Quality & Outcomes Framework Assessment Visits PCT Manager s Report Practice Name PCT QOF Manager GMS/PMS Contract Lead Partner Clinical governance lead Caldicott Guardian Practice manager GP Assessor Lay assessor Computer system Cheshire West Primary Care Trust July 2004
Two months before the visit Arrange to meet the Practice manager to go through the process and the evidence required Arrange for Consent letters to be handed out in the Practice Letter confirming date of assessment visit including names of assessors for this practice PCT Contact Assessors comments QMAS Maureen Swanson Kerry Winsland Graphnet Liz Keight Clinical Governance self assessment Lyn Hillier Interim Aspiration Utility Sharon Hibbert Medicines Management Report Jean Fairbrother R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 2 of 17
Clinical Domains Comments Heart Disease Diabetes Stroke Hypertension Asthma COPD Mental Health Cancer Hypothyroidism Epilepsy R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 3 of 17
Records Evidence supplied Comments Records 5-1 point KEY INDICATOR The practice has a system for dealing with any hospital report or investigation result which identifies a responsible health professional and ensures that any necessary action is taken Records 12-2 points KEY INDICATOR When a member of the team prescribes a medicine other than a non-medicated dressing, topical treatment or OTC medicine there is a mechanism for that prescription to be entered into the patient s general practice record R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 4 of 17
Information for Patients Evidence supplied Comments Information 3-0.5 points KEY INDICATOR The practice has arrangements for patients to speak to GPs and nurses on the telephone during the working day Information 4-1 point KEY INDICATOR If a patient is removed from a practice s list, the practice provides an explanation of the reasons in writing to the patient and information on how to find a new practice, unless it is perceived such an action would result in a violent response by the patient R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 5 of 17
Education & Training Evidence supplied Comments Education 8-3 points KEY INDICATOR All practice-employed nurses have personal learning plans which have been reviewed at annual appraisal Education 9-3 points KEY INDICATOR All practice-employed non-clinical team members have an annual appraisal R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 6 of 17
Practice management Evidence supplied Comments Management 5-3 points KEY INDICATOR 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 with the PCO Management 7-3 points KEY INDICATOR The practice has systems in place to ensure regular and appropriate inspection, calibration, maintenance and replacement of equipment including: a defined responsible person clear recording systematic pre-planned schedules reporting of faults Management 10-4 points KEY INDICATOR There is a written procedure 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 R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 7 of 17
Medicines management Evidence supplied Comments Med 3-2 points KEY INDICATOR There is a system for checking expiry dates of emergency drugs at least on an annual basis Med 6-4 points KEY INDICATOR The practice meets with the PCO prescribing adviser at least annually and agrees up to three actions related to prescribing Med 10-4 points KEY INDICATOR The practice meets with the PCO prescribing adviser at least annually, has agreed up to three actions related to prescribing and subsequently provided evidence of change R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 8 of 17
Patient experience Evidence supplied Comments Additional services Evidence supplied Comments Cervical screening CS1 11 points 80% KEY INDICATOR The percentage of patients aged 25 to 64 years whose notes record that a cervical smear has been performed in the last three to five years. CS2-3 points KEY INDICATOR The practice has a system to ensure inadequate/abnormal smears are followed up R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 9 of 17
Additional services Evidence supplied Comments Child health surveillance Maternity Services Contraceptive Services CON1-1 point KEY INDICATOR The team has a written policy for responding to requests for emergency contraception Access Comments R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 10 of 17
Contractual & Statutory requirements The practice has an agreed procedure for handling patients complaints, which complies with the NHS complaints procedure and is advertised to the patients. Where patients are requesting to join the practice list, the practice does not discriminate on the grounds of : a. Race, gender, social class, age, religion, sexual orientation or appearance b. disability or medical condition. The practice adheres to the requirements of the Medicines Act for the storage, prescribing, dispensing, recording and disposal of drugs including controlled drugs Batch numbers are recorded for all vaccines administered The practice has a policy for consent to the treatment of children that conforms to the current Children s Act or equivalent legislation The premises, equipment and arrangements for infection control and decontamination meet the minimum national standards. Evidence supplied Comments R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 11 of 17
Contractual & Statutory requirements The practice ensures that all healthcare professionals who are employed by the practice are currently registered with the relevant professional body on the appropriate part(s) of its Register(s) and that any employed general practitioner is a member of a recognised medical defence organisation and registered on a primary care performers list (or equivalent). All professionals working in the practice are covered by appropriate indemnity insurance The practice has a system to allow patients access to their records on request in accordance with current legislation. The practice has a written procedure for the electronic transmission of patient data which is in line with national policy Individual healthcare professionals should be able to demonstrate that they comply with the national child protection guidance, and should provide at least one critical event analysis regarding concerns about a child s welfare if appropriate. For vaccination and immunisation, fridges in which vaccines are stored have a maximum thermometer daily reading take place on working days. Evidence supplied Comments R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 12 of 17
Contractual & Statutory requirements For vaccination and immunisation, staff involved in administering vaccines are trained in the reception of anaphylaxis and able to administer appropriate first-line treatment when it occurs. Evidence supplied Comments Vaccines are stored in accordance with the manufacturers instructions R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 13 of 17
Agenda for the assessment visit including date of the visit Key personnel identified again R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 14 of 17
Summary for report R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 15 of 17
Appendix one Policies and procedures should generally include: Purpose what the Practice is trying to achieve Scope what is covered and what is not Process detailed description of how the task is carried out For the Quality & Outcomes Framework, the following policies and procedures are needed: System for transferring and action on information about patients seen outof-hours. System to record messages and request for visits and the appropriate team member receives and acts on them. System for dealing with hospital reports and investigations that identifies the responsible clinical and ensures that any necessary action is taken. System for informing relevant tam members about patients who have died. System for ensuring that all prescribed mediation is entered into the patient record. System to alert the out-of-hours service to patients dying at home. Arrangements for patients to speak to clinicians on the phone during the working day. Procedure for removing patients from the list. Smoking cessation advice Arrangements for backing up computer data, back-up verification, safe storage and authorisation for loading programmes onto computers. This will be completed at the September meeting of the Practice Managers Responsibility who can do what Review how often it will be reviewed If you are part of the PCT Learning Set Established please give date you expect to introduce the policy Not considered Relevant R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 16 of 17
For the Quality & Outcomes Framework, the following policies and procedures are needed: cont. Decontamination and sterilisation. Calibration, maintenance and replacement of equipment. Fraud prevention Carers policy. Emergency drugs Repeat prescriptions. Medication reviews Monitoring patients receiving injectable neuroleptic drugs. System for following up abnormal and inadequate smears. System for identifying and following up women who do not attend for cervical smears. Provision of emergency contraception Pre-conceptual advice Records summarising Established If you are part of the PCT Learning Set please give date you expect to introduce the policy Not considered Relevant R\QOF\QOF Visits\Assessors Pack\Managers QOF visit Page 17 of 17