History of the RCGP
What Sort of Doctor WSOD
Assessing Quality of Care In General
Practice
(Consolidated report from two working parties 1980-1984.
Published 1985.)
Chairman of First Working aprty J A R Lawson; Second Working
Party T P C Schofield.
Areas of Performance
- Professional Values
- Accessibility
- Clinical Competence
- Ability to
Communicate
2.
Accessibility
3. Clinical Competence
4. Ability to Communicate
1.
Professional Values
(a) The doctor tries to render a personal service which
is comprehensive and continuing.
(b) In his practice arrangements he balances his own
convenience against that of his patients, takes into account his
responsibility to the wider practice community, and is mindful of
the interests of society at large.
(c) He accepts the obligation to maintain his own mental and
physical health.
(d) He puts a high value on communication skills.
(e) He subjects his work to critical self-scrutiny and peer
review, and accepts a commitment to improve his skills and widen
his range of services in response to newly disclosed needs.
(f) He recognizes that researching his discipline and teaching
others are part of his professional obligations.
(g) He sees that part of his professional role is to bring
about a measure of independence: he encourages self help and keeps
in bounds his own need to be needed.
(h) His clinical decisions reflect the true long-term
interests of his patients.
(i) He is careful to preserve confidentiality.
(a) He can be seen quickly for urgent matters, and normally
within two days for non-urgent matters.
(b) He is prepared to visit patients in their homes.
(c) He is available for advice on the telephone at known
times.
(d) His staff are helpful to patients and see themselves as
facilitating the doctor-patient contact.
(e) He provides adequate out-of-hours cover.
(f) His patients are aware of the procedure by which the
doctor or his deputy can be contacted at any time of the day or
night.
(a) The doctor is shrewd, observant, and skilled at eliciting
relevant information.
(b) He works swiftly but surely, without undue sense of
rush.
(c) In general, his history-taking and physical examinations
are economical, and his notes pithy and informative; but when
occasion demands, he is capable of more exhaustive
procedures.
(d) His personal style of consulting is consistent but is
responsive to individual patients' needs and demonstates a logical
problem defining process.
(e) He links physical, social and emotional factors when
formulating his assessment of the patient and when planning further
management.
(f) He makes appropriate use of other members of the
practice's health care team, and of colleagues and agences
outside.
(g) He prescribes effectively, with caution and mindful of
costs.
(h) He carefully follows up his pateints and actively seeks to
learn the consequences of his action or inaction
(i) The clinical records he keeps helps him to monitor
patients' progress and to plan anticipatory care and preventive
measures.
(j) He employs opportunistic health education and constantly
reinforces advice on lifestyles; and by giving relevant infomraiton
freely to patients tries to encourage them to share responsibility
for thier own health care.
4. Ability to communicate
(a) The doctor is receptive, and conveys a sense of
attentiveness, of professional concern for the patient's unfolding
problem, and of personal commitment to the patient.
(b) He shares information and decision-making with the patient
as much as possible; the patient feels supported and encouraged by
the doctor and better informed than before, and so feels more
capable of handling future episodes of a similar illness.
(c) Notices and educational displays in the waiting room are
clear, and as far as possible positive and optimistic.
(d) The staff handle enquiries sensitively.
(e) Entries in the clinical records are legible, ordered,
pertinent, accurate and retrievable.
(f) They are capable of being used for teaching, research and
audit.
(g) Letters to consultants are informative and explicit about
the reason for referral and the doctor's expectations.
(h) The ancillary staff and other members of the practice's
health care team have frequent opportunity to meet the doctors
informally to discuss aspects of practice policy or matters of
mutual clinical interest.
(i) Times are set aside for more formal meetings when
longer-term issues can be discussed.
(j) The doctor is sensitive to the views of staff and anxious
to involve them in policy-making as far as
possible.
Criteria for
Assessment
Perception of Role
| The doctor sees himself as providing a service to his practice
population, sharing with others responsibility for promoting,
preserving and restoring the health of individual patients |
The doctor regards medical practice solely as a way of earning
a living or of encountering interesting clinical promoting,
preserving and restoring the health of individual material. |
Responsibilities
|
He balances his own convenience
against that of his patients, and keeps the interests of the
wider community in mind
|
He invariably puts his own convinience above the needs of
patients, and has no concern for his wider responsibility to
society. |
Personal Care
|
He believes in the importance of continuity of care, gives a
personal service, and tries to make it as comprehensive as
possible
|
He does not think continuity of care matters, delegates
excessively, and his clinical interests are dominated by one
or two hobby horses. |
Development
| The practice has continually evolved over the years
in response to newly disclosed health care needs, and
is continuing to do
so.
|
The nature of his practice is static. He is
not in touch with fresh developments within his own profession. He
regards the development of his practice as finished.
|
Professional Growth
|
He maintains and improves his skills, and continually
widens his horizons. He maintains his clinical curiosity and at the
same time feels involved with his patients' problems.
|
He allows intellectual atrophy to set in and practises in
a narrow, disjointed, mechanistic way. He relates only
superficially to his patients. |
Self-Awareness
| He subjects his work to
critical self-scrutiny and review by colleagues. He
enjoys being a general practitioner and he accepts the
obligation to maintain his own physical and mental
health. |
He is complacent about the quality of his
work and sees no point in reviewing it. He never reflects on what
he is trying to achieve. He has become cynical or defeated, or
drives himself excessively.
|
Personal
Behaviour
|
He is of good repute and known for his integrity. He displays
dignity in his personal behaviour and honourable dealing with his
partners.
He has good relationships with colleagues and staff.
|
In his personal
and private life he is not a good model. He is not well regarded by
his peers. |
Teaching and Research
|
He is interesd in teaching and research and sees these
activities as part and parcel of professional
life.
|
He is antipathetic towards anything to do
with the academic aspects of general practice and has no thought
for those who will follow him in his profession.
|
Communication
|
He places high value on communication,
and recognizes the importance of achieving a shared view of
problems with patients. Patients are open with him, trusting his
and his staffs discretion.
|
He does not see communication as a two-way process, and does
not know or care whether he is getting through to patients. He is
careless about confidentiality. |
Patients'
Autonomy
|
He encourages patients' self-help, and
keeps in bounds his need to be needed.
His clinical decisions reflect the true long-term
interests of his
patients.
|
He allows the development of unwholesome dependence on himself
or on psychotropic drugs. |
Professionalism
| He is a thorough professional: a thinking, questioning
doctor |
He equates being a doctor with being a provider; he behaves as
a grocer, or a bartender. |
2. Accessibility
Consulting
Arrangements
| The doctor can be seen very quickly by patients for urgent
matters during normal working hours. Patients with non urgent
matters are normally seen by their doctor within two days. |
The doctor cannot usually be seen quickly for urgent for urgent
matters during normal working hours. Patients with non urgent
matters usually have to wait several days for an appointment to see
their own doctor. |
Home visits
| The doctor is prepared to visit patients in their homes:
clear arrangements exist for requests. |
The doctor is very reluctant to do home visits;
arrangements for requests are confusing, and difficult for
patients. |
Patient queries
| The doctor deals with patients' queries himself, or gives clear
guidelines to his staff on how to deal with them. |
The doctor avoids dealing with queries himself, and does
not give clear guidelines to his staff on how to deal with
them. |
Contactability
|
The doctor can be very readily contacted
by his staff for advice.
|
The doctor is very difficult to contact for advice. |
Out of Hours
Cover
|
The doctor provides adequate
out-of-hours cover; the arrangements are clearly known and
acceptable to his patients. He personally takes a share in the rota
duty.
|
The doctor provides inadequate out-of-hours cover. The
arrangements are poorly understood by his patients. He does not
share in the rota duty.
|
Access to staff
|
Access to ancillary and attached staff is
easy and the arrangements are made clear to
patients.
|
Access to staff is difficult; arrangements are poorly
understood by patients. |
Facilitation
|
The ancillary staff facilitate
doctor-patient contacts in the most helpful
way.
|
The ancillary staff are over-protective of the doctor and make
it very difficult for patients to have access to him. |
Punctuality
|
The doctor does not keep patients and
staff waiting unnecessarily.
|
The doctor is regularly late with appointments. |
3.
Clinical Competence
History
Taking
| The doctor consistently gives evidence of his ability to take a
relevant history. He appears to be listening to what his patient
says and is able to respond to the verbal and non- verbal cues
which he is given. He constructs his questions logically and puts
them clearly. He uses the medical record both to verify and to
amplify the history. |
The doctor persistently fails to elicit a relevant history. He
gives evidence of not hearing what his patient is saying, or of
actively preventing the patient from communicating. He does not
follow up verbal and non-verbal clues, or he actively pursues
irrelevant aspects of the patient's history. He fails to verify
points in the history by reference to the medical record, or fails
to use the medical record itself as a source of further information
about past events |
Physical examination
|
The doctor consistently makes an appropriate
physical examination based on the history. His
examinations are skilled and carried out with obvious
consideration for the patient; they are more often concerned
with clinical problem-solving than with ritual
behaviour.
|
The doctor persistently fails to elicit a
relevant history. He gives evidence of not hearing what his patient
is saying, or of actively preventing the patient from
communicating. He does not follow up verbal and non-verbal clues,
or he actively pursues irrelevant aspects of the patient's history.
He fails to verify points in the history by reference to the
medical record, or fails to use the medical record itself as a
source of further information about past events
|
Defining the problem
|
The doctor's definition of the patient's
problem is clearly based on the evidence
presented.
He does not make a habit of naming a disease,
where there are no reasonable criteria for such a diagnosis. He
consistently relates physical, social and psychological
factors.
|
The doctor's definition of
the patient's problems, his 'diagnosis', is
unsupported by the evidence that he has collected, or by a
reasonable interpretation of the probabilities. In formulating
these problems he persistently fails to
relate physical, social and psychological
factors.
|
Seeking further information
|
The doctor's
search for further inform-
ation is
clearly rooted in the clinical work which precedes it,
or can be supported by a reasonable interpretation of
probabilities.
He tries to understand how the patient sees
the problem.
|
The doctor's search for further
information by investigation
cannot be supported either by the
clinical work which precedes it, or by a statement of reasonable
probabilities.
He is not interested in how the
patient sees the problem.
|
Use of resources
|
He refers appropriately to other members of
the primary health care team and to the hospital services,
including consultants. He makes appropriate use of diagnostic and
treatment equipment which the practice possesses.
|
He either fails appropriately to refer the
patient to other members of the primary health care team, or he
does so
inappropriately. Similarly, his referrals to hospital are either
unsupported by the preceding clinical work, or fail to occur when
they should. He fails to use the diagnostic and treatment equipment
in the practice when appropriate.
|
Explanation to the patient
|
His explanations are informative and clearly
expressed; where appropriate he explains the likely causes of
the problems and likely course of coming events.
|
He fails adequately to explain his
understanding of the patient's problems,
including, where appropriate,
the causes of the problems and the likely course of events.
|
Management
|
He involves the patient in decisions on
management. He gives clear and
concise advice about
management, especially lifestyle, diet, work and drug therapy.
|
He does not involve the patient in decision
making. He fails to give clear advice about management, especially
lifestyle, diet, work and drug therapy.
|
Prescribing
|
His use of drugs is appropriate. He has a
disciplined and logical approach.
|
His use of drugs is inappropriate. He gives no
evidence of a disciplined approach.
|
Preventive medicine
|
He consistently gives evidence of a
willingness and ability to give both
opportunistic and anticipatory care.
|
He fails to give appropriate
opportunistic or anticipatory care.
|
Continuing care
|
The doctor, wherever appropriate, demonstrates
his ability to make plans for the adequate follow-up of the
patient. He goes out of his way to take personal responsibility for
the continuing care of the patient, and imparts a sense of that
continuity to the patient when appropriate. He has a considered
approach to the long-term management of chronic conditions.
He makes adequate provision for the immeidate
care of emergencies which he may encounter in his practice.
|
The doctor persistently fails to make plans
for the adequate follow-up of the patient. He gives scant evidence
of taking personal responsibility for clinical problems, or for
ensuring that the patient has a sense of continuing care, when this
might be appropriate. He has an ad hoc approach to the
long-term management of chronic conditions.
He is unable to provide adequate care for
emergencies which he may encounter in his practice.
|
4. Abilitiy to Communicate
Communication with the patient
|
The doctor creates a receptive and calm
atmosphere in the consulting room, and the patient is encouraged to
communicate freely.
He communicates his interest in the
patient and his story. He actively explores the patient's view of
the problem, and seeks to achieve a high degree of agreement
between it and his own view of the problem. He gives evidence of
his own commitment to the patient now and in the future. There is
clear and adequate information on the services provided by the
practice. The doctor's communication with his patient helps him to
define the reasons for the patient's attendance at the surgery, to
manage the patient's problems, to educate the patient on relevant
health care matters, to offer support to the patient and to promote
health in its broadest sense.
|
The doctor's lack of communication with his
patient hinders him from defining the reasons for the patient's
attendance at the surgery, managing the patient's problems,
educating his patient on relevant health care matters, offering
support to his patient or promoting health in its broadest sense.
He fails to create a receptive and calm atmosphere in the
consulting room, such that the patient may be encouraged to
communicate freely. There is inadequate information on the services
provided by the practice.
|
Communication with ancillary staff
|
There are frequent opportunities for informal
meetings, and written communications are clear and concise. There
is evidence of negotiated practice policies about such matters as
the handling of requests for repeat prescriptions, home visits and
urgently required consultations. The doctor shows overall concern
for the welfare of his staff.
|
There is little evidence of communication with
the staff. He provides no guidelines for handling such matters as
requests for repeat prescriptions, home visits, and urgently
required consultation. He shows little or no concern for the
welfare of his staff.
|
Communication with colleagues and
other memebers of the health care team
|
Regular meetings take place. The doctor
shows sensitivity to the problems
encountered
by his colleagues and an understanding
of the respective roles of each member of the team. The doctor
encourages a free exchange of ideas between all those involved in
the provision of health care in the practice.
|
The doctor discourages communication between
members of the health care team. He is insensitive to their
problems and shows no understanding of their various roles.
|
Referral letters
|
Usually the doctor's letters are typewritten
and copies are kept on file. The letters are succinct, giving a
clear summary of the relevant evidence and a statement of the
doctor's formulation of the problem. The consultant is clearly
informed about the general practitioner's expectations of the
consultation requested. The letters convey a vivid thumbnail sketch
of the patient as a person.
|
The doctor's letters are not usually
typewritten, nor are copies kept in the patient's file. They do not
clearly summarise the relevant evidence, nor do they clearly state
problems. The doctor's expectations of help from the consultant are
rarely made explicit. The letters persistently fail to refer to the
patient as a unique individual in a particular social context.
|
Clinical records
|
The practice records are complete and accurate
in regard to basic data. All entries in the records are legible and
entered sequentially. Notes of each consultation or visit are made
in such a way as to convey the key features. Hospital reports,
laboratory and x-ray reports are filed in date order and how
evidence of having been 'pruned'. The clinical records are capable
of use in decision-making, teaching, research and audit.
|
The doctor's records give incomplete or
inaccurate basic data. The clinical notes are illegible and are not
entered sequentially. The reader cannot clearly and quickly
summarize the key features of past consultations. The accompanying
letters, hospital reports and laboratory reports are not in date
order and show no evidence of having been 'pruned'. The records
cannot easily be used for decision-making, teaching, research or
audit.
|
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