MEADOWSIDE FAMILY
HEALTH CENTRE
QUALITY ACCOUNTS
2010/2011
1
MEADOWSIDE FAMILY HEALTH CENTRE QUALITY ACCOUNT
1. Who We Are - An Introduction to Meadowside Family Health Centre
Page 3
2. Our Mission Statement
Page 4
3. Senior Management Team Statement
Statement from Patient Participation Group
Page 5
4. Priorities for Improvement
Page 6
5. Statements of Assurance
Page 9
6. The services we deliver
Page 11
7. Statement from Solihull Primary Care Trust
Page 18
2
WHO WE ARE – An Introduction to Meadowside Family Health Centre
Meadowside Family Health Centre is a six partner general Practice working under a PMS
contract with Solihull Care Trust. The Practice list size is circa 8350.
The team is made up of:
G P Partners
6
Salaried GP
Registrar
Practice Nurses
1
1
3
Healthcare assistants
2
Practice Manager
Secretaries
Reception/Administrative staff
Patient Participation Group
Chairman
1
2
10
8
Dr Martin Powis
Dr John Wilkinson
Dr Carolyne Smith
Dr Sheila Vanhouse
Dr Liz Edwards
Dr Mike Baker
Dr Liz Neethling
Dr Ahmad Anwar
Sr Jan Maclaurin
Sr Julie Chatwin
Sr
Mrs Jan Donovan
Mrs Amanda O’Hara
Mrs Vicki Baker
Chair: Mr Jim Harris
Meadowside FHC is a training practice, and actively supports the education of medical students
from Birmingham University Medical School and Warwick Medical School, as well as the
continued training of qualified doctors as GP Registrars from the Birmingham Deanery.
The Practice is housed in extended purpose-built accommodation encompassing 7 GP
consulting rooms, 2 nurse treatment rooms, an isolation room, staff offices, a multi-purpose
meeting room, and staff kitchen/rest room. There is a spacious waiting room for patients with
Amscreen TV and electronic check-in desk. There is a lower height reception area for disabled
access and a hearing loop is available. Notice boards are changed frequently to ensure content
is up to date and appropriate. A car park is available for patients and staff.
3
MEADOWSIDE FAMILY HEALTH CENTRE
MISSION STATEMENT
To be proactive in promoting health and well-being for
patients of all ages and to provide high quality medical care
with a holistic approach, by working together with other
agencies for the benefit of patients, whilst providing a safe
and friendly working environment for staff.
4
SENIOR PARTNER STATEMENT
The Health Act 2009 puts a duty on all providers of NHS services to produce annual Quality
Accounts to the public. For general Practice this will be a legal requirement from April 2012. The
Meadowside Family Health Centre agreed to anticipate this with this first draft of Quality
Accounts covering the 2010/11 year in review and planning head for 2011/12.
The accounts focus on three areas:
• Patient Safety
• Clinical effectiveness
• Patient experience
The aim of the report is to look back at the services delivered during the previous 12 months, to
identify areas for development focus, and to plan what the practice aims to achieve in the
forthcoming 12 month period.
It is our aim that this report provides the following:
• An overview of who we are and what we do
• Assurance of the validity of the report covering 2010 – 2011 by the Senior management
Team
• Recognition of areas for development in the forthcoming 12 months with appropriate plans
• A review of services delivered in the preceding 12 months and the quality of that delivery
supported where possible with details of the measurement of quality
This report has been produced after consultation with the Practice’s Patient Participation Group
and after discussion with the Partners and Practice Team. I am confident that the data and
information found in this report is an accurate representation of the services delivered by the
Practice. We have endeavoured to make the report simple, relevant and accessible to all.
Dr Martin D Powis
Statement of Approval fro Patient Participation Group
I have read in detail your proposed Quality Accounts and can only say that in my opinion it is a
superbly written and detailed document. It is clearly laid out without any ambiguous or misleading
statements and I feel that it is an excellent statement of facts for our Practice and I must
compliment you for this proposed submission. On a personal note the PPG thanks you for our
inclusion in this report.
Jim Harris
Chair of Meadowside PPG
5
Part 2 – Priorities for Improvement and Statements of Assurance
Priorities for Improvement
Having completed the review of services and consultation with the Partners, staff and PPG, the
following areas for development have been identified:
Priority for Improvement 1
Domain:
Patient Experience
Clinical Effectiveness
Improve two-way communication with patients by
• Improving patient access to information
• Facilitating easy and accessible methods for patients to provide feedback on current and
future services
Action to be taken
To explore the acquisition of a Touch Screen Patient Information service to provide:
• Information re services offered
• Patient information re specific clinical areas
• Signposting for appropriate alternative/additional services
• Information re clinical governance i.e. how data is used, consent issues, access to
medical records
Also to incorporate surveys/questionnaires to enable:
• Patient feedback on current services to ensure clinical effectiveness and inform
development
• To seek patient opinion on the development of effective new services
Monitoring – how and by
whom
How will it be measured
Reporting
Installation of Touch Screen
VB
Number of uses / completion
of surveys
Quarterly review of activity
and feedback received to be
presented to Partners meeting
and PPG
Monitoring usage figures VB
6
Priority for Improvement 2
Domain:
Patient Experience
Clinical Effectiveness
Improve patient access to GP by telephone consultation
Action to be taken
To increase the number of telephone consultations undertaken by:
• Promoting the availability of telephone consultations via website and through reception
team
• Enabling telephone consultations to be booked online
Monitoring – how and by
whom
How will it be measured
Reporting
Quarterly review of number of
telephone consultations
undertaken. VB
Increase in telephone
consultations undertaken
Final review against baseline
2010/2011 figures to be
undertaken at year end
Priority for Improvement 3
Patient Safety
Medication reviews to be regularly undertaken and recorded.
Action to be taken
• All clinicians to ensure a medication review is undertaken and recorded in a timely
manner – alerts will be available on the patient home page and are to be actioned.
• Repeat the audit of hospital discharge letters to ensure continuity of medication is
appropriate
• To record in the patient record when a clinician decides it is not appropriate to prescribe
a drug detailed on a hospital letter.
• To review medication in dementia patients to ensure appropriate prescribing of atypical
antipsychotics.
Monitoring – how and by
whom
Medication reviews to be
undertaken annually. Recall
system to be utilised to
facilitate monitoring by
VB/admin
How will it be measured
Reporting
Outstanding review dates to
be searched quarterly and
actioned
PM to report to Partners,
numbers undertaken and
numbers outstanding
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Priority for Improvement 4
Clinical effectiveness
Patient Safety
Improve services for patients with chronic lung disease
Action to be taken
•
•
•
•
•
To continue to support the nurse in training to complete her diploma qualification
To undertake a re-audit to quantify the progress made through our work with
POINTS/Quintiles
To plan a rolling programme for the forthcoming year to ensure all patients are reviewed
appropriately
To recruit an additional nurse with some experience and /or willing to train.
To establish specialised clinic sessions to deliver an improved services
Monitoring – how and by
whom
How will it be measured
Reporting
Regular monthly lists of
patients to be reviewed to be
monitored by VB/PP
No of reviews undertaken and
number of outstanding recalls.
QOF outturn improvement
Monitoring through QOF
reports VB
QOF reports
Patient satisfaction survey
Spring 2012
8
Statements of Assurance
Review of services
During the period 1/4/10 to 31/3/11Meadowside FHC provided a NHS Services under a PMS
contract
Meadowside FHC has reviewed all the data available to them on the quality of care in this
service.
The income generated by the NHS services reviewed in 1/4/2010 to 31/3/2011 represents 100%
of the total income generated from the provision of NHS Services by Meadowside FHC for the
period 1/4/10 to 31/3/11
Participation in clinical audits
During 2010/2011 Meadowside FHC did not take part in any clinical audits or confidential
enquiries
The reports of 11 local clinical audits were reviewed by the provider in 2010/2011 and
Meadowside FHC intends to take the following actions to improve the quality of healthcare
provided:
MFHC has acted on the information gained by updating patient records and/or changing
medication to increase clinical effectiveness/cost-effectiveness as appropriate.
Participation in clinical research
The number of patients receiving NHS services provided or sub-contracted by Meadwside FHC
in 2010/2011 that were recruited during that period to participate in research approved by a
research ethics committee 0.
Goals agreed with commissioners
Use of the CQUIN payment framework
Meadowside FHC income in 2010/2011 was not conditional on achieving quality improvement
and innovation goals through the Commissioning for Quality and Innovation payment framework
because Meadowside FHC does not use any of the NHS National Standard Contracts and is
therefore not eligible to negotiate a CQUIN Scheme.
What others say about the provider
Statements from the CQC
Meadowside FHC is not required to be register with the Care Quality Commission until April
2012. An application is in progress of development for that time.
Data Quality
Meadowside FHC will be taking the following actions to improve data quality:
• Data quality audits – using the E-audit tools available through PRIMIS/CHART
NHS Number and General Medical Practice Code Validity
Meadowside FHC did not submit records during 2010/2011 to the Secondary Uses service for
inclusion in the Hospital Episode Statistics which are included in the latest published data.
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Information Governance Toolkit attainment levels
Meadowside FHC Information Governance Assessment Report score overall
score for 2010/2011 was 89% and was graded Satisfactory.
Clinical coding error rate
Meadowside FHC was not subject to the Payment by Results clinical coding audit during
2010/2011 by the Audit Commission.
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PART 3
THE SERVICES WE DELIVER
Patient Experience of Services
APPOINTMENT AVAILABILITY
The Practice has provided extended opening hours on Monday evenings 6.30pm to 8pm and
Saturday mornings from 8.30am to 10am. In order to try and meet demand, a proportion of GP
appointments are available for booking up to 2 weeks in advance, a further proportion are
available from 2 days in advance and a final quantity kept for on the day booking. These
proportions are established by undertaking periodic audits of incoming telephone calls.
Appointments offered in 2010/2011
Clinician
Appointments
provided
Did not attend
Did not attend rate
Doctor
30249
1255
4.14%
Nurse/HCA
15891
1352
8.5%
Home visits - Doctor
Home visits –
Nurse/HCA
2301
Telephone
consultations
330
888 (1.92%)
Total face to face consultations were 48441 giving a consultation ratio of 5.8 (National ratio 5.3)
What patients thought of the Practice appointment provision – taken from the 2010/2011patient
survey results:
Question
Satisfaction with availability of particular doctor
Satisfaction with availability of any doctor
Satisfaction with availability of a nurse
Satisfaction with phoning through to the practice
Satisfaction with phoning through to the doctor for advice
Satisfaction with phoning through to the nurse for advice
% response
good
and above
52
69
67.5
61
48
51
% response
fair
and above
82
92.5
90
85
68
82
Summary of patient experience on contacting the surgery for an appointment taken from the
audit conducted February 2011
11
Telephone Audits
Telephone audits are undertaken periodically to establish if the apportionment of appointment
embargoes are in line with patient demand. The results of the most recent audit undertaken in
February 2011 are below:
Appt booked
in time requested
Telephone
consultation booked
398
77%
Requested Specified
Doctor
173
Asked to
phone back
7
2%
Secured satisfactory
alternative option
85
16%
29
6%
Unresolved
calls
0
0%
Total
calls
520
Booked with
specified Doctor
147
85%
COMMUNITY EVENTS
The Practice has undertaken several community events. In July 2010, working with another local
practice, an event was held at the nearby Solihull Ice Rink with the main aim of raising
awareness amongst the younger population of the Sexual Health Services available. Many other
local organisations were invited and took part such as the Smoking Cessation Service, local
Police regarding security, Healthy Eating, Chlamydia Screening service, Alcohol and Drug
services.
PPG INVOLVEMENT (Practice Participation Group)
Meetings are held every other month at the practice in the evening in order that working patients
can also be involved. The PPG are also active at various times of year within the practice,
supporting seasonal flu vaccination clinics, assisting in promoting the patient survey and also
with hands on help at community events.
COMPLAINTS RETURN
During the year under review, the practice has received 4 complaints which have been
responded to and reviewed. Two related to the booking of appointments, 1 related to
communication/attitude and 1 related to administration. All were resolved with the patients
concerned.
RECALL PROGRAMMES
Patients are routinely called for the following:
• Diabetic reviews
• Asthma reviews
• COPD reviews / spirometry
• Blood pressure reviews
• Repeat blood glucose tolerance tests
• Mental health reviews
• Epilepsy reviews
• Reviews for patients in residential nursing homes
ONLINE SERVICES
Patients have access to online appointment booking, prescription ordering and submission of
general queries.
The % of patients registered for this service is currently 22%
The % of appointments booked online for 2010/2011 was 5.82%
3558 prescription requests were received online in 2010/2011
58 patient enquiries were made online in 2010/2011
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GENERAL PRACTICE SERVICES
Alongside daily general surgery session, the following services are routinely offered:
•
Anti coagulation – clinics are held on Wednesday mornings and Friday afternoons, and if
required, home visits are made to housebound patients. Patient survey undertaken in
February in 2011 shows a 98% satisfaction with the clinic and 100% happy to attend at
the surgery rather than the hospital for this service.
•
Diabetic reviews – clinics are held on Monday afternoons and Wednesday mornings.
Patients are routinely recalled twice-yearly for diabetic review
•
Blood clinics – these are held on Tuesday, Wednesday and Thursday from 11.30am –
12.30pm on a drop-in basis, for the convenience of patients rather than attending the
clinics in central Solihull
•
Flu clinics – are held in the autumn on Saturday mornings and some late evenings in
addition to normal surgery hours to minimise the impact on appointment availability
•
Nursing services- include ECG, wound care/dressings, child immunisations, travel health
(risk assessment and vaccination), ear irrigation, blood pressure checks, weight
management, smoking cessation, asthma reviews and COPD/Spirometry reviews
•
Minor operations – Clinics are held weekly on Monday mornings for procedures such as
excisions/biopsies/cryotherapy
•
Sexual health services – Safe & Well Clinic every Wednesday afternoon from 4pm for all
ages incorporates STI screening, general sexual health advice, pre-pregnancy
counselling, cytology
•
Contraception services – Every Wednesday from 4pm alongside the Safe & Well Clinic.
All contraceptive methods discussed. Guidance and further appointments offered for IUCD
and Nexplanon fitting.
•
National screening programmes – The Practice partakes in the National Screening
programmes for cytology, mammogram, Chlamydia screening
•
Mental health – Access to CBT/counselling services. The Practice hosts members of the
IAPT service to provide a local service to our patients and those of other local practices.
This increases the opportunity of appointment times by utilising various venues.
•
Learning disabilities – annual reviews are held for all patients with a registered learning
disability. The Practice Manager meets with a representative of the Learning Disabilities at
least twice a year to review the list and ensure any movement is appropriately responded
to.
•
NHS Health checks are undertaken for all those aged between 40 and 74. Invitations are
issued in accordance with the risk stratification undertaken. Patients are also advised that
they can self refer to this service if they are in the appropriate age group.
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Patient Safety & Clinical effectiveness of services
QOF Clinical Achievement As at 31.3.11
The chart below shows the Practice achievement in QOF clinical areas for 2010/2011:
Item
Clinical
Asthma
Atrial Fibrillation
COPD
Cancer
Cardiovascular Disease Primary Prevention
Chronic Kidney Disease
Coronary Heart Disease
Dementia
Depression
Diabetes
Epilepsy
Heart Failure
Hypertension
Hypothyroidism
Learning Disabilities
Mental Health
Obesity
Palliative care
Smoking
Stroke And Transient Ischaemic Attacks (TIA)
Organisational
Medicines (not submitted)
Records
Points
685.0 / 694
45 / 45
27 / 27
25.6 / 30
11 / 11
12.3 / 13
36.7 / 38
86.4 / 87
20 / 20
52.1 / 53
99.4 / 100
15 / 15
29 / 29
81 / 81
7/7
4/4
38.7 / 39
8/8
3/3
60 / 60
23.8 / 24
92.5 / 94
15 / 15
77.5 / 79
Patient survey results
The patient survey gives an indication of the perceived clinical effectiveness of consultations as
shown below:
Question
Satisfaction with continuity of care
Satisfaction with Doctor’s questioning
Satisfaction with nurse’s questioning
Satisfaction with how well doctor listens
Satisfaction with how well nurse listens
Satisfaction with how well doctor puts patient at ease
Satisfaction with how well nurse puts patient at ease
Satisfaction with how much doctor involves patient
Satisfaction with how much nurse involves patient
Satisfaction with doctor’s explanations
Satisfaction with nurse’s explanations
Satisfaction with time doctor spends
Satisfaction with time nurse spends
Satisfaction with doctor’s patience
% response
good
and above
68
96
95
96
97
95
98
94
95.5
93
98
92
96
95
% response
fair
and above
94
99
98
99
99
99
99
99
99
99
99
99
99
99
14
Satisfaction with nurse’s patience
Satisfaction with doctor’s caring and concern
Satisfaction with nurse’s caring and concern
98
96
97.5
99
99
99
After seeing the doctor today do you feel more able to
understand your problem/illness?
Yes
85
After seeing the doctor today do you feel more able to cope
with your problem?
Yes
83
After seeing the doctor today do you feel more able to keep
healthy?
Yes
79
Anticoagulation Clinics
The practice takes part in quarterly NEQAS surveys to ensure accuracy of readings and the
latest result from February 2011 survey is shown.
The practice also reviews data reported from INR software, a summary of which is below:
Number of patients / tests 1/4/10 to 31/3/11 was 154 patients and 1756 test
Variance report 1/4/10 to 31/3/11
Within 0.5
Within 0.75
INR above 5
INR above 8
>1 INR unit below Target
1196
1422
13
0
71
Percentage 68%
81%
1%
0%
4%
Number
Adverse events report 1/4/10 to 31/3/11
There were 7 minor adverse events recorded. All made a full recovery with observation only and
did not involve admission
Cardio Vascular Disease Checks (NHS Health checks)
Since the launch of this service in November 2010 the Practice has undertaken 104 reviews. Of
those 20 patients were referred on for Lifestyle interventions and 21 were started on specific
treatments. This is therefore proving to be a clinically effective service.
Infection control audit
The annual Infection Control Audit was undertaken in February by Solihull Care Trust Infection
Control team and the Practice received a 96% compliance rating. An action plan has been
developed to address areas that did not reach 100% compliance, although some of these are
beyond immediate control or have been deemed acceptable risk i.e. carpets in GP consulting
rooms.
15
Minor Operations
The following figures show a breakdown of the minor surgical procedures carried out during the
last 12 months. The incidence of wound infection was zero.
Report Results: Minor Surgery Audit
Procedure
Patient
Count
12
2
1
142
154
4
12
78
7
6
Injection of carpal tunnel
Minor surgery done -aspiration
Minor surgery done - incision
Minor surgery done - excision
Minor surgery done - injection
Golfer's elbow injection
Tennis elbow injection
Injection of knee joint
Injection for plantar fasciitis
Injection for tenosynovitis of finger
Item
Count
17
2
1
153
221
4
16
106
7
8
Percentage
of the total
4.0 %
0.7 %
0.3 %
46.9 %
50.8 %
1.3 %
4.0 %
25.7 %
2.3 %
2.0 %
LARCS (Long acting reversible contraceptive services)
During the preceeding 12 month period the following fitting/removal of LARCS have been
undertaken.
Name
Implanon fitting
Implanon removal
IUCD Fitting
IUCD removal
Count
45
18
44
28
A survey of patients who had received an Implanon was undertaken to test the quality of the
service delivered. The return was 24%. Results are shown below:
Have you had an implant fitted?
Where was the implant fitted?
Do you feel all options were
discussed before fitting?
How did you find the fitting?
Do you still have an implant
fitted?
Would you recommend this
method?
Has your cycle settled down
after the fitting?
Overall how satisfied are you
with this method?
100% yes
Surgery 82%
Family Planning Clinic 18%
82% yes
V painful 0%
Painful 0%
Uncomfortable 36%
Not painful 64%
Yes 82%
No 18%
Yes 91%
No 9%
Yes 64%
No 36%
Very satisfied 45%
Satisfied 45%
Not very satisfied 0%
Dissatisfied 9%
Chronic Obstructive Pulmonary Disease
With a change of nursing staff the Practice was left without a qualified COPD nurse and was
aware that this would put a real strain on the service we deliver to patients. To minimise the
impact of this, the Practice worked with an organisation called POINTS through GSK who have
undertaken an audit and risk stratification and have worked with the nurse currently undergoing
the diploma course to maximise the reviews undertaken and the learning achieved.
16
The Practice will continue to support the nurse in completing her diploma and are looking to
recruit a further experienced nurse. This is an area for continued development for the
forthcoming year.
Prescribing audits
The Practice has undertaken several prescribing audits with the help of the Practice Prescribing
Support Pharmacist and these have resulted in ensuring ongoing effective and appropriate
clinical prescribing. The practice has also been able to make several switches to more costeffective drugs and a leaflet was produced to inform patients why this work is undertaken and
explain the difference between branded and generic drugs (“Why change my medicine?
Are generics really as good as their originals?”)
An audit of medication advised by hospital discharge letter was undertaken during the year and
showed an anomaly rate of 24%. This was repeated following discussion and the anomaly rate
was reduced to 4%. This audit is still being followed through as there are some concerns
regarding the basis and process of audit and this will therefore feature as part of the
developments for the forthcoming year.
Significant events
A Significant event is any event from which a learning point can be drawn. This can be positive
as well as negative. The Practice has a robust process for reporting, reviewing and learning from
significant events where appropriate. All reports are written up by clinician/staff involved and
passed to the Practice Manager who will arrange review at the next practice meeting (or earlier if
appropriate). All events are available on the practice intranet under the education pages in order
that they can be revisited and used as learning aids.
During the last 12 month period, the practice reported on 9 events, 4 of which were in response
to actions taken by other agencies that had impacted or had the potential to impact our service.
There were no RIDDOR reportable events
Research initiatives
The practice has previously been involved in national research initiatives through the MRCP,
however none have been undertaken in the last 12 months.
We are currently considering taking part in the Active Women Study: Exercise & menopausal
symptoms.
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Statement from Solihull Primary Care Trust
Quality accounts are not yet mandated for primary medical services. Solihull Primary Care Trust is
therefore pleased to be able to provide a supporting statement for Meadowside Family Health Centre ‘dryrun’ quality account, which covers the period 1st April 2010 – 31st March 2011.
It is pleasing to note that Meadowside Family Health Centre has to date implemented a number of
initiatives to improve and enhance patient experience, patient safety and clinical effectiveness. Primary
medical services have a busy year ahead with the requirement to register with the Care Quality
Commissions ‘essential standards of quality and safety’. The PCT will continue to support the practice in
any future challenges and is committed to working together to ensure the achievement of the intended
2011/2012 quality initiatives detailed within this document. In addition this account has identified that the
participation of clinical audit (both at a national and a local level) could be further strengthened and the
practice will be supported in this. This will be a key priority for the PCT over 2011/12.
In our assurance role the information contained within this account is in our view a reasonable
interpretation of the data however it must be recognised that Solihull PCT is not able to corroborate the
accuracy of all data within this quality account.
It remains a key priority of Solihull PCT to ensure high quality, safe and effective primary medical
services are available for the population of Solihull. The continued implementation of the 2011/2012
quality initiatives detailed in the quality account provided by Meadowside Family Health Centre will drive
forward this priority.
E•N•D
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