MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
QUALITY ACCOUNT 2014-15
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. The practice we have successfully navigated
through CQC inspection, RCGP quality award, yellow card notification, responding
to the Francis report , piloting the Moor Green Lane Friends and Family’s test,
undertaking safeguarding training & monthly safeguarding MDT meeting, publishing
our first practice quality account but not forgetting the yearly QOF activity and
DES/ES performance, piloting 15 minutes appointments, the work indeed seem
unremitting but rewarding.
The level of work undertaken in the practice on quality and safety issues in the last 12
months is really unprecedented and we have successful completed all the work around
CQC’s 28 outcomes and RCGP accreditation especially domains 2, 3, 4, & 5. Some
examples such as audits, PACT review, personal learning plan, practice business
development plan and in house education strategy all reflect strongly the quality &
safety agenda.
CQC inspection visit highlighted the following:
 Patients' needs were assessed and care and treatment was planned and delivered in
line with their individual wishes. Patients told us they were treated with care and
respect and provided positive feedback. One patient told us: "I just think generally
the patients are at the heart of this practice and care is paramount".
 We spoke with another patient about the care their relative received. They said: "I
just know whoever she sees she'll have good treatment".
 We found that the premises were appropriate and all areas of the practice were seen
to be hygienic and well organised.
 The practice had an effective system to regularly assess and monitor the quality of
the rest of the service that patients received. All patients spoken with were
complimentary about the services they received
Patient’s safety will be the focus of our activity with the yellow card/service alert
notification scheme, significant event analysis, patient safety folder update on shared
drive, review of patient complaints, weekly review of high impact patient reviews,
MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
problem case reviews and CQC related safety measures implementation e.g. infection
control audit, adopting the NPSA safety audit toolkit & policy reviews.
The challenge is to maintain our current high standards in primary care quality
metrics as reflected in our current performance in QOF, CQC inspection & primary
care dashboard. Rising practice list size, workload and shrinking resources remain the
main threats to quality and safety performance.
Weekly Friday clinical meeting remains the bedrock of our practice quality and
safety review. These meetings continue to be the focus for reflection, and putting our
collective heads to together to share and solve problems. Minutes of the meetings
reflect this well and continuous improvement and learning is strongly embedded in
the practice. Core topics on the agenda are high impact patients, referral
benchmarking, problem case reviews, audit feedback, guidelines updates and
evidence based practice. Joint learning with our colleagues is the way forward and our
local primary care team including district nurses and community matrons and health
visitors join us on a fortnightly basis. We spend considerable time on individual
reflective case reviews during these meetings.
Feedback from our patients and service users is a good barometer of our quality
performance and helps us capture the quality metrics that is important to patients. The
development of a modified GPAQ survey/friends & family with the assistance of our
PPG group. The results will be reviewed by the patient group and published on our
website and patient newsletter. Our quality data is captured in our quality account
document & practice development plan which will be published annually.
The key areas we would like to prioritise within our quality improvement strategy
over the next 12 months (2014-2015) are
1. Over 75 enhanced care via the housebound MDT visits
2. Sustain our response to the Francis report with provider FFT & yellow
card/service alert notification & also introduce own practice FFT
3. Achieving quality targets & positive patient experience data capture within
LIS & DES/ES performance
4. Improve clinical coding of problems on EMIS (read codes)
5. Improve respiratory care via the PCRS quality award.
6. Improving quality of access
What actions
1. Over 75 enhanced care
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Maintain housebound & ambulant over 75 years patient register
Record carer details in all patient records
Full MDT health review visit/review at least once a year (GP, district nurse & community
matron & case manager)
Develop over 75 years care plan & housebound patient medical pack with all important
medical information updated
Mailing list for quarterly newsletter to housebound patients
Capture patient experience/feedback via patient survey
MOOR GREEN LANE MEDICAL CENTRE
339, MOOR GREEN LANE, MOSELEY, BIRMINGHAM B13 8QS
TELEPHONE: 0121 411 0393 FAX: 0121 471 2925
2. Provider FFT & yellow card notification & Practice FFT
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Prepare report of provider FFT (7 questions) on feedback received so far for CCG
Develop new FFT questionnaire tool (LMC model) to monitor & record patient experience
Continue to report any complaints or compliments via the yellow card /service alert system
Link any incidence from yellow card reporting to significant event reporting where
appropriate
3. BSC LIS & DES/ES quality targets achievements
 Review and provide care plans to LTC patients
 Capture patient experience via patient satisfaction survey e.g modified GPAQ/FFT
 Continue to undertake weekly referral benchmarking/review high impact patients
 Review monthly referral league tables
 Identify learning needs and invite to local speaker meetings
 Greater IT use/data review e.g. GPADS or MICS to review real time data on hospital activity
 Maximise use of patient education leaflets
 Keep patient informed of local services via website and newsletters
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Use Blue Stream Academy eLearning for staff training
Keep on track on offering CVD risk assessment or other risk profiling tool to all patients over
40 years
4. Emis clinical coding
 Clinical read coding of significant problems from docman letters where appropriate
 Updating clinical active problems
 Linking all repeat medication to active significant problems with medication reviews
 Migrate to EPS prescribing
 Read Code all referrals with active significant problem
 Update population manager and pop up utility on EMIS system
 Develop paperless solution including electronic referrals, e-fax & email platform
 Undertake year end audit on clinical coding
5. PCRS Respiratory Quality award
 Complete the 9 modules and associated standards covering clinical, organisational and practice
team topics.
 NC to undertake diploma in COPD
 Improve quality respiratory care via RQIP
 Develop action plan to submit evidence within 18 months.
6. Improving quality of access
 Piloting 15 minutes routine appointments with doctors
 Access to online appointments via NHS choices website
 Explore online access to records/summary care records
 Provide care plans and telephone access
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. New IP telephones. 96% satisfaction with access
ranked one of the highest in the CCG
 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
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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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.
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!!)
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
 Smoking clinic level 1
 Minor injuries service
 Wound management
 Extended minor surgery service – cryotherapy, intra-articular injection, excision and
incision
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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Travel vaccination and advice clinic
Second line therapy drug monitoring/near patient testing
ECG service
Enhanced diabetic service including insulin initiation
Learning disability service
Weight/diet advice
In- house phlebotomy
Zoladex injections
Extended hours half day /extended evening LES
Respiratory quality improvement programme
NHS health check DES
Dementia screening DES
Choose & Book
I&MT
BSC CVD LIS
Enhanced respiratory services including spirometry
24hr hour BP monitoring and ECG service
Referral benchmarking and high impact patient reviews
Other services
 *** New*** ultrasound service
 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)
 Bi annually PACT data analysis
 Achievement of prescribing incentive scheme targets
 Lowest prescriber of cephalosporins and quinolones with Central network
Audits & Surveys 2013-2014
 Audit gout management
 Management of hypertension
 Audit on long term reversible contraception
 Patients on proton pump inhibitors
 Vitamin b12 audit
Equipment levels
 6/12 lead ECG with interpretation and PC link (full computerised)
 Omron ECG heart scan
 24 hour ABPM BP monitor
 Microloop spirometer
 Vital Signs Spot check
 Nonin Pulse Oximeters ( measuring oxygen saturation)
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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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 2013-14
Full compliance to CQC standards June 2013
 RCGP practice accreditation December 2013
 Finalist GP awards – CVD team & respiratory team & commissioner of the year
respiratory
 Consistent high scores (GPAQ & Mori Poll) with patient enablement questions >90%
 Primary care dashboard NHS West Midlands QI & Public health Observatory data–
higher level
 Flu vaccination over 65’s 92% ranked 2nd highest position 57% for at risk group &
pregnant women pregnant women within BSC CCG
 Cervical cytology ranked 2nd highest 85-87% in BSC CCG
 Childhood Immunisation targets 1st year 100%, year 2 & MMR 95%
 Housebound Patient health reviews
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