MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
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QUALITY ACCOUNT 2015-16
Introduction
Quality is at the heart of everything we do within the NHS and is deeply embedded
into the DNA of Moor Green Lane Practice. Below is our quality strategy and outline
of the key quality priority actions we would like to carry out in the next 12 months.
We have also summarized the quality metrics that the practice has already achieved.
Quality improvement strategy
We remain committed to our core values in delivering high quality personal care to all
our patients. Our aim is to provide the high quality of care in a friendly environment
with good access and continuity of care. Having achieved RCGP quality award in
December 2013 we have made steady progress piloting the Moor Green Lane Friends
and Family’s test, introducing FFT feedback via paper but also online on our new
practice website, undertaking housebound MDT visits, achieving CQC band 6 rating
with intelligent monitoring (lowest risk), extending to 15 minutes GP & nurse
consultations, adopting e-GP form reporting on patient safety but also not forgetting
achieving the highest QOF targets and DES/ES performance, the work indeed seem
unrelenting but rewarding.
How did we perform in the last 12 months?
Over 75 enhanced care – key elements achieved
 Housebound register maintained/coded
 All housebound patients visited at least once, many twice. No of visits=
 Introduced a health care pack which will be offered in a plastic wallet with magnetic strip that
can attached for e.g. to the fridge for easy access.
 Care plans provided =
X Feedback captured verbally but need to administer patient questionnaire
Provider FFT & yellow card notification & Practice FFT
 Report of provider FFT (7 questions) on feedback received presented to CCG board (plans
discussed how to progress this further within the CCG) see key finding below in appendix
 FFT questionnaire tool with additional quality questions agreed with PPG and now
implemented via an online tool on our new practice website –www.moorgreenlanemc.nhs.uk
 Feedback so far excellent (see below headline results)
 Continue to report any complaints or compliments via the yellow card /service alert system
has been achieved. Number of yellow cards submitted=
 Supporting development of new revised yellow card
 Activated and submitted serious incident reporting via e-GP form
 Serious incidence from yellow card reporting linked to significant event reporting where
appropriate –achieved
BSC LIS & DES/ES quality targets achievements
 Care plans to LTC patients patient achieved maximum targets reached with CVD LIS & RQIP
 Capture patient experience via patient satisfaction survey achieved using CCG designed
survey and our own FFT questions
“Quality, Friendly, Personal, care for all”
MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
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Continue to undertake weekly referral benchmarking/review high impact patients achieved
Review monthly referral league tables (partially achieved recent 2 quarters not reviewed due
to workload and shortage of admin staff)
 Identify learning needs and invite to local speaker meetings achieved with talk on ENT and
orthopaedics
X Greater IT use/data review e.g. GPADS or MICS to review real time data on hospital activity
– using GP homepage UHB as main source, others difficulty assessing due to ongoing IT issues at
the practice. See our new IT quality indicator for this year
 Maximise use of patient education leaflets partially achieved some IT issues
 Keep patient informed of local services via website and newsletters achieved with launch of
our new website.
X Use Blue Stream Academy eLearning for staff training – although available little time for staff
to achieve training except via practice PLT
 Keep on track on offering CVD risk assessment or other risk profiling tool to all patients over
40 years- achieved and good progress with NHS health checks = over 40 ..% achieved
Emis clinical coding
 Clinical read coding of significant problems from docman letters where appropriate –making
good progress but rising workload
 Updating clinical active problems –making progress
 Linking all repeat medication to active significant problems with medication reviews –
ongoing
 Migrate to EPS prescribing –work in progress estimated September 2015
 Read Code all referrals with active significant problem -ongoing
 Update population manager and pop up utility on EMIS system
X Develop paperless solution including electronic referrals, e-fax & email platform –slow
progress due to IT issues (see our new quality indicator)
X Undertake year end audit on clinical coding –due to ongoing IT issues
PCRS Respiratory Quality award
X Improve quality respiratory care via RQIP –unfortunately no progress due to staff changes
Improving quality of access
 Piloting 15 minutes routine appointments with doctors – now adopted as practice standard
 Access to online appointments via NHS choices website –achieved online booking now
available via EMIS web on both websites
 Explore online access to records/summary care records – now made available on surgery
website
 Provide care plans and telephone access –achieved. Net increase in telephone consultation
seen last 12 months.
Achievements
It is pleasing to see that we have achieved most of the targeted activity with a few
exceptions despite the significant increase in workload and difficulty with recruitment
and retention. Having lost a key member of the nursing team and several
receptionist/admin staff we not able to progress with the respiratory quality award.
Migration to a new server and Windows 7 had a major negative impact on practice
performance and there is still ongoing issues. It was an ambitious programme with 6
key areas for improvement and our assessment and based on the above assessment we
have done well with the majority of the workflow from 5 out of the 6 targets achieved.
The challenge is to maintain our current high standards in primary care quality
metrics as reflected in our current performance in QOF, CQC IM & primary care
“Quality, Friendly, Personal, care for all”
MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
3
dashboard. Rising practice list size, workforce (recruitment and retention), workload
and shrinking resources remain the main threats to quality and safety performance.
The key areas we would like to prioritise within our quality improvement strategy
over the next 12 months (2015-2016) are:
1. Reduction in Medicine wastage and Quality Prescribing initiatives
2. Patient Safety focus with a raft of new reporting & monitoring tools such as
the use of the new yellow card system and NRLS e-GP form submissions
3. Achieving quality targets & positive patient experience data capture within
LIS & DES/ES programmes (roll over from last year)
4. Improve IT applications and solutions in clinical practice
5. Workforce training and awards
6. Improving quality of access (ongoing)
What actions
1. Reduction in Medicine wastage and Quality Prescribing initiatives
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Review current repeat prescription policy
Tighten rules on request of prescriptions no third party request
Campaign to promote reduction medicine waste & awareness of cost - Patient leaflet and
newsletter/information/flyers via PPG involvement
 Reduce antibiotic and NSAI/analgesia prescribing
 Face to face review of repeat meds including OTC medicines use
 Increase reporting of prescribing SI
 Migration to Electronic prescribing system
 Improve communication with local pharmacist
 Reduce quantity and volume of prescribing e.g insulin
2. Focus on patient safety
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Continue to report any complaints or compliments via the revised yellow card /service alert
system
Link any incidence from yellow card reporting to significant event reporting where
appropriate
Undertake reporting via E-GP form to NRLS
Undertake significant incidence review/RCA’s within practice and local network
In house PLT patient story on quality and safety standing item
Referral under 2 weeks rule monitor patient outcome
Review all complaints related to patient safety
3. BSC LIS & DES/ES quality targets achievements & improving patient experience
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Capture patient experience via patient satisfaction survey FFT/CCG QOL patient experience
questionnaire
Review and publish NHS survey & FFT with PPG consultation
Continue to undertake weekly referral benchmarking/review high impact patients
Promote & maximise use of patient education leaflets e.g. self-help organisation booklet, NHS
tests etc. link to surgery website tools
Keep patient informed of local services via website and newsletters
Audit LIS performance e.g. diabetic prevalence, health check uptake, dementia diagnosis, post
hospital discharge reviews.
4. Improve IT applications and solutions in clinical practice
“Quality, Friendly, Personal, care for all”
MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
4
 Review and re install all word document templates configured to EMIS web with support from
IT clinical facilitator
 Achieve paperless solution including electronic referrals, e-fax & email platform
 Paperless solution -Reduce paper copies/fax and use electronic e-fax or email.
 Progress to 80% GP2GP record transfers
 Implement online expanded record access
 Updating clinical active problems (patient summary pop up prompt)
 Linking all repeat medication to active significant problems with medication reviews
 Migrate to EPS prescribing
 Read Code all referrals with active significant problem
 Develop linked clinical protocols
5. Workforce training and awards
 Identify learning needs and invite to local speaker meetings
 Use Blue Stream Academy eLearning for staff training
 Identify staff learning needs via appraisals
 Recruit Apprentice training
 Support doctors & nurses revalidation & appraisals
 Develop & maintain practice staff training register & CPD activity
 Annual staff award for outstanding contributions
6. Improving quality of access
 15 minutes routine appointments with doctors & nurses standard
 Open Access appointment to children under 12 years
 Access to online appointments via NHS choices website/mysurgery website
 Online access to expanded coded records/summary care records
 Provide care plans and telephone access
 Ensure adherence to referral pathway- coding/patient information on referral/internal
benchmarking
WHAT DO WE OFFER AT THE SURGERY
Access & information
 Average 90% of patients seen within 48 hours
 Surgery open all day from 8.00am to 7pm every weekday and till 8pm on Wednesdays
 Telephone access all day as above. 96% satisfaction with access ranked one of the highest
in the CCG (source: NHS MORI poll survey)
 Urgent appointment same day/emergency appointment available during current surgery
session
 Telephone consultation/triage doctor & nurse available between 12.30-1.30 p.m. & 44.30pm
 Dedicated line for health professionals/high impact patients
 Online booking appointment and repeat prescription request
 Updated Choices Surgery website -internet access/ up to date information 24 hours a day
which patient can access.
 New surgery website –mysurgery
 Flu vaccination over 65years >92%, breast screening 79% and smears >85%
 Practice patient Newsletter every quarter
 Comprehensive Practice booklet
 LED plasma screen patient information & call system in the waiting room (up to date
information while you wait!!)
“Quality, Friendly, Personal, care for all”
MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
5
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PHILS – patient information leaflets on a wide variety of clinical and non clinical
information (** currently 150 different leaflets available)
GP services focus – a series of patient leaflets on the services we offer at the practice
Primary Care team - a series of information leaflets on who and what staff do at the
surgery
Female doctor available 5 evening surgeries and 5 mornings every week**
Health care assistant 5 days per week with walk in blood test &investigations clinic
28 general surgeries per week (16 morning & 12 evening)
5 clinics per week – antenatal/CHS/well person& travel/respiratory/Vascular &
diabetes/hypertension
Practice nurse available 5 mornings and 5 evenings
Surgery facilities
 Purpose built surgery
 Compliant for CQC and disability access regulations
 Surgery extension 2009 with new health care assistant room, 3 consulting rooms and
offices & conference room on 1st floor
 24 hrs CCTV security system
 Disable access and disabled toilet facilities ** automatic front entrance doors
 Breast feeding facilities *** new ***
 Refurbished Emergency room 6
 Nappy changing facilities
 Private secure car-park with **security cameras
 Staff library/internet access/equipped kitchen
 Fully equipped treatment room
 Practice library - new books and material & computerised (Microsoft access data base)
 Hearing loop
Chronic disease management
 Hypertension/IHD/Asthma/COPD/Diabetic/Well women/man clinics
 ARTP accredited Spirometry /nebuliser service
 High level achievement local improvement service/ES and RQIP
 >90% CVD/NHS health check undertaken
 92% of practice population (15-110years) BP recorded
 93% of BMI/weight
 93% of smoking history age 15 years onwards last 15 months
 90% of alcohol history
Enhanced services /Direct enhanced service and local improvement scheme
 Insulin initiation LES to continue quarterly submission (see schedule) to CCG (new
LIS being developed)
 ECG LIS – current roll over quarterly submission, but new LIS being developed
ES
 Minor surgery
 Smoking cessation level 2
 Avoiding unplanned admission
 Diagnosis and Support for People with Dementia
DES
 Learning disability
“Quality, Friendly, Personal, care for all”
MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
6
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Extended hours access scheme DES
CVD screening 40-75 years
Hepatitis B for new born babies at risk
MenC vaccination booster for freshers
MMR (SFE) - for patients over 16 who self present at practices
Seasonal Flu vaccine- carers/liver disease/pregnant women
Seasonal Flu 2-4 years old
Pneumococcal
Shingles (routine cohort patients aged 70 & Catch up programme (patients aged 7879)
Pertussis in pregnant women
Rotavirus routine childhood vaccination
Meningococcal B vaccine childhood immunisation programme
Meningococcal ACWY (MenACWY) 14-18 year olds
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LIS
 BSC CVD LIS
 RQIP
 Over 75 yrs LIS
 Quality Premium LIS – safeguarding/end of life/Impact risk profiling/MDT meeting
 Patient promises LIS – cancer f/up & pathway
Other services
 Ultrasound service now extended to gynae scans
 All higher childhood vaccination targets met
 Mental health advisor 1 sessions per week
 **CBT practitioner session 1 per week
 Chiropody 1 session per week
 Housebound patient MDT reviews
 Yellow card/service alert monitoring
 Full IT and paperlight accreditation since 2010 including E-fax
Prescribing
 High generic prescribing 86% and high level of compliance with prescribing
performance indicators
 Indication labelling with prescriptions (recent audit 90% of repeat prescriptions)
 Achievement of prescribing incentive scheme targets
 2nd lowest prescriber of cephalosporins and quinolones with Central network
 Astro PU/NIC - 42.33 2nd best in the central network
Audits & Surveys 2014-2015
 Urgent appointment Audit
 Stroke prevention in AF patients
 Gestational diabetes
Equipment levels
 6/12 lead ECG with interpretation and PC link (full computerised)
 Omron ECG heart scan
 24 hour ABPM BP monitor
 Microloop spirometer
“Quality, Friendly, Personal, care for all”
MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
7
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Vital Signs Spot check
Nonin Pulse Oximeters ( measuring oxygen saturation)
Fetal Heart Doppler/CO monitor
Pro-pulse 11 ear irrigation system
Vascular flow Doppler
Cryo- success Cryotherapy equipment
Electro- cautery/dermalite basic
Fully equipped for minor surgery with disposable equipment
Fibro-optic Auroscope and Opthalmoscope/new Reister LED diagnostic sets
TENS machine/resuscitation kit/electronic sphygmomanometer/CO monitor
Defibrillator
Electrically operated plinth and many more!
Practice
 100% of medical records summarised
 Electronic transfer of records
 Fully computerised/ read code use 99%/fully computerised appointment system.
 15 minutes booking intervals for doctor consultations and 15 minutes for nurse
consultation.
 Active patient participation group
 NHS net/direct Path links/Choose & Book
 Accredited training practice GP registrars, FY2’s and medical students
 Personal learning plan (staff & doctors)
 Annual Practice development plan
 Practice health directory ( comprehensive list of local services/health care access)
 Practice manual – complete reference to administrative and clinical procedures/ protocols/
guidelines used in the practice.
 Regular practice educational/ clinical meetings
 Referral benchmarking
 GOLD framework palliative care
 Significant event monitoring
 Regular staff training/appraisals
 BMA staff contracts
 Active PPG group
Quality Achievements 2014-15
Consistent high scores (GPAQ & Mori Poll) with patient enablement questions >90%
 Maximum QOF performance
 Full achievement RQIP & CVD LIS
 Demand management targets met (reduction) in outpatient activity and non elective
admissions
 Flu vaccination over 65’s 92% ranked 2nd highest position 57% for at risk group &
pregnant women pregnant women within BSC CCG (2013-14)
 Cervical cytology ranked 2nd highest 85-87% in BSC CCG
 Childhood Immunisation targets 1st year 100%, year 2 & MMR 95%
 Housebound Patient health reviews
 1st outpatient appointment per 1000 12th lowest ranking within CCG
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“Quality, Friendly, Personal, care for all”
MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
8
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DNA 1st outpatient appointment lowest in CCG
1st attendance orthopaedics per 1000 6th lowest ranking in CCG
Respiratory admission 3rd lowest in CCG per 1000 patients
Diabetes admission 9th lowest per 1000
Emergency admission for chronic condition per 1000 3rd lowest raking in CCG
10th lowest total admission expenditure per patient in CCG (2010)
5th lowest emergency admission expenditure per patient in CCG
Childhood Immunisation targets 1st year 100%, year 2 & MMR 100%
Maximum QOF score 2014-15
Highest ranking in CCG for overall patient satisfaction ,quality & access (MORI
Poll)
SMI health check highest ranking
Emergency admission 3rd lowest per 1000
A&E attendances 2nd lowest in CCG per 1000
CVD screening re-audit – 95% screened
Primary care dashboard GPOS higher achieving practice status
92 % smoking status recorded
Last BP reading in 15months <150/90 third highest in CCG 95.8%
% satisfied with telephone access -100% ranked top place in CCG
Ranked 2nd place within CCG for satisfaction with opening hours
“Quality, Friendly, Personal, care for all”