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GENERAL PRACTICE NURSES

Unit Six
Quality improvement and evaluating practice from a general practice nurse’s perspective

Key Messages

This unit will help you to :

  • provide the best quality care
  • enable standards to be monitored or measured
  • develop tools that can help measure quality and guide you to evaluate your clinical performance, such as annual appraisals
  • monitor and evaluate your performance, for example audits and patient satisfaction surveys.

As a general practice nurse (GPN), you will no doubt be delivering high-quality care to all your patients. In order to reliably consider the quality and consistency of care delivered by you and the practice team, it may be useful to consider your work under the seven pillars of clinical governance1 that underpin the Healthcare Commission's Standards for Better Health.2

The seven pillars of clinical governance

1. Risk management

 GMS Requirement 21

 

In order to minimise risks to patients and raise awareness of unsafe practice, you could conduct the following:

  • complete a skills-based assessment tool to ensure your competences are recorded
  • consider whether or not induction programmes for new or locum GPNs are adequate – eg, do they include everything that is needed?
  • set up a system to ensure that ‘near miss’ incidents are reported and acted on
  • organise sessions with other GPNs or for the whole practice team to analyse significant events.

Tool – Sample induction programme - GPNs who complete a programme such as this can prove that they have been assessed as competent to undertake a variety of tasks. Keep adding to this file as you gain more competences, as it will provide future employers with a level of certainty about what you can and cannot do.

Tool – Reporting on ‘near miss’ incidents - – use this tool to develop a more open attitude to risk so that everyone can learn from difficult experiences.

2: Clinical effectiveness

To consider clinical effectiveness, first set up a meeting with other GPNs and GPs from the practice to look at the guidelines and protocols specific to clinical care that have been created within the practice. The latest versions of these should be gathered together. At the meeting, go through as many of the protocols as you can and make sure that they are all within their review date. Check that they are linked to national guidelines or based on robust evidence. Protocols should be kept together in a central folder so that any new staff or locum GPNs will have easy access to them.

Consider how you get access to evidence-based information. You may wish to start a small 'library' of journal articles categorised by clinical topics, for example articles relating to diabetes, coronary heart disease, and so on. Ask everyone in the practice to make a note of the websites they have found to be particularly useful and ensure a laminated copy of these is kept by every computer with internet access. See Tool - Using protocols, standards, policies and guidelines to enhance confidence and career development

See www.equip.ac.uk/practiceManagement/docs/protocols/protocols.htm for examples of over 100 protocols for use in general practice.

Example from Thistlemoor medical practice (Peterborough) - effective use of protocols in practice

'When setting up a nurse-led service, the practice was anxious to provide foolproof and safe guidelines for nurses who would be responsible for assessing patients' needs. Clinical templates were therefore developed and attached to Read codes to guide history taking and data collection. All conditions for which a patient might present to the surgery were considered. Questions were then created that would enable appropriate management of these conditions. Risk-management angles and clinically relevant history and examination components were also incorporated as prompts in the template, which made the process safe and effective. Clinical guidelines were attached to the templates so that these could be accessed, if needed, at the time of consultation. An information technology (IT) network system was also developed, so that this information is available to all staff at any time.

When a patient presents with headache, the entry 'headache' as a clinical problem brings up a prompt that informs the user that there is a template attached, and asks if they would like to use it - the clinician has to answer 'yes' to access the template. On accessing the template, the prompts include:

  • when the headache came on
  • type and duration of onset
  • associated symptoms
  • visual acuity
  • presence of vomiting, rash and temperature
  • whether the patient has seen or been referred to an optician
  • effectiveness of any over-the-counter medication taken.

 

There is a write-up about causes of headaches, types of headaches and recommended treatment for each type. This information can then be discussed with the patient to determine optimal management.

Clinical presentations for most conditions have been added onto the system and this is a continual process. All national service frameworks (NSFs) have also been converted into templates, to ensure they are incorporated into everyday clinical routines.'

For more information contact Nalini Modha at: Nalini.Modha@gp-d81625.nhs.uk.


3. Education, training and continuing professional development

 QOF Education 8 3 points

Appropriate training is essential for the delivery of quality, evidence-based care. As a registered nurse, you have a responsibility to ensure that you remain up-to-date and well informed about your area of practice.3 It is your responsibility to demonstrate commitment and support to education and training. It is also in your own interests to have your competence assessed, so that you have an objective measure of what you are and are not able to do. See Unit: Competences of general practice nurses.

The practice is required to provide opportunities for your development as part of the new General Medical Services contract (nGMS).4 If you have worked in the practice for a while, you may want to evaluate the support you receive for learning and development.
Tool – Learning and personal development – evaluation by a GPN - will help you review whether or not you are receiving adequate support to enable you to achieve your full potential.

The Quality and Outcomes Framework of the nGMS contract (section 4.20)4 also clearly states that 'all practice-employed nurses should be supported to participate in clinical supervision and appraisal'. Clinical supervision is a supportive, developmental and educational process that helps you look at your own practice alongside your peers and explore how you can assist in improving the quality of service. It encourages reflective practice through consideration of critical incidents.

Clinical supervision is defined as a formal process of professional support and learning that enables individual practitioners to:

  • develop knowledge and competence
  • assume responsibility for their own practice
  • enhance consumer protection and safety of care in complex clinical situations.

Clinical supervision should therefore be viewed as an integral component of clinical governance.
Tool – Clinical supervision: how and why?

 

Example from Horden group practice (Durham) – clinical supervision in practice

‘Monthly practice nurse meetings and clinical supervision sessions are sponsored by the PCT. Payment is made for time spent attending these meetings.’

For more information contact Angela Fisher (Practice Development Manager) at:
angela.fisher@GP-A83044.nhs.uk.

Appraisal is a vital part of continuing professional development (CPD) because it helps you to identify your strengths and weaknesses. Although this should be conducted annually, it may be useful to have additional less-formal reviews more frequently.

You must have adequate time to prepare for your appraisal in advance. An appraisal without preparation is a worthless exercise - to benefit fully, you need to think about what you have done over the past year and what skills you want to improve on. The appraiser will then link these to the objectives for the practice. Your personal development plan (PDP) should be developed in response to your appraisal, and a good appraiser will check that you are implementing this following your appraisal. See
Tool - Documentation for appraisals - using an action plan and Tool - Creating a personal development plan .

Setting up a GPN forum to assist with CPD
Working as a GPN can mean that you are in danger of professional isolation, for example if you work in a small or single-handed practice. Whereas health visitors and district nurses are likely to have regular staff meetings where they can catch up with issues and exchange information, this is less likely to happen for GPNs. Establishing a GPN forum may be one way of trying to achieve better communication and solidarity.

It may be difficult initially to encourage practices to give you time off to attend forum meetings, but if they are informed of some of the benefits, such as support, sharing ideas and professional updating, they may be more keen for you to attend. If you do not have such a scheme in your primary care trust (PCT), you could approach the GPN professional lead to request that this is started or settle for other options that encourage networking and communication between GPNs. Tool - Setting up a GPN forum provides ideas and suggestions for setting up a forum to attract local GPNs and incorporate CPD activities.

Peer review of performance can be extremely helpful to inform you about your skills in dealing with patients. You may have annoying little habits that you really need to know about or you may be better than you think at dealing with sensitive issues. Although you will inevitably self-assess your performance, it can be useful and re-energising to undertake the following exercise - Tool - Using peer review to improve practice provides a new way to gain insight into your own strengths and weaknesses.

Induction programmes QOF Employment 8 3 Points

Staff who are new to the practice should have a comprehensive induction programme that also assesses their competence in order to minimise risk to patients. It is also important to remember that when you, as a GPN, are delegating tasks (eg to health care assistants, junior GPNs or bank staff), it is your responsibility to ensure that they are competent to undertake the activity. As with all types of practice, rather than relying on the fact that you may have an induction programme in place, you need to evaluate how effective it is.
Tool - Induction - evaluation by a GPN will help you to see whether the induction programme provided by the practice is as comprehensive as it should be.

4. Use of information

The information highway means that it is easy for GPNs to keep up-to-date in their area of practice. Connecting for Health promises some fantastic opportunities for the future - with the advent of electronic patient records.5 Over the next 10 years, the national programme for IT in the NHS will connect more than 30,000 GPs in England to almost 300 hospitals. General practices have introduced computerisation at a varied pace, but it is now viewed as an essential tool to improve efficiency of care. IT is a key component of the nGMS contract.

As a GPN you need to be sure that, when entering information about patients, you are using defined Read codes. This makes auditing and categorising information much easier. You should also consider whether or not you could benefit from using decision-making support software such as PRODIGY6 or IT to access evidence-based information for patient management.

5: Staffing and staff management

When using electronic patient records, it is essential to ensure that all care plans can be individualised and that alert systems are put in place to identify particular areas or needs.

General practice partnerships are often fairly small, but it is still important to have clearly identifiable lines of managerial responsibility. As a GPN you may be asked to supervise junior staff or health care assistants. You need to be clear whether or not this means you are being asked to take on their line management. If so, you should be adequately prepared for the role. You should also determine if you are responsible for monitoring staff performance and undertaking appraisals.

The nGMS contract4 refers to improved human resources services for staff, including entitlement to all NHS conditions and initiatives to improve working lives. Achieving quality care within general practice is all about teamwork.

Tool – Teamwork – how well is your team functioning?

Tool – Is your practice a good place to work?

 

Example from Thistlemoor medical practice (Peterborough) – emphasis on team working in practice

‘We believe that role redesign and delegation cannot be successful if the whole team is not working as one. We recognise the importance of communicating with staff as a means of empowering them and engaging them in change. Therefore, for the past 4 years, we have met twice a week with staff – one of these is a clinical meeting, where we discuss clinical protocols, make practice formulary changes, discuss interesting or significant events, and discuss risk management issues, which we use for inhouse training, presentations, etc. The other is a staff meeting, where we decide on practice policies, training issues, significant events, issues to do with running of the practice, etc. Everyone is encouraged to participate and once decisions are made, they are operational with immediate effect. Attendance at these meetings is compulsory and overtime is paid to those who come in especially to attend. Contributions from staff members are recognised and good ideas are rewarded. It encourages systems thinking, teaching people to reintegrate activities to see how what they do is interconnected with what others do.’

For more information contact Nalini Modha at: nalini.modha@gp-d81625.nhs.uk.

6: Clinical audit
Audit is a reliable way of determining whether or not the services you deliver are effective. It can be surprisingly simple to undertake, and should be considered as an essential element of health care practice. Basically, an audit measures performance against a defined standard to see if a service is as good as it should be. See Tool - How to undertake an audit .

Wording of the questions used in an audit is crucial.7 Some key points are as follows:

  • use simple language
  • be consistent
  • do not assume common knowledge
  • keep away from leading questions
  • avoid complicated questions
  • use care with questions referring to time
  • only collect essential data
  • think carefully about the type of questions to use
  • collect data only on subjects that you can do something about.

Tool – Judge how well you have performed an audit allows you to check whether or not your audit has been as thorough as possible.

Another way of ensuring that best practice is measured is to use the benchmarking process outlined in Essence of Care.8 Tool – Essence of Care benchmarking

The role of patient and public involvement is clearly indicated within The NHS Plan.9 The intention is to involve and consult patients and the general public about key issues within the NHS. These include identifying local needs and priorities, and evaluating the quality of services from a patient-satisfaction perspective. Consider whether or not the opinions of patients are sought within the practice - for example, from the Patient Advice and Liaison Service or the practice patient committee - if their opinions are not already sought, contact these services and ask what method would be most appropriate to gain their views.

7: Evaluating what patients think QOF Employment 8 3 Points QOF PE3 PE5 PE6 75 points

Although you may feel you know if patients get on well with you or not, this is subjective and may be linked to your personality rather than the service you deliver. If you undertake regular patient-satisfaction surveys, you will have a more-robust method of determining patient's views.
Tool - Patient experience of care provided by a GPN - evaluation by a patient provides a structured way of receiving patient feedback that could highlight areas in your practice you may want to change.

It is important to ask patients about the service you provide, but you must be careful not to use predetermined standardised questions that are based on your values and assumptions as a health care professional. Simply providing blank forms or asking open-ended questions will be more likely to provide an accurate reflection of what the service is really like for patients.

If you want to conduct a patient-satisfaction survey, consider using a validated tool that has been proved to yield meaningful results. An example of this is the General Practice Assessment Survey.10 Some validated tools may incur costs, but you should consider whether the benefits to the practice (and the avoidance of having to spend time and effort in drafting your own survey) are worthwhile.

If you want to know more about the things that matter to patients in general practice, read the Department of Health's National Survey of NHS Patients: General Practice11 or articles based around this.12 This survey covers a wide range of issues, including access, waiting times, views of GPs and GPNs, and the quality and range of services in general practice.

Although the tools within this Unit all look at quite different aspects of work within general practice, they all use a similar approach that you can adapt to evaluate any aspect of your work that is important to you. They all explore the structure, process and outcome of the evaluation. In other words, this type of evaluative approach considers:

  • what actually happened – such as the content of an induction, your PDP or your inclusion in team meetings
  • how it worked out – how well the induction ran, the type of help you received in pulling your PDP together and the associated learning, or how communications in your team happen
  • the outcome – what you achieved as a result of your induction, how you apply what you learnt in your GPN post as a result of completing your PDP, or the changes in the way care is delivered as a result of your practice team-working.

You might evaluate the 'what', 'how' and 'outcome' of your personal development or a clinical aspect of your work that is important to you, or just one of these. Evaluating the 'outcome' and what you achieved, or the changes made to the service you provide to patients as a result, will be more challenging to evaluate than the 'what' and the 'how' aspects.

References

  1. Chambers R, Wakley G. Making Clinical Governance Work for You. Oxford: Radcliffe Medical Press; 2000.
  2. Healthcare Commission. Standards for Better Health. London: Department of Health; 2004.
  3. Nursing and Midwifery Council (NMC). Code of Professional Conduct. London: NMC; 2002.
  4. Department of Health. Investing in General Practice: the New General Medical Services Contract. London: Department of Health; 2003. Available at: http://www.doh.gov.uk/gmscontract/thecontract.htm.
  5. Connecting for Health. National Programme for IT in the NHS. Available at: http://www.connectingforhealth.nhs.uk.
  6. PRODIGY. Prodigy Knowledge Website. Available at: http://www.prodigy.nhs.uk.
  7. Parsley K, Corrigan P. Quality Improvement in Healthcare: Putting Evidence into Practice. 2nd Edn. Stanley Thornes Cheltenham; 1999.
  8. NHS Modernisation Agency. Essence of Care: Patient-focused Benchmarks for Clinical Governance. London: Department of Health; 2003. Available at: http://www.dh.gov.uk/assetRoot/04/12/79/15/04127915.pdf.
  9. Department of Health. The NHS Plan. London: Department of Health; 2000. Available at: http://www.dh.gov.uk/assetRoot/04/05/95/26/04059526.pdf.
  10. Ramsay J et al. The General Practice Assessment Survey (GPAS): Tests of data quality and measurement properties. Family Practice 2000;17(5):372–379. Available at: http://www.gpaq.info.
  11. Department of Health. National Survey of NHS Patients: General Practice. London: Department of Health; 1999. Available at: http://www.dh.gov.uk/assetRoot/04/02/36/11/04023611.pdf.
  12. Bower P, Roland M, Campbell J, Mead N. Setting standards based on patients’ views on access and continuity: secondary analysis of data from the general practice assessment survey. British Medical Journal 2003; 326(7583): 258.

 

This document is intended as a guide only.
© Crown Copyright September 2006.
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