given of the system to ensure regular and appropriate inspection, calibration, maintenance and replacement of equipment meeting the stated criteria. (Grade B)

Management 7.3 Assessment visit

Assessors should undertake a review of equipment requiring maintenance, and the log of inspection and maintenance.

Management 7.4 Assessors’ guidance

The practice should have in place a system which includes risk assessment of equipment and a schedule of inspection, calibration and maintenance. This should include electrical equipment.

The responsible person will not always be the person actually carrying out the inspection; this should be specified in the schedule.The intervals between inspection, calibration and maintenance will be different for various types of equipment dependent on their associated level of risk. Inspection, calibration and maintenance should be recorded.

There should be a clear system for reporting faults.

The practice should be able to provide a written record of inspection, calibration and maintenance for some randomly selected pieces of equipment. It would be useful to consider a range of equipment from small items (e.g. printer) up to larger items such as a steriliser or defibrillator.

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Management indicator 9

The practice has a protocol for the identification of carers and a mechanism for the referral of carers for social services assessment

Management 9.1 Practice guidance

The practice should have a procedure for how carers are identified and a referral protocol to social services for assessment of carers support needs or to other local support such as carers centre.

A carer is defined as ‘someone who, without payment, provides help and support to a partner, relative, friend or neighbour, who could not manage to stay at home without their help due to age, sickness, addiction or disability.’

The practice should remember to include any young carers who are particularly vulnerable.

Further information Supporting Carers: An action guide for general practitioners and their teams. Second edition.
http://static.carers.org/files/supporting-carers-an-action-guide-for-general-practitioners-andtheir- teams-second-edition-5877.pdf

Focus on Carers and the NHS-identifying and supporting hidden carers. Good Practice.
www.carers.org/publications,185,GP.html

Scottish Government and COSLA Caring Together: The Carers Strategy 2010-15.
http://www.scotland.gov.uk/Publications/2010/07/23153304/0

Management 9.2 Written evidence

The protocol is available. (Grade A)

Management 9.3 Assessment visit

The policy is discussed.

Management 9.4 Assessors’ guidance

The assessors should enquire of various team members what action they would take when they identify that a carer may benefit from social services involvement.

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Management indicator 10

There is a written procedures manual that includes staff employment policies including equal opportunities, bullying and harassment and sickness absence (including illegal drugs, alcohol and stress), to which staff have access

Management 10.1 Practice guidance

It is good employment practice to have established written procedures, which are available to staff, so that both staff and employer are clear about the steps to be taken if a problem arises. As well as the policies mentioned, the manual could include the disciplinary and grievance procedure.

Useful guidance on writing these policies can be found as follows:

Management 10.2 Written evidence

Employment policies should be recorded (Grade B). Policies should be consistent with current legislation and indicate a date when the policy has been reviewed.

Management 10.3 Assessment visit

The procedures manual should be inspected.

Management 10.4 Assessors’ guidance

The procedures manual should contain dated copies which are made available to staff of the policies relating to their employment. It should be confirmed with employed staff that they are aware of the content of the procedures manual and its whereabouts.

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Medicines Management

Medicines indicator 2

The practice possesses the equipment and in-date emergency drugs to treat anaphylaxis

Medicines 2.1 Practice guidance

Good medical practice for general practitioners (2002) states that the excellent doctor “has up-to-date emergency equipment and drugs” and anaphylaxis is one condition that may constitute an emergency in the practice premises.

Medicines 2.2 Written evidence

There is a list of equipment and drugs that the practice has available to deal with an anaphylactic emergency. (Grade C)

Medicines 2.3 Assessment visit

The appropriate equipment and drugs are inspected.

Medicines 2.4 Assessors’ guidance

The dates of emergency drugs should be checked.

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Medicines indicator 3

There is a system for checking the expiry dates of emergency drugs on at least an annual basis

Medicines 3.1 Practice guidance

Good medical practice for general practitioners (2008) states that the unacceptable GP “has drugs which are out of date” and a system is required to prevent this. The system should include all emergency drugs held in the practice premises and in the doctors’ bags.

Medicines 3.2 Written evidence

The system is described. (Grade C)

Medicines 3.3 Assessment visit

A random sample of doctors’ bags and other emergency drugs is checked.

Medicines 3.4 Assessors’ guidance

All drugs should be in date and the doctors should be questioned on the system for keeping them up to date.

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Medicines indicator 4

The number of hours from requesting a prescription to availability for collection by the patient is 72 hours or less (excluding weekends and bank/local holidays)

Medicines 4.1 Practice guidance

Practices should provide a reasonably fast service for their repeat prescriptions. Details of how the practice’s system works should be contained in the practice leaflet. If the practice can deliver the service in 48 hours, another indicator is also achieved (Medicines indicator 8).

Medicines 4.2 Written evidence

The practice leaflet or policy is available. (Grade A). The receptionists are questioned on the policy.

Medicines 4.4 Assessors’ guidance

The assessors should check that the system for issuing repeat prescriptions can be described by the receptionists and should observe it in action.

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Medicines indicator 6

The practice meets the PCO prescribing adviser at least annually and agrees up to three actions related to prescribing

Medicines 6.1 Practice guidance

If the PCO prescribing adviser is unable to visit within the year and there has been no contact with another PCO-recognised source of prescribing advice within the year, then the practice is exempt from this indicator. In that circumstance, the practice should provide written confirmation from the PCO prescribing adviser that he or she has been unable to visit within the relevant year.

Three actions agreed with the PCO prescribing adviser should be produced, or written confirmation from the PCO prescribing adviser that he or she has been unable to visit within the relevant year. (Grade A)

Medicines 6.3 Assessment visit

The actions should be discussed.

Medicines 6.4 Assessors’ guidance

This indicator will be considered to have been met if the prescribing advisor and the practice have reached agreement on the action points.

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Medicines indicator 8

The number of hours from requesting a prescription to availability for collection by the patient is 48 hours or less (excluding weekends and bank/local holidays)

Medicines 8.1 Practice guidance

Patients tend to prefer a reasonably fast service for their repeat prescriptions. Details of how the practice’s system works should be contained in the practice leaflet. If the practice can achieve this in 72 hours, then another indicator is achieved (Medicines indicator 4).

Medicines 8.2 Written evidence

The practice leaflet or policy is available (Grade A). The receptionists are questioned on the policy.

Medicines 8.4 Assessors’ guidance

The assessors should check that the system for issuing repeat prescriptions can be described by the receptionists and should observe it in action.

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Medicines indicator 10

The practice meets the PCO prescribing adviser at least annually, has agreed up to three actions related to prescribing and subsequently provided evidence of change

Medicines 10.1 Practice guidance

Normally, improvements should be demonstrated in all three areas. However, if good reasons can be presented by the practice for not having achieved improvements, then the practice can still achieve this indicator. The practice should be able to provide written support from the PCO prescribing adviser for its reasons for not achieving the areas in question.

If the PCO prescribing adviser is unable to visit within the year, then the practice is exempt. The practice should provide written confirmation from the PCO prescribing adviser that he or she has been unable to visit within the relevant year.

Medicines 10.2 Written evidence

Three actions agreed with the PCO prescribing adviser and evidence of change should be produced, and/or written support from the prescribing adviser for the reasons for not achieving change, or written confirmation from the PCO prescribing advisor that he or she has been unable to visit within the relevant year.

Medicines 10.3 Assessment visit

Actions and improvements should be discussed.

Medicines 10.4 Assessors’ guidance

Normally, improvements should be demonstrated in all three areas. However, if good reasons can be presented by the practice for not having achieved improvements, then the practice can still achieve this indicator. The practice should be able to provide written support from the PCO prescribing adviser for its reasons for not achieving the areas in question.

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Medicines indicator 11

A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed four or more repeat medicines

Standard 80%

Medicines 11.1 Practice guidance

Medication is by far the most common form of medical intervention. Four out of five people over 75 take a prescription medicine and 36% are taking four or more (Medicines and older people – supplement to the National Service Framework for older people, 2001). However, we also know that up to 50% of drugs are not taken as prescribed, many drugs in common use can cause problems and that adverse reactions to medicines are implicated in 5–17 per cent of hospital admissions.

Involving patients in prescribing decisions and supporting them in taking their medicines is a key part of improving patient safety, health outcomes and satisfaction with care. Medication review is increasingly recognised as a cornerstone of medicines management. It is expected that at least a Level 2 medication review will occur, as described in the Briefing Paper linked below:
http://www.npc.nhs.uk/review_medicines/intro/resources/5mg_medreview.pdf

The underlying principles of any medication review, whether using the patient’s full notes or face to face are:

  1. all patients should have the chance to raise questions and highlight problems about their medicines
  2. medication review seeks to improve or optimise impact of treatment for an individual patient
  3. the review is undertaken in a systematic way by a competent person
  4. any changes resulting from the review are agreed with the patient
  5. the review is documented in the patient’s notes
  6. the impact of any change is monitored.

Medicines DO NOT include dressings and emollients but would include topical preparations with an active ingredient such as steroid creams and ointments and hormone preparations.

Medicines 11.2 Written information

A survey of medication review should be undertaken (Grade A). This could be a computerised search and print out or a survey of 50 records of patients on four or more medications.

Medicines 11.3 Assessment visit

Inspection of records should be carried out.

Medicines 11.4 Assessors’ guidance

The assessors should ask the staff to demonstrate how the system works and in particular how an annual review is ensured.

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Medicines indicator 12

A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines.

Standard 80%

Medicines 12.1 Practice guidance

See Medicines 11.1

Medicines 12.2 Written information

See Medicines 11.2

Medicines 12.3 Assessment visit

See Medicines 11.3

Medicines 12.4 Assessors’ guidance

See Medicines 11.4

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Prepared By Jean Keenan