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CHAPTER2 Practicemanagement

Audit andresearch

Audit is dened as the systematic critical analysis of quality of healthcare. Its purpose is to appraise current practice (What is happening?) by measuring it against pre- selected standards (What should be happening?), to identify and implement areas for change (What changes are needed?) and thus improve performance. Audit is a continual process and an integral part of quality improvement activity (E p. 52).

Criterion- based audit: the audit cycle The process of identifying

areas of care to be audited, implementing necessary changes, and periodically reviewing the same issues is known as the audit cycle.

• Choosing a topic Any practice matter— clinical or administrative. Make sure

the topic is important, manageable, clearly dened, and data is available to assess the criteria chosen. Good starting points:signicant events, QOF targets, complaints, clinical guideline topics, and personal observations

• Choosing criteria Criteria are specic statements of what should be

happening. Criteria might be those laid down for quality payments, ‘gold standard’ care as dened in guidelines, or generated within the practice. Use evidence- based criteria wherever possible. All criteria have to be measurable— ideally with data already collected

• Setting standards Standards are minimum levels of acceptable

performance for a criterion. 100% achievement of standards is unusual so set realistic standards based on quality framework levels and standards achieved by other practices (e.g. comparative practice data, audits from other practices) or previous audits within the practice

• Observing practice You can collect information from:computer

registers; medical records; questionnaires— patients, sta, or GPs; data collection sheets (e.g. drugs in doctor’s bag are all in date)

• Comparing results with standards Consider why standards have not

been met— what should be done? Who’s going to do it? When? How?

• Repeating the audit cycle To ensure action taken is eective

Signicant event review Process in which individual episodes (when

there has been a signicant occurrence either benecial or deleterious) are analysed, in a systematic and detailed way to ascertain what can be learnt about the overall quality of care, and to indicate changes that might lead to future improvements. Methods of reporting— Table 2.1.

Table2.1 Methods forreporting signicant event audits

Reporting method 1 Reporting method 2

Description of event This should be brief and can be in note form

Learning outcome This should describe the aspects which were of high standard and those that could be improved. Where appropriate, it should include why the event occurred

Action plan The decision(s) taken need to be contained in the report. The reasons for these decisions should be described together with any other lessons learned from the discussion

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

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AUDIT ANDRESEARCH

What is thedierence betweenaudit and research? Research

is discovery of new knowledge. Research diers from audit as research aims to establish what best practice is globally; audit aims to discover how close practice is to best practice on a local level and identify ways of improving care.

Drug company research E p. 122

The research process GPs may be involved in research at many

levels— as part of an academic department, in a research general practice, or just by taking part in a project. If considering doing some research:

• Turn your idea into a specic research question What is your aim/

hypothesis? Review the literature. Is your idea novel? Why does it matter?

• Design the study and develop your methods Involve participants/ other

researchers. Qualitative/ quantitative methodology? Survey design/ sample size? How will you choose/ randomize participants? Who will do the work?

• Obtain permissions, funding, and Primary Care Research Network

(PCRN) acceptance Ask the healthcare trust in which the research will

be performed. Ensure that you contact the research governance ocer of the organization within which your research will be carried out, and comply with local and national requirements. Obtain ethics permission. Obtain funding to cover the costs of the study and sta required. Gain acceptance onto the PCRN (or another research network) portfolio

• Collect and collate data Remember data protection (E p. 47)

• Analyse and interpret data Consider involving a professional statistician

for quantitative data; think about the implications of the study ndings; identify how ndings can be put into practice

• Write up and disseminate ndings Journal articles; conference

presentations; press releases; submission for higher degrees

National Institute for Health Research (NIHR) Commissions

and funds NHS and Social Care research in England, and provides infrastructure to support both studies and researchers within the NHS. M www. nihr.ac.uk

University departments ofgeneral practice Every UK medical

school has a department of general practice. There are few GP academic posts but these departments are valuable sources of advice and support if you contemplate doing any original research of your own.

Ethics An ethics committee must pass all medical research involving

human participants. Information, contacts, and application forms are available from the Health Research Authority. M www.hra.nhs.uk

Funding Numerous sources of funding for primary care research are

available (including NIHR, RCGP, Medical Research Council, and Wellcome Trust) but all are keenly fought for. Contact your local medical school academic primary care department for advice and help if you are thinking of applying for research funding.

Further information

Healthcare Quality Improvement Partnership (2016) Best practice in clinical audit. M https:// www.hqip.org.uk/ resource/ best- practice- in- clinical- audit/

ALGRAWANY

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CHAPTER2 Practicemanagement

Outcomes ingeneralpractice

Within the NHS there are i demands for accountability/ improvements in quality of care. Measuring this requires use of appropriate outcomes.

Quality and Outcomes Framework Ep. 33

Patient satisfaction Implies meeting both the wants and the needs of

the patient. Satisfaction measures are increasingly being used to judge the eectiveness of the NHS. Surveys of satisfaction show 780% of patients are overall satised with GP care, but if questioned more specically about dierent components of care (e.g. information provided, communication, etc.), fewer than half are completely satised.

Revalidation Measuring patient satisfaction of ≥34 patients, using a validated tool approved by the GMC, is a requirement for GPs once in every 5y revalidation cycle. GPs must reect on results and address any development needs.

Peer feedback A tool widel y used in business to assess worker perform-

ance. It may take many forms from team meetings during which colleague feedback is encouraged, through annual appraisal by a practice manager to 360o or multisource feedback forms.

Revalidation Feedback from ≥15 professional colleagues representing the range of your professional activities using a validated multisource feedback (MSF) tool approved by the GMC is a compulsory element of revalidation and must be performed once in every 5y cycle. GPs must reect on results and address any development needs.

Comparative practice data The government’s ‘transparency agenda’

has resulted in publication of data held by government departments on the performance of public services including general practice. Data now in the public domain are listed in Box 2.3.

Box 2.3 Examples ofGP practice data available inthe publicdomain

• Local demography— age, ethnicity, deprivation

• Life expectancy of the practice population

• Overall QOF achievement

• QOF prevalence data, e.g. rheumatoid arthritis, DM, CVD

• Cancer care— new cancer cases, emergency cancer presentations,

cancer prevalence based on QOF data, cancer screening uptake rates

• Child health— A&E attendances, emergency and elective admissions,

outpatient attendances

• Antibiotic prescribing— prescribing rates, proportion of quinolones

and broad- spectrum antibiotics

• Patient satisfaction

• Clinical sta details— names and roles

• CQC inspection reports

• GP income

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OUTCOMES INGENERALPRACTICE

Referral rates There are wide variations in referral rates (3– 12/ 100

consultations) not accounted for by population characteristics. Experience in a specialty i referrals implying high referrers are not always inadequate.

Referral management schemes Attempts have been made to judge appropriateness of referrals either at practice or at locality level through referral management schemes. All referrals are scrutinized to judge whether the referral is needed at all, and (if referral is warranted) whether referral is being made to the most cost- eective service.

Prescribing rates There are wide variations in prescribing rates, e.g.

variation in the rate of statin prescription cannot be accounted for by population characteristics; prescription rates for antibiotics for minor illness vary widely between GPs. Whether and how these reect quality of care are controversial but comparison of practice prescribing data within localities and prescribing quality targets are used to drive down prescribing costs.

Procedures Comparisons of procedure outcome (e.g. inadequate smear

rates, diabetic outcome measures, immunization rates) between practices can be a way to identify individuals or practices clearly performing less well than others. The reasons must then be investigated.

Doctors’ ability todetect illness There are wide variations between

GPs in their ability to detect certain illnesses, e.g. mental illness. GPs adept at identifying mental health problems have:empathy, early eye contact, use directive rather than closed questioning; clarify the complaint at an early stage. Whether this is a marker of quality of care or just the diversity of general practice is debatable.

Compliance/ concordance E p. 116

Further information

National General Practice Proles M https:// ngertips.phe.org.uk/ pro- le/ general- practice RCGP Colleague feedback. M www.rcgp.org.uk/ training- exams/ prac- tice/ revalidation/ guide- to- supporting- information- for- appraisal- andrevalidation/ feedback/ colleague- feedback.aspx RCGP Patient feedback. M www.rcgp.org.uk/ training- exams/ practice/ re- validation/ guide- to- supporting- information- for- appraisal- and- revalidation/ feedback/ patient- feedback.aspx

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Chapter3

Consulting withpatients

The consultation 60 Consultation models 62 Telephone consulting and home visits 64 Referrals and electronic media 66 The doctor’s bag 68 Evidence-informed decision-making 70 Guidelines, protocols, and integrated care pathways 72 Breaking bad news 74 Conrmation and certication of death 76 Organ donation 78

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experience of illness

investigations

framework

Patient presents cues of

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CHAPTER3 Consulting withpatients

Theconsultation

Over the past 15y, in the UK, there has been a 40% i in demand for GP appointments. Each patient has an average of 5.5 appointments/ y. Older people have the highest consultation rate (those >80y have 13.5 appointments/ y), and the consultation rate is set to i as the population ages.

Potential barriers to eective communication Lack of time, lan-

guage problems, diering gender, age, ethnic or social background of doctor and patient, ‘sensitive’ issues to address, ‘hidden’ or diering agendas, prior dicult meetings, and lack of trust between doctor/ patient.

The consultation Good communication is essential for all aspects of

a GP’s work. The consultation is the cornerstone of general practice and focuses on successful information exchange. Various consultation models exist (E p. 62) to help GPs evaluate their consultations and make optimum use of the time available. There is no ‘correct’ way to perform a consultation. Approach will vary according to situation and participants.

Patient centredness Means that the patient’s viewpoint is considered and integrated into the diagnosis and decision- making process (Figure 3.1). It improves patient satisfaction and may improve health outcomes. It consists of 6 interactive components:

• Exploring the disease and illness experience

• Understanding the whole person in context

• Finding common ground regarding management

• Incorporating prevention and health promotion

unwellness

Disease

Doctor performs parallel

search of 2 frameworks

Illness

framework

History, physical

examination,

Dierential

diagnosis

Figure3.1 The patient- centred process

Doctor weaves back and forth

Understanding the

Integrated understanding

Patient’s ideas,

expectations,

feelings. Eect

on function

patient’s unique

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THECONSULTATION

• Enhancing the doctor– patient relationship

• Being realistic

Patient records E p. 44

Patient recall Many studies suggest that >50% (some estimate up to

90%) of information has been forgotten within a few minutes of leaving the surgery. Characteristics of memorable information:

• The patient perceives it as important

• The patient understands it (avoid the use of jargon and medical terms,

keep language brief and simple, support information with sketches/ diagrams ± patient information sheets)

• The information is given early in the consultation

• The information is given in small chunks (not too much at once)

Consultation length Although consultations are usually booked at

10min intervals in the UK, average consultation length is now 11.7min. Instead of managing acute illness, GPs now focus on management of long- term conditions and multimorbidity, resulting in i complexity of consultations. Despite this, UK consultations are still a third shorter than those in most other parts of the world, e.g. the USA, Switzerland, New Zealand, Belgium, and Australia.

Timekeeping Running late is stressful and frustrating for patients.

General practice does not t conveniently into 10min (or any other size) slots. Even the best time keepers occasionally run late. Tips:

• Endeavour to run to time Start on time; make appointments long enough

(e.g. book double appointments for dicult problems, schedule catch- up slots in the middle of surgeries, change to longer appointments); break dicult problems or multiple problems up into chunks

• If you are running late Ask reception sta to apologize to patients as

they check in, and tell them the expected delay

Benets of longer consultation times Include:

• i patient and doctor satisfaction • i health promotion

• i detection of psychosocial problems • d reconsultation rates

• Improved doctor– patient communication • d minor illness prescribing

‘Dicult’ patients Characterized by: frequent presentation— the top

1% of attenders at GP surgeries generate 6% of GP workload; highly complex, often multiple problems— some explicable, others not; and exasperation generated between patient and doctor

0 This is a two- way process. Some GPs report more dicult patients than others. The problem relates to the GP’s perception of patients as well as the patients themselves.

Management strategy Do a detailed review of notes ± chart of life.

• Agree contacts (e.g. limit to 1 GP, agree appointment frequency)

• Agree an agenda within consultations, e.g. problem list— 1 problem/ visit

• Employ reattribution techniques— see Somatization disorder, E p. 975

• Avoid unnecessary investigation and referral

• Be aware of your own reaction to the patient

• Acknowledge that such patients may be genuinely ill

• Consider psychiatric diagnoses— especially chronic anxiety, depression,

somatization disorder. Screening questionnaires can be useful

• Consider referral for CBT and/ or specialist mental health support

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CHAPTER3 Consulting withpatients

Consultationmodels

Consultation models are not rules; they provide a toolkit of dierent techniques for GPs to apply to their consultations. Abrief overview of the most commonly used models is presented here— for more information, consult the original texts:

The medical model Traditional medical school model. History taking

l examination l investigation l diagnosis l treatment l follow- up. Does not recognize the complexity/ diversity of the consultation in general practice.

Balint, 1957 The Doctor, His Patient and The Illness— a philosophy rather

than a consultation model:

• Psychological problems are often manifested physically

• Doctors have feelings. Those feelings have a role in the consultation

• Doctors need to be trained to be more sensitive to what is going on in

the patient’s mind during a consultation

Reference:Churchill Livingstone; ISBN:0443064601.

Berne, 1964 Games People Play— describes how to recognize behaviours

(‘games’) patients might use and roles patient and doctor might adopt— ‘Parent, Adult and Child’.

Reference:Penguin Books; ISBN:0140027688.

RCGP, 1972 The triaxial approach— physical, psychological, and social

aspects of the consultation.

Reference:Working party of the RCGP, 1972.

Becker and Maiman, 1975 Health Belief Model— Involves exploration

of ICE— Ideas, Concerns, and Expectations of the patient. 5 elements:

• Health motivation

• Perceived vulnerability

• Perceived seriousness

Reference:Med Care 1975;13:10– 24.

Byrne and Long, 1976 Doctors talking to patients— 6 aspects:

1. Doctor establishes a relationship with the patient

2. Doctor attempts to/ actually discovers the reason for attendance

3. Doctor conducts verbal ± physical examination

4. Doctor, or doctor + patient, or patient consider the condition

5. Doctor (or occasionally the patient) details treatment and investigation

6. Consultation is terminated— usually by the doctor

Reference:RCGP; ISBN:0850840929.

Stott and Davis, 1979 Exceptional potential of the consultation. 4 tasks:

1. Management of presenting problems

2. Management of continuing problems

3. Modication of help- seeking behaviour

4. Opportunistic health promotion

Reference:JRCGP 1979;29:201– 5.

• Perceived costs/ benets of an action

• Cues to action— stimuli/ triggers for beliefs

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CONSULTATIONMODELS

Helman’s folk model, 1981 Disease vs illness in general practice:

• What has happened?

• Why has it happened?

• What would happen if nothing were done about it?

• What should Ido and who should I consult for further help?

Reference:JRCGP 1981;31:548– 52.

• Why to me?

• Why now?

Pendleton etal., 1984 The doctor’s tasks:

• Dene the reason for patient’s attendance

• Consider other problems— continuing problems and risk factors

• Choose an appropriate action for each problem— involves negotiation

between doctor and patient

• Achieve a shared understanding of the problem between doctor/ patient

• Involve the patient in the management and encourage the patient to

accept appropriate responsibility

• Use time and resources appropriately

• Establish and maintain a relationship between doctor and patient

Reference:Oxford University Press; ISBN:0192632884.

Neighbour, 1987 The Inner Consultation. Checkpoints:

• Connecting— doctor establishes rapport with the patient

• Summarizing— doctor claries the patient ’s reason for consulting

• Handing over— doctor/ patient negotiate and agree a management plan

• Safety netting— planning for the unexpected; managing uncertainty

• Housekeeping— doctor is aware of his/ her own emotions

Reference:Petroc Press; ISBN:1900603675.

Fraser, 1992 and 1999 Areas of competence:

1. Interviewing and history taking 5. Relating to patients

2. Physical examination 6. Anticipatory care

3. Diagnosis and problem- solving 7. Record- keeping

4. Patient management

Reference:Butterworth Heinemann; ISBN:0750640057.

Kurtz and Silverman, 1996 and 2002 Calgary— Cambridge

Observation Guide. 5 tasks:

1. Initiating the session 4. Giving information— explaining and planning

2. Gathering information 5. Closing the session

3. Building the relationship

Reference:Med Educ 1996;30:83– 9 and Acad Med 2003;78(8):802– 9

Warren, 2002 4 avenues of consultation analysis (BARD):

• Behaviour— non- verbal and verbal— needs of patient/ personality of GP

• Aims— purpose of the consultation and priorities

• Room— setting for the consultation

• Dialogue— tone of voice, what is said, etc.

Reference:Update 2002;5 Sept:152– 4.

Further information

Bradford VTS. Consultation models. M www.bradfordvts.co.uk

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