Glasgow LMC Limited Glasgow LMC & NHS GG&C GMS Contract Meeting 6 th June 2013 LMC CENTENARY YEAR 1913 - 2013

Glasgow LMC Limited

Glasgow LMC & NHS GG&C

GMS Contract Meeting

66thth June 2013 June 2013

LMC CENTENARY YEAR1913 - 2013

Glasgow LMC Limited

Agenda7.00 pm Welcome and Introductions

Dr Michael Haughney - Chairman, LMC

7.05 pm Scottish Patient Safety Programme

Climate Survey

Dr Paul Ryan - Clinical Director, Glasgow City CHP (NE Sector)

Trigger ToolRachel Bruce – Lead Clinical Pharmacist, Interface Pharmacist

7.30 pm Anticipatory Care Planning

Why? What?How? When?

Dr John Nugent – Clinical Director, Glasgow City CHP (NW Sector)

7.50 pm QoF Clinical Domain

Dr John Ip – Medical Secretary, Glasgow LMC

8.10 pm Questions – Panel Discussion

Dr Paul Ryan, Rachel Bruce, Dr John Nugent, Dr John Ip, Tom Clackson GMS Contracts Manager

8.30 pm Close

Scottish Patient Safety Programme -Safety Climate SurveyDr Paul Ryan, Clinical Director, NE Sector Glasgow City CHP6th June 2013

National Objectives

•To reduce the number of events which cause avoidable harm to people from healthcare delivered in any primary care setting.

•All NHS territorial boards and 95% of primary care clinical teams will be developing their safety culture and achieving reliability in 3 high-risk areas by 2016.

Work streams Interventions relating to

1.Safer Medicines •Safe and reliable prescribing, monitoring and administration of high alert medications (e.g. DMARDs, warfarin, insulin, lithium•Reducing high risk prescribing – data / alerts•Medication reconciliation

2.Safe and reliable patient care across the interface and at home.

•Management of test results•Communication at point of referral •Handling written communication

3.Leadership and Safety Culture

•Promoting a culture of safety and learning using Trigger Tool, Safety Climate Survey, safety walk rounds•Promoting organisational learning from Significant Event Analysis (SEA)•Building capacity and capability to support the programme•Ensuring patients become partners in making care safer.

Guidance Patient Safety Indicators

Indicator Points

PS 1 The practice conducts two case note reviews, using a validated tool, to detect patient safety incidents, meets to discuss the results, and shares a reflective report on actions and themes that arise from this with the Health Board

6

PS 2 The practice conducts a safety climate survey with all staff,clinical and non-clinical, using a validated tool, meets to discussthe results, and shares a reflective report on actions that arise

from this with the Health Board 5

Adverse Event Causation

AccidentCausation

Technical Factors

Human Factors

SafetyCulture

OperatorBehaviour= +

(30-20%)

(70-80%)

What is Safety Culture?

Why is a strong Safety Culture Important?

A strong safety culture essential to safe reliable care in any workplace

Francis Report and Culture • There was an atmosphere of fear of adverse repercussions

• There was a lack of openness

• It did not listen sufficiently to its patients and staff or correct deficiencies highlighted

• Above all it failed to tackle an insidious negative culture involving tolerance of poor standards

How does the SafeQuest Safety Climate Survey work in practice?

Safety Climate Survey• On line• Practice centred• Measurement• Diagnosis• Catalyst for change

5 key factors:• Teamwork• Workload

• Communication• Leadership

• Safety systems and learning

Not the Safety Climate Survey!

Distribute- who to?

• We recommend that all practice staff and anyone involved in or considered part of the practice team complete the survey. However, it remains the discretion of individual practices to decide who they invite to participate.

“Weren’t as good as we thought we were”

“Mismatch between what the clinical and non clinical staff thought”

“Prompted some very open discussion”

Increased frequency of staff meetings.At least one doctor to attend staff meeting.2 way communication over a variety of issues.Newsletter/minutes after each meeting.Quarterly meeting involving whole practice.

Positive Change

Reflection Sheet• What positive aspects of your team’s safety culture were highlighted in

the report and your discussions?

• What aspects of your safety culture do you as a team feel you could improve?

• What steps will you take to improve these aspects of your safety culture?

• What else might you change to improve your safety culture?

• Would you like any support or guidance to make changes in your practice? If so, what would be useful?

Climate Survey

http://www.healthcareimprovementscotland.org/safetyclimate.aspx

http://gpsafetyclimate.com

http://www.healthcareimprovementscotland.org/safetyclimate.aspx

http://gpsafetyclimate.com/

Knowledge Page

http://www.knowledge.scot.nhs.uk

http://www.knowledge.scot.nhs.uk/

Quality Education for a Healthier Scotland

Medicine

Safety & Improvement in General Medical Practice

Trigger Review of Clinical Records

“The Trigger Tool”

Dr Rachel Bruce

Lead Clinical Pharmacist – Interface Prescribing

Presenting on behalf on NES!


Medicine

Content and Purpose of Session

Content

• What is the Trigger Tool?

• Trigger Review Documentation

• What do you need to do?

Purpose

• To describe the Trigger Review concept and provide brief overview in applying the method

• Signpost you to the experts!

Learning outcomes

• Understand the principle of the Trigger Review Method

• Know where to access the relevant support/documentation


Medicine

Why?


MedicineContext

• Patient Safety• The trigger review process forms part of the Scottish

Patient Safety Programme in Primary Care• Incorporated into the 2013/14 GMS contract: “patient

safety” indicators• PS1 (Quality Improvement) = “trigger tool” review• 6 points


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The “Trigger Tool”


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What is the Trigger Tool?

A simple checklist for a number of selected clinical “triggers” The trigger tool facilitates a rapid structured, focused review of a selected

sample of clinical records in the practice

Using these “triggers” can potentially identify previously undetected patient safety incidents


Medicine

Safety Incidents in GP – Feedback Sources e.g.

Patients

Clinical Records

Incident ReportingOmbudsman Reports

Colleagues

Self-report

Complaints

SEA

Pharmacist


Medicine

What is a trigger review of clinical records?

• Trigger review is simply a method of audit that involves the systematic evaluation of a small batch of patient records by a clinician (GP or Practice Nurse)

• A ‘Trigger’ is a pre-defined prompt or sign in the record that MAY indicate that a patient safety incident has occurred – roughly defined as any incident, however minor, where a patient was harmed, may have been (i.e. a near miss), or could be in future (i.e. a latent risk)

• Detected Trigger(s): a signal for the reviewer to undertake a more in-depth review of the record to determine if evidence of a safety incident exists

• For example, an INR>5.0 (a trigger) was detected by a clinical reviewer - further review of the record found evidence of the patient having suffered a bleed and being admitted to a local hospital (a patient safety incident)

• If a safety incident is uncovered, the reviewer makes a professional judgement on whether it was avoidable or not, how severe it was and if it originated in primary care or elsewhere

• This grading helps to pinpoint incidents where learning and improvement are a greater priority - may be necessary if multiple incidents are detected


Medicine

What are the “Triggers” in Clinical Records?

‘‘Triggers’’ are defined as easily identifiable flags, occurrences or prompts in patient records that alert reviewers to actual or potential safety incidents

(undetected)

Sections in GP Records Triggers

Clinical encounters (documented consultations)

≥3 consultations in 7 consecutive days

Medication-related (acute and chronic prescribing)

Repeat medication item stopped

Clinical read codes High, medium, low, allergies

New ‘high’ priority or allergy read code

Correspondence SectionSecondary care, other providers

OOH / A&E attendance / Hospital admission

Investigations Requests and results

eGFR reduce <5, Hb < 10.0, INR > 5.0


Medicine

Detecting Patient Safety Incidents in GP Clinical Records: Proof of Principle

• Two GPs reviewed 500 randomly selected electronic patient records (100 x 5 Scottish GP practices): 12-month period.

• Clinical triggers developed and tested help to pinpoint safety incidents

• 9.5% of records contained evidence of unintentional harm to patients

• 60+% were judged to be preventable

• Most cases low to moderate severity, all severe cases originated in secondary care

• Scope for safety-related learning and improvement (in the same way as SEA or Audit)

De Wet & Bowie, Postgraduate Medical Journal, 2009


MedicinePS1 Indicator: Quality Improvement

1.1. Aim: to identify and reduce patient safety incidents within practices

1.2. Background: use of rapid structured case note review using a trigger tool in high risk patient groups can identify patient safety incidents and near misses which practice teams can learn from and so reduce the risk of future patients from being harmed


Medicine

When and What do we need to do?

1.3 Using the NES primary care Trigger Tool each practice will complete a structured case note review twice in 2013/14, at least three months apart

Review to be conducted on 25 patients each time (x 2) from the recommended risk groups:

• Patients on DMARD therapy

• Patients with diagnosis of Left Ventricular Systolic Dysfunction

• Patients on Warfarin therapy

• Patients with a higher SPARRA score e.g over 40

• Recent admissions with COPD Care home residents

• Patients on chronic District nursing caseload

• Patients aged 75 years on 6 or more medications


Medicine

How do we do it - The trigger tool process

STEP 1: Planning and preparation

STEP 2: Review a random sample of records

STEP 3: Reflection and further action


Medicine


Medicine


MedicineStep 1: Plan

- Decide on patient group e.g. patients on warfarin- Run search and randomly select 25 patients- Decide if you want to add an optional trigger e.g

acute Rx of a NSAID- Agree the time frame to look for triggers. This should

ideally be a 3 calendar month period with a preceding month’s gap from the current date (for example in Sep 2012 I looked at May, June and July 2012 time frame)

- Identify who will undertake the trigger tool review


Medicine

Step 2: Review. How to Undertake a Trigger Review

When examining a record, the reviewer looks to answer the following 5 questions:

1. Can triggers be detected? • If yes, the reviewer examines the relevant section of the record in more detail to

determine if the patient came to any harm. • If no, move onto the next record - average review time is 2 to 3 minutes

2. Did harm occur? • If yes, move onto the next question on the proforma sheet. • If none is detected, move onto the next record.

After 20 minutes if unable to decide if harm occurred you ignore the record and move on.

3. What was the severity of harm detected?• The reviewer should rate the severity of every incidence detected

4. Was the detected harm incident preventable?• The reviewer should determine whether the detected incident was preventable - based on

a combination of evidence found and professional judgement.

5. Where did the harm incident originate?• The circumstances leading to the incident may have originated in primary or secondary

care, or a combination of both.


Medicine


Medicine

Step 3: Reflect

Reflection can be at different levels and is the most important part of the trigger review process

Patient level: acknowledge, apologise, audit, consider interventions to prevent recurrence

Practitioner level: identify any PDP/CPD needs, complete TT process, submit for appraisal

Practice level: share, reflect, discuss findings, prioritise any incidents and possible interventions, compare findings to previous reviews

Interface: should any incidents be reported through local or national systems

The indicator requires practices meet to discuss the results, and share a reflective report on actions and themes that arise from this with the Health Board.


Medicine

Repeat the process (steps 1-3) on your chosen patient group (25 different patients) after a minimum time period of 3 months has elapsed


Medicine

Examples of improvements made during trigger review:

1. Nephrotoxic medication discontinued.

2. Drug dosage (warfarin) adjusted.

3. Referral letter to secondary care done (x3).

4. Allergy or adverse reaction code updates.

5. Medication reviews done.

6. Medication adjustments made.

7. Initiated follow up appointment for patients requiring review.

8. Cardiotoxic drug discontinued.

9. Updated notes with investigation.

10. Follow up blood test arranged.


Medicine

To Summarise…..

• Quick and Structured

• Clinical triggers help you to navigate your records quickly

• Looking for evidence of (undetected) safety incidents/latent risks

• Reflection, learning and improvements made following the trigger review is the key part of the process - help you direct safety-related learning and improvement

• Links with SEA and Quality Improvement

• Evidence for QOF, Appraisal and GPST etc.

• Tested with large groups of GPs, Practice Nurses and GP Trainees


Medicine

…and finally

• The focus is patient safety incidents and not error. Ask yourself: ‘Would I have wanted this to happen to me or my family?’

• Only review the specific period in the record (3-months).

• Choose full calendar months to facilitate the review.

• The maximum time spent on reviewing any record should be twenty minutes. The objective is to detect ‘obvious’ problems, rather than every single episode.

• Most records do not contain triggers or evidence of incidents – these only take a few minutes to review

• If there is reasonable doubt whether a safety incident occurred, the incident should not be recorded.

• Use the team to assist in searching (admin) for and reviewing (nurse) records


Medicine

Resources

ONLINE RESOURCES:http://www.healthcareimprovementscotland.org/our_work/patient_safety/

spsp_primary_care_resources/trigger_tool.aspx

http://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/patient-safety-and-clinical-skills/tools-and-techniques/safety-and-improvement-in-primary-care.aspx#Trigger%20Tool

TRAINING: Glasgow City CHP RCGP Quality Improvement Training – 13th June 2013. Hampden Park

THE EXPERTS!

Dr Carl de Wet: [email protected] John McKay: [email protected] Paul Bowie: [email protected]

mailto:[email protected]

Anticipatory Care Planning

6th June John Nugent

Clinical Director

51

Guidance to date

• Document 4: December/January• ACP ‘Summary Guidance…’ April/May • Scottish QOF Guidance May

52

Document 4

• Improving Care for Patients at High Risk of Emergency Admission

• ‘…appropriate ACP can improve the quality of care, reduce the risk of medication harm and either (or both) the number of future admissions and lengths of stay…’

• ‘As poly-pharmacy can significantly increase the risks (of admission/harm)…it has been agreed as appropriate to include’

53

Document 4

• Support to practices;• ACPs uploaded/accessed/utilised (added to?)• Support Community Nursing Teams (members of

the primary care team) to participate in developing ACPs and attending MDTs

• Prescribing support…to participate in poly-pharmacy reviews

• Data on bed days utilisation• Local development support

54

‘Summary Guidance’

• Improving the quality of care;• ‘Anticipatory care planning encourages people

to adopt a ‘thinking ahead’ approach and to have greater control and choice by planning for what their preferred support and care interventions would be in the event of a future flare-up or deterioration in their condition, or a carer crisis.’

55

Summary Guidance

• Identifying patients for ACP and Poly-pharmacy Reviews

• Using a SPARRA risk threshold of between 20% and 60% will generate a cohort of around 5% of patients in the practice to fulfil the QP006 indicator

• Working down from an ‘upper ceiling’ of those with a 60% risk score will enable the practice to improve outcomes for people most likely to benefit from an Anticipatory Care Plan and a poly-pharmacy review.

• This will complement other local ACP initiatives that target cohorts with greater than 60% SPARRA risk

56

Summary guidance

• Patients < 60% SPARRA risk more likely to be engaged with the practice team than active on the community nursing caseload i.e. mobile

• Interventions < 60% represent earlier intervention likely to reduce escalation of dependency and to optimise adherence to medicines.

57

Summary Guidance

• Scope to apply clinical judgement to what constitutes 'at risk of emergency admission' ; may be patients who would benefit from an ACP but do not have a risk score within the risk thresholds specified

• The Key Information Summary (KIS); tool by which practices create and share (with consent) ACPs

• Summary of medical history/patient wishes, replaces paper based faxing between GPs and OOH

• More generic version of the electronic Palliative Care Summary (ePCS).

58

Summary Guidance• Current ePCS patient information will transfer

automatically to KIS but needs checked once KIS is switched on (ePCS patients that transfer automatically to KIS will not count as part of the cohort required for QP006 and QP007)

• NHS24, SAS, A&E, OOH and Acute Admission Areas already have access to KIS

• Access in other acute areas/departments depends on Board PMS systems and clinical portal developments

• Flow chart included

59

Poly-pharmacy

• 50% drugs not taken as prescribed

• 5-17% admissions due to adverse reactions

• If on multiple medications more side effects

• Potential harm of drug may outweigh benefit

QOF QP; QP004(S), 7 points

• QP004(S). The contractor meets internally to review data on emergency admissions, for patients on the contractor's registered list, provided by the NHS Board and the learning from at least 25 per cent of the Anticipatory Care Plans (ACPs) completed for QP007(S)

• Template for reporting will be agreed nationally

61

QOF QP; QP005(S), 17 points• QP005(S). The contractor participates in an

external peer review with either a group of local practices, or practices from within the board area, to compare its data on emergency admissions and to share the learning from at least 25 per cent of the Anticipatory Care Plans (ACPs) completed for QP007(S), and proposes areas for internal practice improvement and service design improvements for the NHS Board.

62


• QP006(S). The contractor produces a list of 5 per cent of patients in the practice, who are predicted to be at significant risk of emergency admission or unscheduled care. This list can be produced using a risk profiling tool accessible to practices e.g. SPARRA, or where this is not available/required (by local agreement), alternative arrangements can be agreed between the NHS Board and LMC. 63

QOF QP; QP007(S), 30 points• QP007(S). The contractor identifies a minimum of 15 per cent (in 2014/15, 30 per cent) of those patients from the list produced in indicator QP006(S) who would most benefit from an Anticipatory Care Plan (the ACP must include a poly-pharmacy review), be shared with the local out of hours service and has an appropriate review date. The frequency of each patient’s review should be determined in the light of their clinical and care needs. The contractor will be responsible for ensuring that an appropriate system is in place for monitoring and reviewing the patients identified in this cohort.

64


• QP008(S). The contractor holds at least 4 meetings during the year to review the needs of the relevant patients in the practice ACP cohort, to agree any required changes in the patient management and to share learning/ identify learning needs. These meetings should be open to multi-disciplinary professionals who support the practice’s patients 65

QOF QP; QP009(S), 10 points• QP009(S). The contractor produces and submits a report to the Board before 15 March 2014 on internal practice and wider NHS Board system changes that may benefit patients with Anticipatory Care Plans (ACPs). The report should include Significant Events Reviews (SERs) on 1/1000, to a maximum of 3 patients per practice, of patients with ACPs from the cohort in QP007(S), who were admitted during the QOF year, after their ACP had been created. If less than the required number of patients with ACPs were admitted during the QOF year then the practice should write SERs of the care of an equivalent number of these patients who remained in the community.

66

Summary

• Patient centred care; closer to home, reduced harm

• Carers; communication, support• Practices; supports review, professionally

satisfying, reduces ‘chaos’ (use)• Boards; reduced admissions/lengths of stay• Improves interface working• Not about keeping anyone out of hospital who

needs hospital

67

Issues - now

• SPARRA; ‘push not pull’• Review and decide who would most benefit• See in surgery/home• KIS; EMIS now, VISION 2 weeks• MDTs; membership, review• Poly-pharmacy review; overlap with LES• ‘Face-to-face’

68

Poly-pharmacy; overlap with LES• Practices should generally only make one claim for payment

for a poly-pharmacy medication review, per patient, during 2013/14

• Exceptional cases may arise when an ACP/PP should be developed after a Poly-pharmacy LES review has occurred or vice versa

• Payment can only be claimed on behalf of the same patient for a Poly-pharmacy LES and a ACP poly-pharmacy medication review during 2013/14 if;

a. there are 2 distinct reviews recorded in the patient’s recordb. there is clear clinical justification to demonstrate the need for

a repeat review for the same patient during the lifetime of the 2013/14 Poly-pharmacy LES

Clinical Justification• The clinical justification would include a change in a patient`s

clinical status due to one or more of the following occurring;

1. Hospital admission at least 1 month after the first poly-pharmacy review (ACP/PP or PP LES) had taken place

2. New clinical diagnosis

3. Deterioration in existing clinical condition requiring 3 or more either changes to drug or drug dose (oral or parenteral medication only)

4. Patient needing to go onto the palliative care register

Issues - later

• Role of DN/PN/Pharmacy support?

• Learning?

• Board support?

71

Information held on KIS

• Significant Diagnoses and PMH• Prognosis• Medication and allergies• Current Care Needs• Help at home (e.g. Social Services / Care Packages)• Legal Issues (e.g. AWIA, Power of Attorney)• Preferred Place Care• End of Life Care wishes• DNA-CPR information• Free-text Anticipatory Care Plan

Example of a KIS which has been developed over a period of time?

Summary of main issues


Plan of action in event of a deterioration



Medication that can be used as PRN




Details of other professionals involved in care




Details of other professionals involved in care

Contact details of family member

Information available on KIS

Glasgow LMC

QOF Clinical Domain2013/14

Dr John Ip

Glasgow LMC

QOF Changes

• New Domain- Rheumatoid New Domain- Rheumatoid ArthritisArthritis

• New Clinical IndicatorsNew Clinical Indicators• Increases in thresholdsIncreases in thresholds• All 15 month targets now 12 All 15 month targets now 12

monthsmonths• Numbering changesNumbering changes

Glasgow LMC

New Work

• Rheumatoid Arthritis domainRheumatoid Arthritis domain• 4 indicators- 18 points4 indicators- 18 points• Register (1 point)Register (1 point)• Review (5 points)Review (5 points)• CVD Risk (7 points)CVD Risk (7 points)• Fracture Risk (5 points)Fracture Risk (5 points)

Glasgow LMC

New Clinical Indicators• DM dietician review, referral to DM dietician review, referral to

Structure learning programmeStructure learning programme• DM- ED screening, advice & DM- ED screening, advice &

treatmenttreatment

• COPD- OCOPD- O22 sat for Grade 3 and above sat for Grade 3 and above

• Depression- BPS assessment for new Depression- BPS assessment for new patients, 10-35 day review after patients, 10-35 day review after diagnosisdiagnosis

Glasgow LMC

New Clinical Indicators

• CVD-PP SCOT-PASQ for patients CVD-PP SCOT-PASQ for patients with HT diagnosed after 1 April with HT diagnosed after 1 April 20092009

• Smoking- transfer from Smoking- transfer from Information 5Information 5

Glasgow LMC

Atrial Fibrillation

AF001 5 Register. No change from AF1 AF002 10 CHADS2 Score. 15 to 12

months (AF5)AF003 6 Score 1 on anti-coag or anti-

platelet. 15 to 12 months (AF6)

AF004 6 Score >1 on anti-coag or anti-platelet. No change from AF7

Glasgow LMC

Secondary Prevention of CHD

CHD001 4 Register. No change from CHD1

CHD002(S)

17 BP <150/90. 15 to 12 months and threshold 40-75% to 50-85% (CHD6)

CHD003(S)

17 Chol <5. 15 to 12 months and threshold 40-75% to 50-85% (CHD8)

CHD004(S)

7 Flu. No change from CHD12

CHD005(S)

7 Aspirin, anti-platelet, anti-coag.15 to 12 months (CHD9)

CHD006(S)

10

MI- ACE, aspirin, BB, statin. No change from CHD14

Glasgow LMC

Heart Failure

HF001 4 Register. No change from HF1

HF002 6 Echo. Specifies 3mth prior to 12 mth after entering register (HF2)

HF003 10 LVSD- ACE or ARB. 45-80% to 50-85% (HF3)

HF004 9 LVSD- BB. 40-65% to 50-75%

Glasgow LMC

Hypertension

HYP001 6 Register. No change from BP1

HYP002 55 150/90 or less (9 months). No change from BP5BP4 gone- record of BP last 9 months. 8 points

Glasgow LMC

Peripheral Arterial Disease

PAD001 2 Register. No change from PAD1

PAD002 2 BP <150/90. 15 to 12 months (PAD3)

PAD003 3 Chol <5. 15 to 12 months (PAD4)

PAD004 2 Aspirin or alternative. 15 to 12 months (PAD2)

Glasgow LMC

Stroke and TIASTIA001 2 Register. No change from Stroke1STIA002(S)

2 Record of referral 3 months before to 1 month after entering latest recording. 45-80% to 50-90% (Stroke13)

STIA003(S)

5 BP<150/90. 15 to 12 months (Stroke6)

STIA004 2 Chol reading. 15 to 12 months (Stroke7)

STIA005 5 Chol <5. 15 to 12 months (Stroke8)

STIA006(S)

2 Flu. 45-85% to 50-90% (Stroke10)

STIA007(S)

4 Anti-platelet. No change from Stroke12

Glasgow LMC

Diabetes MellitusDM001 6 Register. No change from

DM32DM002(S) 8 BP <150/90. 15 to 12 months

(DM30)DM003(S) 10 BP <140/80. 15 to 12 months

(DM31)DM004 6 Chol <5. 15 to 12 months

(DM17)DM005 3 Change from

microalbuminuria test to albumin:creatinine ratio test. 15 to 12 months (DM13)

DM006(S) 3 Nephropathy or micro-alb- ACE. 45-85% to 50-90% (DM15)

Glasgow LMC

Diabetes MellitusDM007(S) 1

7HBA1c < 59. 15 to 12 months (DM26)

DM008(S) 8 HBA1c <64. 15 to 12 months (DM27)

DM009(S) 10 HBA1c <75. 15 to 12 months (DM28)

DM10(S) 3 Flu. 45-85% to 50-90% (DM18)DM11 5 Retinal Screening. 15 to 12

months (DM21)DM12 4 Foot exam & risk

classification. 15 to 12 months (DM29)

Glasgow LMC

Diabetes MellitusDM13 3 NEW- Annual Dietician review

(all)DM14 11 NEW- Referral to Structured

Learning Programme (newDM15 4 NEW- Erectile Dysfunction

ScreeningDM16 6 NEW- ED Advice and Treatment

Glasgow LMC

HypothyroidismTHY001 1 Register. No change from

Thyroid1THY002 6 TFTs. 15 to 12 months

(Thyroid2)

Glasgow LMC

AsthmaAST001 4 Register. No change from

Asthma1AST002 15 Variability or reversibility

testing of 3 months before or anytime after diagnosis (Asthma8)

AST003 20 Asthma Review in past 12 months. No change from Asthma9

AST004 6 Smoking status 14-20 years. 15 to 12 months (Asthma10)

Glasgow LMC

COPDCOPD001 3 Register. No change from

COPD14COPD002 5 Spirometry between 3 mths

before and 12 mths after entering register (COPD15)

COPD003 9 Annual Review 15 to 12 months (COPD13)

COPD004(S)

7 FEV1. 15 to 12 months. 40-75% to 50-85% (COPD10)

COPD005 5 NEW- Grade 3 and above O2 Sats in past 12 months

COPD006(S)

5 Flu. 45-85% to 50-90% (COPD8)

Glasgow LMC

DementiaDEM001 5 Register. No change from

DEM1DEM002 15 Face to face review. 15 to 12

months (DEM2)DEM003 6 New diagnosis blood tests. No

change from DEM4

Glasgow LMC

DepressionDEP001 2

1NEW- Bio-Psychosocial Assessment at Diagnosis

DEP002 10

NEW- Review of patient between 10 days and 35 days after diagnosis

Glasgow LMC

Mental HealthMH001 4 Register. Includes other

patients on Li therapy (MH8)MH002 6 Care Plan. 15 to 12 months.

30-55% to 40-90%MH003 4 BP reading. 15 to 12 months

(MH13)MH004 5 Chol:HDL ratio. 15 to 12

months (MH19)MH005 5 Blood Glu or HBA1c. 15 to 12

months (MH20)

Glasgow LMC

Mental HealthMH006 4 BMI reading.15 to 12 months

(MH12)MH007 4 Alcohol. 15 to 12 months

(MH11)MH008(S) 5 Cervical Screening. No change

from MH16MH009 1 Lithium- creatinine and TFT in

past 9 months. No change from MH17

MH010 2 Lithium therapeutic range 4 months. No change from MH18

Glasgow LMC

CancerCAN001 5 Register. No change from

Cancer1CAN002 5 Change of time period of

cancer diagnosis within preceding 15 months from 18 months. Patient review recorded within 3 months instead of 6 months. (Cancer3)

Glasgow LMC

Chronic Kidney DiseaseCKD001 6 Register. No change from

CKD1CKD002(S)

11 BP <140/85. 15 to 12 months (CKD3)

CKD003 9 Proteinuria on ACE or ARB. No change from CKD5

CKD004 6 Urine Alb:creat ratio. 15 to 12 months (CKD6)

CKD2 (4 points) gone. Record of BP

Glasgow LMC

EpilepsyEP001 1 Register (over 18). No change

from Epilepsy1EP002 6 Seizure Free. 15 to 12 months

(Epilepsy8)EP003 3 Contraceptive, conception &

pregnancy advice. 15 to 12 months (Epilepsy9)

Glasgow LMC

Learning DisabilityLD001 4 Register. No change from LD1

LD002 2 Down’s & TSH level. 15 to 12 months (LD2)

Glasgow LMC

OsteoporosisOST001 3 Register. No change from

OST1OST002 3 50-75yrs, fragility # confirmed

on DXA treated with bone sparing agent. No change from OS2

OST003 3 75 and over, fragility fracture treated with bone sparing agent. No change from OST3

Glasgow LMC

NEW- Rheumatoid Arthritis

RA001 1 Maintains Register Of Patients 16 years and over with RA

RA002 5 Face to Face Review in the past 12 months

RA003 7 Aged 30 to 85 having a CVD Risk Assessment with tool adjusted for RA (ASSIGN +DM) in preceding 12 months

RA004 5 Aged 50 TO 91 having a Fracture Risk Assessment with tool adjusted for RA (FRAX) in preceding 24 months

Glasgow LMC

Palliative CarePC001 3 Register. No change from PC3

PC002 3 3 monthly MDT case review meetings. No change from PC2

Glasgow LMC

CVD Primary PreventionCVD-PP001 1

0Similar to PP1 but payment is for putting new HT patients who have had CVD risk assessment on Statins if risk is over 20%, Points increase to 10 from 8. Threshold increased from 40-75% to 40-90%

CVD-PP002(S)

5 Lifestyle Advice for HT patients diagnosed after 1 April 2009. 15 to 12 months (PP2)

CVD-PP003(S)

5 NEW- PATIENTS GIVEN LIFESTYLE ADVICE IN CVD-PP002 HAVE SCOT-PASQ DONE

Glasgow LMC

Glasgow LMC

ObesityOB001 8 Register 16 years and over

with BMI >30. 15 to 12 months (PC3)

Glasgow LMC

SmokingSMOK001 1

1Change from 27 to 24 months for recording smoking status (Smoking7)

SMOK002 25 Chronic disease & Smoking status recorded.15 to 12 months (Smoking5)

SMOK003 2 NEW- PRACTICE HAS STOPPING SMOKING LITERATURE AND OFFERS APPROPRIATE THERAPY(same as Information 5 indicator)

SMOK004 12

Change from 27 to 24 months for smokers to have an offer of support and treatment (Smoking8)

Glasgow LMC

Cervical ScreeningCS001(S) 7 Practice Protocol. No change

from CS7CS002(S) 11 20-60yrs smear in past 5 years.

45-80%. No change from CS1CS003 2 System for informing results.

No change from CS5CS004 2 Auditing policy & 2 yearly

inadequate smear audit. No change from CS6

Glasgow LMC

Child Health SurveillanceCHS001(S)

6 Offer child devlopment checks. No change from CHS1

Glasgow LMC

Maternity ServicesMAT001(S)

6 Antenatal care and screening offered. No change from MAT1

Glasgow LMC

ContraceptionCON001 4 Register. Specifies age group as

aged 54 or under (SH1)CON002 3 LARC advice. 15 to 12 months

(SH2)CON003 3 Emergency contraception &

LARC advice. No change from SH3

Glasgow LMC

Patient ExperiencePE001(S) 3

3Length of consultation 10mins. Same as PE1

Glasgow LMC

NEW Quality Improvement

QI001(S) 6 NEW- 2 CASE NOTE REVIEWS USING A VALIDATED TOOL, MEETS TO DISCUSS AND SHARE REPORT WITH BOARD

QI002(S) 5 NEW- SAFETY CLIMATE SURVEY, MEETS TO DISCUSS AND SHARE REPORT WITH BOARD

Glasgow LMC

Medicines ManagementMM001(S)

4 Similar to Medicines6- meet prescribing advisor and agree 3 actions. Previously it was “up to 3 actions”.

MM002(S)

9 Similar to Medicines10 (4 points) Meet with prescribing advisor and agree 3 actions and provide evidence of change. Now includes doing an audit.

MM003(S)

10

Similar with Medicines11 (7 points) Med review recorded for patients on 4 or more meds. 15 to 12 months.

Glasgow LMC

Public HealthBP001 1

5Similar to Records11 (10 points)BP recorded in preceding 5 years. Age group now 40 and over (previously 45 and over)Threshold now 40-80% (previously target was 65%)

Glasgow LMC

What has Happened to the Organisational Domain?

Glasgow LMC

Organisational Domain

• 77 transferred to Core Funding77 transferred to Core Funding• 37 moved to Clinical QOF indicators37 moved to Clinical QOF indicators• 15 moved to Public Health domain15 moved to Public Health domain• 2 moved to Smoking2 moved to Smoking• 23 moved to Medicines Management23 moved to Medicines Management• 0.5 moved to QOF QP0.5 moved to QOF QP

Glasgow LMC

New Records Standard The practice has an effective The practice has an effective

system for maintaining safe system for maintaining safe clinical records for patients, clinical records for patients, including communication with including communication with OOH services and a minimum OOH services and a minimum clinical summary level of 80%.clinical summary level of 80%.

Proposed subsections/Global sum %:Proposed subsections/Global sum %:• information sharing with OOH (0.125%),information sharing with OOH (0.125%),• drug indication and allergies (0.375%),drug indication and allergies (0.375%),• clinical summaries (0.5%).clinical summaries (0.5%).

Glasgow LMC

New Education Standard

The practice has an effective system The practice has an effective system for Continuous Professional for Continuous Professional Development for nurses, annual Development for nurses, annual appraisal for nurses and non-clinical appraisal for nurses and non-clinical staff and completes a minimum of 3 staff and completes a minimum of 3 SEAs annually.SEAs annually.

Proposed subsections/Global sum %:Proposed subsections/Global sum %:• Life support training (0.25%),Life support training (0.25%),• Complaints and SEA (0.25%),Complaints and SEA (0.25%),• CPD for nurses, appraisal for nurses and practice staff (0.25%).CPD for nurses, appraisal for nurses and practice staff (0.25%).

Glasgow LMC

New Management Standard

The practice has an effective The practice has an effective system for handling repeat system for handling repeat medicine requests within 48 medicine requests within 48 hours (2 working days) and staff hours (2 working days) and staff employment policies.employment policies.

Proposed subsections/Global sum %:Proposed subsections/Global sum %:• Written procedures and employment policies Written procedures and employment policies

accessible by staff (0.25%),accessible by staff (0.25%),• Repeat prescription availability timescales of 48 Repeat prescription availability timescales of 48

hours (0.25%).hours (0.25%).

Glasgow LMC

Questions?

Documents

Glasgow LMC Limited Glasgow LMC & NHS GG&C GMS Contract Meeting 6 th June 2013 LMC CENTENARY YEAR 1913 - 2013