Aiming for Excellence
RNZCGP Standard for NZ
General Practice
2011
Dr Chris Fawcett
Maureen Gillon
Waveney Grennell
Aiming for Excellence
– what is it & who uses it?
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RNZCGP Standard for NZ General Practice
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Reinforces the unique character & contribution of general practice
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Makes the values of general practice explicit
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Provides a guide to building a platform to manage increasing diversity and
complexity to facilitate a patients journey
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Is the standard used by 800 practices in the CORNERSTONE programme
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Increasingly used by other sector organisations as a benchmark
Review of Aiming for Excellence
RNZCGP Governance
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RNZCGP Council
RNZCGP Board
RNZCGP Professional Practice Expert Advisory Group
Aiming for Excellence Expert Advisory Group
Sector interest
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General practices
RNZCGP Programmes; CORNERSTONE, Education, MOPS
CORNERSTONE Assessors
NZ College of Practice Nurses NZNO
PMAANZ – practice managers
Wellington School of Medicine – clinical effectiveness work
General Practice Networks
Consumer/communities
Health & Disability Commissioner
PHOs
DHBs
NGO/Community sector, Te Wana
MOH
Health Quality & Safety Commission
Health IT Board
ACC
The Development Team:
Aiming for Excellence Expert Advisory Group
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Dr Chris Fawcett (Chair, CORNERSTONE Chief Censor)
Dr Jane Burrell (Chair, Professional Practice Expert Advisory Group)
Dr Tane Taylor (GP, Te Akoranga a Maui, CORNERSTONE Assessor)
Dr Jim Vause (GP Te Akoranga a Maui, GP Assessor)
Dr Jocelyn Tracey (GP, PHO Performance Programme)
Dr Malcolm Dyer (GP, PHO Performance Programme)
Dr Jane O’Hallahan (RNZCGP Group Manager Professional Practice)
Dr Keri Ratima (GP, RNZCGP Tumauaki Maori Principal Advisor)
Helen Bichan (Service User)
Jane Ayling (CORNERSTONE Assessor, Practice Nurse, NZNO)
Rosemary Gordon (CORNERSTONE Assessor, ProCare Quality Manager)
Hayley Lord (Quality Manager, Midlands Health Network)
Luis Villa (Advisor, Midlands Health Network)
Kevin Rowlatt (Practice Manager)
Waveney Grennell (RNZCGP CORNERSTONE Manager)
Jeanette McKeogh (RNZCGP Senior Policy Advisor, legal)
Madhukar Mel Pande (Advisor, Research)
Helen Glasgow (RNZCGP CORNERSTONE QI Coordinator)
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Dr Roshan Perera (Academic Advisor)
Dr John Wellingham (Peer reviewer)
Stella McFarlane (Peer reviewer)
Maureen Gillon (Project Lead)
Method
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First consultation phase – 6mths
Review of quality landscape & literature
Feedback from CORNERSTONE practices & assessors on 2009 version
Legal, safety and risk criteria updated
Other criteria reviewed
A4E working group – rebuild
Testing for SMART – specific, measurable, achievable, relevant, timely:
– Notified general practices, networks and sector organisations
– Consumer workshops
– Practice visits
– Sector workshops
– Targeted organisations
Second consultation phase
Refinement by A4E Working Group
Peer review
A4E Expert Advisory Group Handover & recommendation
Signoff by College Board & Council
Result of feedback on previous version
Improved relevance and acceptability:
– Legal safety & risk measurements were revised and
updated
– Duplication stripped out
– Reduced number of indicators and criteria
– Clarity was improved
– More emphasis on the patient journey – integration,
continuity, transfer of care
– Emphasis on results
– Greater emphasis on clinical effectiveness
– Standards ratified by College
A new structure was developed to reflect current
thinking by the College
4 areas:
– Patient experience
– Practice Environment &
Safety
– Clinical Effectiveness
Processes
– Professional Development
Purpose:
– Focus on improving
outcomes for patients
Improving
outcomes
for patients
Improved understanding about the intent of criteria
– Needed to improve specificity of each criterion
– Removal of the guide to interpretation to improve
understanding and enable the CORNERSTONE programme to
provide better advice to practices
– Introduction of a rationale
Indicator 16
The practice ensures effective infection control to protect the safety of patients and team members
Criteria
16.1
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Rationale
The practice can demonstrate that its infection
control policies and procedures align with the
AS/NZS 4815: 2006 Standard
Effective infection control
measures protect the health and
safety of people using and
working in the practice, and
implementing them is a prudent
risk management activity
A focus on supporting the patient journey
Supported by the findings from the Voyage to Quality work –
R. Perera, more emphasis on:
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Clinical effectiveness
Systems to manage patient care
Robust information
Transfer of care
Continuity
• Integration
Next steps: Enabling clinical effectiveness
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A General practice Quality System
RNZCGP Quality Framework
New three year structure incorporating clinical effectiveness
requirements for CORNERSTONE
Clinical Effectiveness Modules
A CORNERSTONE resource library – practice access to
modules
Clinical outcome indicators
The Healthcare Quality Measures NZ – library of indicators
(Patients First) – practice access to clinical measures
Clinical management tools – PHOs
Patient self management
Feedback loops – results
Publish the Profile of CORNERSTONE General Practices 20092011
Principles
Self directed PDSA cycle
Based on quality framework
Team process
Years 2 and 3
Peer mediated
Variety of modules and measures
• National, local or individual practices
Example
Notes
Area of interest
Define the area of interest in
broad terms initially.
Prescribing analgesics
Goal of activity
What do you hope to achieve?
Start with broad objectives and
refine as required.
The scope needs to be clear,
sometimes working through the
module development the scope
will need to become more
focussed but sometimes it may
need to become broader.
To ensure safe repeat
prescribing of analgesics.
Scope of activity
All processes for repeat
prescriptions of analgesics.
Note: This could be widened to
all prescribing (including first
time prescriptions) or narrowed
to repeat prescribing in the
absence of a face to face
consultation.
Practice
Environment
Description of
current situation.
In what setting
does this currently
occur?
Notes: Have you
identified all
possible settings?
Patients ring for
scripts from the
nurse
What is the
system(s)?
Scripts written at
request of nurse.
Perceived
problems or
questions about
the current
situation
Not all patients have
phones.
Scripts needed very
quickly – i.e. same
day
Receptionists take
the notes.
Potential solutions
No checking of time
since last
prescribed, change
of dose, other
providers prescribing
or interactions.
Potential for abuse
of drugs, escalating
doses and short
times between
scripts.
Protocol for the
checking of scripts
e.g. last time seen,
last time prescribed,
any visits to pain
clinic, Oncology etc
every time a script is
requested by the
nurse
There is a mix of
prescribing, both
generic and by
brand. The nurses
don’t always
understand the
drugs.
Education session
about the drugs
names and
prescribing by the
PHO pharmacist
Practice Environment
Notes: Identify all
systems in all
settings. Systems
may be informal or
formal – focus on
what actually
happens not what
is meant to
happen.
What are the
Nurse needs to
competencies
know drug names
required?
and details.
Notes: Align with
the problem
definition and
ensure
competencies of all
All requests to be
left on a prescription
phone line (answer
phone) with a clear
message that
patients need to
leave their details
and the scripts will
be available in one
working day.
Chosen solutions
What are the
organisation and
practice supporting
systems?
Notes: Consider both
formal and informal
systems, i.e. what
really happens?
What are the IT
systems?
Notes: Consider the
IT system in the
practice but also
systems in other
organisations such
as pharmacies, PHO,
manual systems and
gaps.
Are their problems
with practitioner
knowledge?
Notes: Ensure
knowledge of all
relevant practitioners
is covered.
What are the current
educational activities
which can provide
input e.g. RNZCGP
faculty, BMJ learning
etc.?
What are the
important
relationships within
the practice?
Notes: Consider
There is online MIMS
and a pharmacy
website
The information is
not presented in a
user friendly manner
and it is difficult to
identify the critical
information.
Identify a resource
online for quick
access by all clinical
staff or develop one
with the PHO
pharmacist
Scripts are written by
hand in triplicate and
also have to written
into the paper notes
Double handling and
the risk of having a
discrepancy between
the hand written script
and the computer
records
No clear solution – but
lobby the MOH to
change for computer
generated scripts.
Doctor has to
understand the pain
ladder and how to use
the drugs appropriately.
There has to be
coordination between
the doctors about the
approach to pain.
The doctors have a
poor understanding of
the pharmacology of
the drugs, their
interactions and the
pain ladder.
Each patient has a pain
management plan
clearly identified in the
notes.
Training from the PHO
pharmacist about the
pain ladder and
analgesic use.
Education from the
Hospice service.
Education from the
Pain Clinic
The nurses and
doctors have to have a
common approach to
repeat prescribing
The scripts are often
presented to the doctor
at the end of the day
and create frustration
and tension in the
Dedicate specific time
i.e. block out an
appointment for the
doctor and nurse to
review request for
Relationships
What are the
important
relationships within
other providers?
Notes: Consider
formal and informal
relationships and
what actually
happens.
What are the
important
relationships with
patients?
Notes: Consider
formal and informal
relationships and
what actually
Are there other
important
community
relationships?
Notes: Consider
formal and informal
relationships and
what actually
The pharmacists need
to have a clear
understanding of the
processes by which
these drugs are
prescribed and have a
clear understanding of
their role in
communicating with
the doctors about
problems e.g. drug
interactions, excess
prescribing
Patients and doctors
must have a common
understanding about
how the prescriptions
will be written , how
long it will take and
how often they need
to be seen
At times patients may
need the pain clinic,
drug and alcohol
services or even the
police.
Lack of
communication
Invite pharmacist to
be involved in
reporting back
problems with
prescribing in a
manner which is
effective for the
practice, the
pharmacy and the
patient.
Patients expect to get
the medications at
short notice and not to
have to attend for
review.
Communicate with the
patients via a targeted
newsletter and via the
answerphone
message about the
process of getting
repeat scripts
Patients may abuse
the drugs, be involved
in drug seeking or
need more specialised
input into their pain
management
Meet with the pain
clinic team about their
services.
Meet with the alcohol
and drug team.
If appropriate liaise
about general issues
with the community
constable.
Measuring
change
Notes: Measuring
change is important,
but measures must
be focussed on
information that is
useful to the
practice and is easy
to collect as part of
day to day activity.
Measuring
When will measure it?
Baseline measures
Notes: What do we
know about the
problem, both
qualitative and
quantitative
information?
How big is this
problem?
What information do
we need to gather
before we start?
What will we
monitor to
determine if our
changes have been
effective?
Notes: What can we
measure as we go
so that data analysis
can be facilitated?
What do we already
know about this
problem
Now
All patients have a
clear pain
management plan.
6 months
When will we review
this?
Query build and check
all patients have a
Pain Management
Plan
Critical events
Are there critical
events to monitor?
Notes: Do we have a
significant events
monitoring system in
place for this
particular problem.
Are we currently using
this?
Does it need to be
improved?
Prescriptions not picked
up.
Patients not being
reviewed.
6 months
Pharmacist to notify of
uncollected scripts
every month.
Query build to check all
patients reviewed.
Measuring user
evaluation
Notes:
Do we have baseline
measures about
this?
Do we need more
information before
we proceed?
How can we find
out what the
patients think about
this?
What are the
timeframes for
measuring?
How patients perceive 6 months
the service
Target short five point
patient questionnaire
about the service.
What is the
cost?
Notes:
Do we have baseline
measures about
this?
What information
can we gather as we
go?
Are their issues of
equity and how can
they be addressed?
Notes:
Do we have baseline
measures about
this?
What information
can we gather as we
go?
Will this service cost
6 months
money for the practice
or the patient.
Evaluate time spent in
scripts and script
charges.
As most patients on
long term medication
are on a benefit we
could add this to their
disability benefit
Query build to identify
patients on long term
medication and
whether a disability
benefit has been
completed
6 months
CORNERSTONE
• Practices in the CORNERSTONE programme use
Aiming for Excellence standards to develop their
practice systems
• Total number of general practices in NZ – 1086
• Registered with programme – 757 (70%)
• Accredited Cycle 1 – 640 (59%)
• Accredited Cycle 2 – 81 (62%)
• PHO – 69 (prior to amalgamations)
• DHB – 21
Next
• Continue to accept feedback on Aiming for Excellence
• Establish closer links with general practices to identify
clinical effectiveness opportunities
• Work with other general practice and primary care
organisations to support patient improvement
opportunities