Quality and Outcomes Framework (QOF) QI project

In 2019 the RCGP, in collaboration with NICE and the Health Foundation, were commissioned by NHS England and NHS Improvement to develop a series of quality improvement (QI) modules and guidance to form part of QOF. Ten modules were produced in this phase of work.

In 2021 the RCGP has continued to support general practice carry out this QOF activity by producing learning material for the QOF QI module topics supporting people with learning disability and early diagnosis of cancer. Additionally, guidance has been produced to support effective and sustainable QI within a primary care network (PCN). These resources are available below.

This project is clinically led and draws upon expertise from across the system, and from the established evidence base for specific module topics and for QI more broadly.

Resources

Primary Care Network guidance

Leading effective and sustainable Quality Improvement within a Primary Care Network: A How to Guide

Leading effective and sustainable Quality Improvement within a Primary Care Network: A How To Guide (PDF file, 479 KB)

Plain text of document (infographics not included):

Peer review meetings checklist

It is important to take some time ahead of a peer review meeting to plan how to deliver the meeting and what you want to achieve from it. This checklist of key steps is designed to help you do this.

Choose the right format and set clear rules.

  • When meeting online select a platform familiar to participants and make it clear how you want them to participate (e.g. all cameras on, mute when not speaking, requesting to speak via raise hand function).
  • Identify key meeting roles (e.g. chair, recorder, timekeeper, facilitator) and ensure they are allocated to participants.

Ensure that everyone has a voice.

  • Have you included key stakeholders? Think about why you are inviting each participant, and make sure they have the knowledge and support to participate in a meaningful way. This is particularly important for patient and public participants.
  • Send meeting agenda and papers to participants in advance so that they can prepare properly for the meeting.
  • Consider using small break out groups to build relationships and confidence.

Set clear and realistic goals.

Focus on what it is possible to achieve during the meeting and beyond it. It is good to be ambitious, but be conscious of the other calls on participants’ time. If the goals are too demanding, enthusiasm and commitment will soon ebb away.

Think about how:

  • your goals will be delivered, and:
  • progress will be measured.

Make sure the right data is available.

To fully understand a problem, you need to look at it through the widest possible lens, before trying to tackle it.

  • Have you used a mix of qualitative as well as quantitative data, to bring in perspectives from a diverse range of people and settings?
  • Think about how best to share and present these data with participants so that it can be used to inform your discussions e.g. who will be involved or effected by any changes (stakeholder analyses), how the work usually gets done (process diagrams), baseline data and the impact of any previous/future change interventions (audit data and annotated run charts) and questionnaire results (staff satisfaction, patient satisfaction etc).

Focus on creating trust and respect.

To get the most from meetings, participants need to listen carefully and respectfully to the views of others and value their respective experiences and expertise.

  • Ask questions and seek reflections from others in order to involve everyone and create an effective dialogue.
  • Provide measured feedback that builds on the points on which you agree, to create trust and a positive meeting environment.

Encourage learning from experience.

Participants should be encouraged to share their experiences. Identify and discuss:

  • what has not worked as planned
  • examples of success.

Barriers to and facilitators of success.

Take the time to identify and reflect on the learning from these experiences, and think about how this learning can be shared more widely to inform future improvement interventions.

Identify priorities for action and next steps. End each meeting having:

  • set clear action plans that identify the next easiest steps
  • ensured that participants know who is responsible for delivering them
  • prioritised feasible completion dates
  • taken a few minutes at the end to ask participants what they think worked well in the meeting, and what they’d like to see done differently.

Introduction

About this guide

This guide describes how to plan, deliver and sustain Quality Improvement (QI) across Primary Care Networks (PCNs). Drawing on learning from across primary care and the wider NHS, it sets out the skills, behaviours and actions that underpin successful QI interventions. It also offers practical tips on how to lead and manage improvement, as well as links to supportive resources.

Who is this guide for?

This guide is primarily aimed at those involved in leading PCNs. However, the description of the skills, behaviours and actions needed to deliver QI interventions will be of interest to anyone connected to PCNs who wants to get involved in QI. QI is a team activity and works best when people from a range of professional backgrounds, and, of course, patients, collaborate to tackle the quality challenges that matter most to them.

Furthermore, anyone can lead a QI activity: enthusiasm, commitment, and relevant expertise are what count, not their level of seniority.

What does this guide add?

There are lots of training resources to develop an individual’s QI skills. How these skills can be effectively and efficiently used within Primary Care is less clear. PCNs offer an opportunity to work collaboratively, share knowledge, skills and passion to change how care is organised and experienced by staff and patients. This guide outlines how you can maximise efficient QI collaboration within your network.

Where you are at on your PCN improvement journey?

In planning an improvement activity, it is important to take stock of what skills, expertise and support you will need at each step of the journey. It is also useful to think about the challenges you might encounter, and what opportunities you could utilise. These steps are explored in greater detail in sections 3-7 of this guide.

How can your network get the most impact from collaborative quality improvement?

You have specialist knowledge of local needs, strategic priorities, and network members’ expertise. This puts you in a unique position to bring these people together to improve care efficiently. Wherever possible:

  1. Look for opportunities to coordinate QI initiatives.
  2. Capitalise on clinical knowledge and QI skills.
  3. Learn from those doing well.

Leading collaborative Quality Improvement activities

You have a vital role to galvanise, support and align effective improvement activity within your network. Make the most of team members from different practices (including clinical, administrative, and additional workforce members) to undertake QI. Collaborative working across practices will support everyone to meet the contractual arrangements outlined in the Primary Care Network directed enhanced service (DES) and the QOF QI domains. Here are five things to consider when thinking about how to effectively lead PCN QI:

3.1. Create a shared improvement ambition:

Fostering a sense of shared QI purpose across your network can help to encourage collaborative improvement activities that span the system and promote the sharing of learning from improvement. To feel authentic to people in all parts and at all levels of the system, you need to be aware of the improvement culture and history of each practice in the network. Working together take the time to listen to the aspirations of staff and patients; this will help to build your understanding and add to improvement efforts’ value and authenticity.

3.2. Instil a culture of learning:

An improvement culture that enables people to give their best because they feel listened to, valued and supported, is vital. We know that teams are more likely to think creatively and try new things when they feel a sense of psychological safety. This comes when there is a culture of learning in place, rather than one of blame, and when the responsibility for initiating and leading improvement is distributed across the organisation, and not vested in the hands of a few senior leaders. A positive attitude to diversity and inclusion, so that improvement is shaped by a representative range of voices and perspectives from within the community, is equally important.

3.3. Protect time for improvement:

It is important to consider the extent and pace of improvement that can be delivered. Time is needed to identify, prioritise, plan and deliver improvement(s). In time-pressured clinical environments, it can be hard for practice staff to switch gear and realise the importance of planning (prior to thinking about implementing solutions). Remove the pressure to get started and demonstrate impact. Taking time to identify the smallest change most likely to have impact, will be more efficient. Regularly reinforce the importance of effective preparation and engagement to understand why current processes are not optimal; and what the easiest and most impactful next step to be tested should be. Identify opportunities to carve out time away from clinical, administrative and management duties so that improvers can meet at relevant points on their improvement journey to plan and reflect.

3.4. Developing capability:

While awareness of QI methods and tools is growing in primary care and the wider NHS, it’s still the case that a majority of practice staff have little or no experience in using common improvement methods, such as Plan Do Study Act (PDSA) cycles. As well as signposting them to external resources and training, identify existing improvement expertise within the system and finding ways to share it with practices with limited improvement experience. There may also be an opportunity to strengthen improvement capability by organising shared training.

3.5. Connecting and aligning improvement interventions:

Spotting connections between different improvement interventions, both within and beyond their local system, and the opportunities they present for collaboration and joint learning is important. Equally necessary is the ability to address interventions that may be out of step with local strategies or lead to variations in care that may have safety or equity implications.

The core dimensions of leadership behaviour are described in detail in the Healthcare Leadership Model developed by the NHS Leadership Academy considering each of these aspects can help with the planning and delivery of collaborative improvement activities.

Harness the expertise across the network

6 To effectively and efficiently lead population health improvement in your network you need to assemble a core team to share this responsibility and deliver improvements. Identify what you ‘know’ and what you ‘don’t know’, but others in different roles do know. To accelerate progress identify:

  • Who fully understands the networks current performance data to identify priorities for improvement across the PCN or within individual practices?
  • Who has the specialist clinical knowledge of the areas outlined in DES and QOF QI domains to inform improvements?
  • Who has previously undertaken improvement projects or training in QI methods?
  • Who can effectively facilitate practice peer review meetings to initiate and sustain improvement?
  • Who has the service delivery expertise to identify, adapt or design change interventions such as EHR searches, computerised templates and prompts?
  • Those with relevant skills needed for effective improvement

Identifying where there is room for collaborative improvement

5.1. Convey why everyone should act now:

As well as being clear about why you’re trying to improve something, you also have to think about why it matters now. At any one time there are lots of priorities for improvement in primary care. So what is it about this problem that means you need to act now? What evidence do you have to show that it’s urgent and important? If you can convince people of the necessity for action, they are more likely to ‘buy into it’ and find the time to get involved and go the extra mile to make it work.

5.2. Use data to identify higher and lower achievers.

Capitalise on what is working well that may be possible to scale efficiently across the network. Identify practices who need specific support to do things differently.

  • Where possible review existing population data (e.g. Atlas of Variation) or use local public health profiles (ask your CCG / local public health team to provide them if they don’t already)
  • Next, identify where there is a need to collect or share ‘current’ or ‘practice-specific’ data?
  • Where can you source ready-made computerised searches to collect patient-specific data?
  • Who has the skills to adapt or develop patient identifiable searches?
5.3. Engaging the right skills and expertise in improvement prior to meeting enable practices to explore the area for improvement:

Use practice achievement data to inform which practice(s) are doing well, and which practices should be supported to improve. Ask each practice to:

  • Create a brief flowchart showing how this work is undertaken by each staff member.
  • Can those doing well identify resources (e.g. patient searches, computerised prompts, templates or patient resources) that could be implemented across the network?
  • Can those who need support identify areas of frustration or duplication?
  • 5.4. Build a coalition of support:

    Who is best placed to influence each of the professional groups and patients whose support you need to get the idea off the ground? And remember it isn’t always the most senior person who’s best equipped to help. Having the support of senior, experienced staff is vital, not least in terms of unlocking access to any resources needed or resolving any teething issues. But as well as people with the right seniority to support improvement work and change, you want people with the right ‘influencing skills’, such as the ability to ‘read others’ and work out what will - and what won’t - convince them to back the idea. And these skills exist at every level of primary care system. It’s important not to rush this engagement work. Time spent at the start in building a coalition of supporters, will almost certainly save you lots more time further down the line.

    5.5. Use existing meetings:

    Such as PCN board meetings or locality based CPD events. You need to balance the pressures on staff’s time with providing sufficient headspace to reflect, get to know each other, create ideas and make plans.

    Some may use phone or e-mail to get things started and maintain momentum. If appropriate and following all relevant (Covid-19) guidelines consider whether meeting face-to-face or online would work best once you have considered the people who need to come together to improve, what will work best for individuals in your team and how well they know each other.

    5.6. Consider who should attend each session to ensure the right mix of skills and expertise:
    • Specialist clinical knowledge
    • Systems and service delivery experience
    • Improvement methodology expertise
    • Patient experience
    • Knowledge of effective interventions to change practice
    • Regularly review who else could support the improvement work: focus on who you could ask to support the team, who is already working to address this topic or a related type of behaviour. Consider the different skills and expertise the team needs, and how to get these people to share the work. Think about the relevance of different types of professional, administrative and management role and the patients likely to be affected by the intervention. Engage with those in leadership positions when official approvals to change are required. A useful model to help you think about the behaviours and skills needed within the team to sustain an improvement intervention is Bill Lucas’s Habits of Improvers model.

    Facilitating improvement sessions

    In the context of COVID-19 there are many more options for how, when and how often to meet (e.g. Microsoft Teams, Zoom, Google Meet).

    6.1. When meeting online:
    • Identify what platform(s) are available, what are your members most familiar with (e.g. Microsoft Teams, Zoom, Google Meet or others)?
    • Make it clear how you would like everyone to show up (e.g. all cameras on)
    • Provide guidance on how you wish everyone to participate (e.g. mute whilst others are talking, raise hands on the task bar to ask questions or respond, use the conversation box to provide content on a one-to-one or group basis).
    • Indicate likes/dislikes or pace too fast/too slow using taskbar icons
    • Consider break-out rooms if technology allows (e.g. MS Teams or Zoom)
    6.2. Ensure improvement teams are built on trust and mutual respect:

    The way in which improvement team members relate to each other and work together has a vital bearing on the success of the intervention. Treating each other with respect, listening carefully to views of others, trusting each other, and valuing everyone’s ideas, regardless of their position or level of experience, are all behaviours that can help the team to gel and get the best out of people. Equally important is a willingness to learn in partnership with others and a sense of humility, founded on an awareness that no single person has the skills and experience to solve a problem on their own. Other vital attributes are the ability to ask questions clearly and frequently, and to share your own knowledge and thoughts in a focused and timely fashion: these ‘teaming’ skills will help to ensure that the team is able to interact effectively from the off and make the most efficient use of what time it is able to spend together.

    6.3. Set realistic goals:

    Think about what realistic improvement targets would be in the time available for each practice. It’s important to stretch practices, but the team’s energy and motivation will soon melt away if the targets are too demanding in terms of time and resources, or require changes that lie outside the control of those involved. Identifying some ‘early wins’ to build confidence within the team and with other stakeholders can be very useful and build motivation to progress.

    6.4. Sequence and prioritise agenda items during peer review meetings
    • Use assertive inquiry to both give advice (advocate) and actively listen (enquire) to all attending.
    • Focus on developing a culture of problem solving. It’s important to look at a problem through the widest possible lens. As well as analysing data that’s most directly relevant to the problem, look at other related data sets that could give you a different perspective and provide you with a more nuanced understanding of the problem. Exploring these ‘neighbouring possibilities’ is, as Stuart Kauffman described, key to the successful development of new ideas. Generate a rapid but long list by asking everyone to generate ideas in the form of ‘we could do this, and this…’. Take time to identify the single easiest action that could make a difference and start there.
    • Share experiences of what has worked and what hasn’t worked.
    • Set clear priorities for action.
    • When agreeing actions – record What, By When, By Whom?
    • Sequence and prioritise agenda items during peer review meetings
    6.5. Consider what needs to be done next?
    • Did it work? If so, Adopt.
    • Did you have problems? If so, Adapt.
    • Did it go wrong? If so, Abandon and learn from the setback and decide how to act going forward.

    Celebrate the progress that you are making together.

    7.1. Celebrate success:

    As well as taking time to learn from setbacks, it’s important that the team pauses to acknowledge and celebrate progress and moments of success. Marking success is not just about building confidence and morale. It’s also about highlighting the expertise and experience that team members gain from taking part in improvement, such as leadership, problem solving and relational skills, all of which will stand them in good stead in other aspects of their job and their career development.

    7.2. Collate examples of the important work:

    Continually remind everyone of the progress being made e.g. PCN QI newsletter or WhatsApp group. Use this ‘Done’ wall (or newsletter or presentation) suggested by Scott Belsky to showcase what has been achieved and motivate others to make similar progress.

    7.3. Maintain a culture of improvement:

    Initiating improvements can require time, patience, persistence and skill. Finding those who are passionate (or frustrated) and harnessing their energy to improve can allow simple changes to have great effect. Keeping momentum going in the following weeks and months, while maintaining your own enthusiasm and commitment, may be demanding given competing pressures.

    7.4. Expect uncertainty and risk:

    The path of every improvement intervention is littered with obstacles, some of which are predictable, others less so. Sometimes the full complexity of the solution required only becomes clear when a project is well underway. This means that an ability to tolerate uncertainty and ambiguity is a key skill for any improver. Another is a willingness to take reasonable risks as new possibilities emerge, and the best one to pursue is hard to identify. It’s important to weigh any such risks against their potential impact on safety, but it’s also worth remembering that avoiding or delaying a decision can pose the greatest risk of all to patients.

    7.5. Resilience is crucial:

    The uncertainty and unpredictability of improvement means that not everything you do will go as planned. On occasion it might feel that you are going backwards rather than forwards. It’s important to respond in the right way to setbacks. Seeing them as an inevitable part of the improvement process and factoring in enough time to learn from them and to use that knowledge to strengthen the intervention is critical. Remaining optimistic about what you can still achieve, particularly if you are an improvement leader, will also help the team to stay positive and resilient in the face of temporary adversity.

    Supportive resources

    Supporting people with learning disability

    How can your practice undertake quality improvement activity to support people with learning disabilities?

    How can your practice undertake quality improvement activity to support people with learning disabilities? (PDF file, 65.8 KB)

    Plain text of document (infographics not included):

    Why is it important?

    42% of Learning Disabled patient deaths are premature, mostly due to delays in diagnosis or treatment. Currently only about 25% of the estimated 1.1 million people in England with a learning disability ae recorded on the current Learning Disability QOF register. Improving the accuracy of the QOF register will help ensure people with a learning disability are offered annual health checks.

    Why is it important for general practice?

    General practice can play a vital role in improving holistic person-centred care for people with a learning disability aiding them to live fulfilled lives in the community. Providing holistic care can improve outcomes and ensure people live safely by raising awareness of the risk of abuse of vulnerable individuals.

    1. Evaluate

    Actions

    Step 1 - Start with an assessment of the current quality of care your practice provides through

    a) Increasing prevalence and register accuracy

    b) Undertaking a training needs analysis re. learning disabilities, Mental Capacity Act and Equality Act

    c) Appraising your practice's general approach to LTCs, health checks, screening, vaccinations and health promotion

    d) Self-assessing your practice's management of reasonable adjustments

    Top tips
    • Undertaking an LEA or SEA
    • SWOT analysis
    • Seeking views of patients and carers and were possible, local community learning disability services
    Practice example

    "We realised only 50% of our patients on the LD register had taken up an annual health check. One of our patients - 45yo - had died. We chose to undertake a practice-wide structured in-house mortality review of the case, and based our proposed changes on the learning points which arose"

    2. Create

    Actions

    Focus QI activities on outcomes such as:

    1. An increase in the number of people on the Learning Disability QOF register to facilitate call and recall
    2. An increase in uptake of annual health checks to 75% of all those on the QOF Learning Disability Register aged 14+
    3. An increase in uptake of flu vaccinations for all ages on the Learning Disability QOF register
    4. Improve understanding, recording and provision of reasonable adjustments
    Practice example

    "Over 12 months we aimed to increase the proportion of annual health checks attended by our adolescent and adult patients on the LD register from 50% to 75%. We opted to run a search every 2 weeks and plotted the % of completed health checks on a visual 'run' chart (and compared it to last year's)"

    Top tips

    Once you have identified your area/s for improvement, teams should clarify SMART aims.

    Aims: What will be achieved?

    Measures: How will they know if a change improves things?

    Changes: What different ways of doing things will be tested?

    3. Implement

    Actions

    Consider using PDSA (Plan, Do, Study, Act) cycles, frequently reviewing changes. Multiple small tests of changes are recommended.

    Aim to involve patients, the whole practice team and external stakeholders i.e. local practices, public

    Practice example

    "We first all agreed to complete 2 online modules (and 3 of us attended a local LD training event); we audited on a monthly basis whether LD action plans were created at the annual checks; clinicians all agreed to add digital review dates for actions; we adapted our call/recall method by using phones and texting earlier; we also changed the wording and format of our letters"

    4. Review

    Two (or more) meetings to share learning across networks

    Meeting 1:

    • To share and compare audit & baseline research outputs
    • To validate each other's improvement plans
    • To align with local and wider priorities and activities

    Meeting 2:

    • To celebrate and share successes, changes and learning
    • To discuss and plan embedding and sustaining
    Practice example

    "Despite LD prevalence equalling the national average, as a PCN we realised that we suffered from similar difficulties in achieving high health check attendances. This made us feel less insular and helped generate further change ideas.

    "We hadn't accomplished out 75% target but we felt we had achieved a health improvement reaching 69% over 9 months. This feeling was shared by our neighbours. We recognised that many of our patients details were out of date and we intended to focus on this next year. We felt we could continue to build on our efforts by incorporating a slightly different approach - put forward by another practice. And that we would offer flu vaccinations to all on the LD register on the 1st September - with those lacking capacity to have a best interest decision made and recorded."

    5. Monitoring

    Self-declare activity completion and attendance at 2+ PCN peer reviewing meetings.

    Case study – improving practice understanding of learning-disabled population’s needs

    QOF QI Case study: Improving the knowledge and understanding of practice team members about the needs of the practice’s learning-disabled population (PDF file, 257 KB)

    Plain text of document (infographics not included):

    Practice details: 10,000 patients, semi-urban training practice; 5 partners, 5 part-time salaried doctors, 3 GP registrars, 4 practice nurses, 1 health-care assistant and 30 part-time admin staff.

    The team elected to focus on the implementation high quality in-house death reviews for learning disabled patients.

    They used the RCGP QI wheel for general practice (available in RCGP’s How to get started in QI guide for advice).

    Culture and context:

    • The practice had a 50% uptake of learning disability annual health checks.
    • The health checks are all organised and completed by a team consisting of 1 receptionist, 1 practice nurse and 1 salaried GP.
    • None of these 3 have had any specific training in the needs of patients with a learning disability.
    • The practice QI lead noted the suggestion of completing a training needs analysis in the QI domain guidance.

    The practice, as a training practice, is used to evaluating registrar learning needs. It decided to evaluate training needs across the whole practice and establish a learning programme for the practice members.

    Diagnose:

    The QI lead met with the trio of staff running the health checks to consider how to evaluate training needs in the practice. It was decided to use a self assessment survey using a Likert rating scale from 1-5 (below average to above average) for each answer and asking for comments. As no-one in the practice had, to date, received any appropriate training it was decided to ask advice from the local Learning Disability team. Together they planned a 10-question survey.

    • overall knowledge of learning disability
    • understanding the definition and causes of learning disability
    • understanding the common comorbidities in learning disability
    • understanding health promotion and screening in learning disability
    • understanding how to complete a high-quality health check
    • understanding what it means to live with a learning disability
    • understanding the concept of reasonable adjustments and how to implement
    • understanding what is meant by capacity and how to assess and record
    • understanding what is meant by a best interest decision and how to implement and record
    • understanding the safeguarding needs of people with a learning disability.
    • The survey plan and questions were shared at a practice meeting for clinicians and at a staff meeting. Two plans for how to circulate the questionnaire were discussed:

    • Emailing a form for completion Creating a Survey Monkey with a rating scale and comment box.
    • A time limit of two weeks was agreed for completion with a reminder to be sent at 10 days.

    Area for improvements

    Aims:

    Both clinical and non-clinical members of the practice team will increase their knowledge and skills in improving outcomes for people with a learning disability registered at the practice by enhanced learning disability awareness, ability to implement reasonable adjustments, and enhanced awareness and application of the Mental Capacity Act.

    Plan:
    • Record self-assessment levels at the start of the year
    • Evaluate learning methods for all staff groups in the practice to meet needs
    • Re-evaluate learning needs using the same method 6 months later.
    Change:

    The survey was circulated, and results were analysed by the practice manager. The results were divided into 5 groups.

    • Learning disability health awareness
    • Living with a learning disability
    • Mental capacity act
    • Reasonable adjustments
    • Safeguarding

    Training opportunities were then researched by the QI lead, practice manager, and the trio running the health checks. Advice was sought from the local learning disability team.

    It was decided that the whole practice shared training for both clinical and non-clinical staff and it would be beneficial to cover:

    • what it means to live with a learning disability
    • how the practice can implement and record reasonable adjustments.

    The local learning disability services provided a learning disability nurse and expert by experience to give a 2-hour training session in the practice.

    It was decided that clinical staff should complete continuing education relevant to their role and record this in their appraisal system. Various options were provided for reading, learning and reflection.

    These included:

    Sustain and spread:

    The practice QI lead shared the Survey Monkey questionnaire with the network at the peer review meeting. Learning resources were also shared. Other practices in the network decided to adopt a similar process.

    Following the training session with the LD nurse and expert by experience, the practice manager and practice nurse involved with the health checks designed a flag to record the reasonable adjustments needed by each person on the LD register. Completion of the flag was audited following the completion of all annual health checks in the practice.

    The administration team were generally inspired by being trained by an expert and considered means of asking the practice’s patients on the learning disability register and their families and carers about their experience of using the practice. The LD nurse assisted the team, and this was planned for the following year.

    The practice evaluated the effectiveness of the reflective learning done by clinical staff to review outcomes for their patients with a learning disability. An audit programme has been established for following years to assess:

    • Rate of hospital admission and reduction in unnecessary hospital admission • Quality of the health check including creation of an action plan and its effective monitoring
    • Patient satisfaction surveys of the learning-disabled population

    What evidence did the practice provide for QOF payment:

    The contractor completed the annual QOF QI domain self-declaration. The practice saved the detail of the survey monkey questionnaire and the results both pre and post training. The practice saved the evaluation record of the training session offered by the LD nurse and expert by experience. The practice saved the dashboard of reflective learning by clinical staff. The planned survey and audits for the following year were saved.

    Case study – learning disability death review

    QOF QI Case study: Learning disability death review (PDF file, 197 KB)

    Plain text of document (infographics not included):

    Practice details: Urban practice 12,000 patients, 50 patients on Learning Disability QOF register = 0.4% prevalence

    The team elected to focus on the implementation high quality in house death reviews for learning disabled patients.

    They used the RCGP QI wheel for general practice (available in RCGP’s How to get started in QI guide for advice).

    Culture and context:

    The learning disability QI Domain document had raised awareness in the practice of the health inequalities experienced by people with a learning disability - including significant premature mortality. Reference was made to the learning disability mortality review programme – LeDeR . The local LeDeR steering group had also shared its recent annual report with the CCG which had made it available to practices.

    As is true nationally the commonest causes of death locally were:

    • Pneumonia
    • Aspiration pneumonia
    • Sepsis
    • Ischaemic heart disease
    • Dementia
    • Epilepsy

    Diagnose:

    The practice manager had made records available to the LeDeR team of a patient on the practice’s learning disability register who had died during the previous year. The patient was only 44 years old. The practice had not conducted a review in-house following this death. It was decided that this would be helpful learning for the whole practice team.

    Plan and test:

    Consideration was given about how to conduct the review. Government guidance on learning from deaths was reviewed. It was decided to develop a clear plan for the review, and a practice meeting was held to discuss this. The following decisions were taken:

    • The person performing the review would be someone who had not consulted with the patient in the past and would be given a half day protected time for the process.
    • A policy of openness and trust should be adopted and that this was a no blame learning experience.
    • A structure for the review was created • The review would be presented to the clinicians in the practice and discussed.
    • Actions from the review would be recorded and their completion monitored by the practice manager.
    • The learning points from the review would be shared with the network

    Diagnose:

    The QI lead met with the person nominated to perform the record review to develop a plan.

    It was agreed that important components for the practice presentation would be as follows:

    • Some personal details of the individual to help visualise and empathise with them as a person – known as a ‘pen portrait’. This would include whether the practice was aware of any reasonable adjustments that would have helped the individual access services. This might involve a discussion with the person who knew them best in the practice.
    • Recorded cause of death and whether the coroner was involved.
    • Significant co-morbidities and how these were recorded and visible in the patient notes.
    • Prescribing history and its rationale including evidence of structured medication review.
    • Evidence of whether the death could have been expected and whether there was any evidence of advance care planning.
    • Evidence of continuity of care and recording of reasonable adjustments in the practice.
    • Evidence of completion of detailed annual health checks using an appropriate template including creation of and saving of a health check action plan.
    • Evidence of health promotion and screening activity e.g. cervical screening, blood tests, sexual health advice, dietary advice, regular annual flu vaccinations etc.
    • Evidence of any recording of implementation of the Mental Capacity Act to assess the person’s capacity and record their best interests if lacking decision making capacity.

    Plan and test:

    The GP, nominated to perform the review, discussed the process with the local learning disability team. The team made it clear that the local LeDeR (learning disability mortality review programme) had a steering group that was attended by a representative (safeguarding nurse) from the CCG. It was suggested that the individual could learn about LeDeR from the CCG rep and possibly ask to attend the meeting with the CCG representative, as an observer.

    These discussions helped the GP understand more about the LeDeR process, how death reviews are conducted, how learning from the review is defined, and how the learning is put into action locally. The GP read the national LeDeR annual report, the summary of the CIPOLD enquiry and latest information from NHS digital about morbidity and life expectancy for people with learning disabilities. The GP developed a template for recording the information to be evaluated from the record. A half day of protected time was allocated for the process.

    The QI lead presented the outline of the plan to the network peer review meeting. Suggestions were made about how to develop actions to improve care from the learning.

    Area for improvement

    The patient had Down’s syndrome, multiple comorbidities including dementia and had died from aspiration pneumonia.
     
    The GP completing the review gave a presentation to the whole practice with background information, suggestions of learning points from the case and possible actions the practice could take from the learning.
    • Health checks had been completed each year but there was no evidence of completion of a health check action plan.
    • Flu vaccinations had been administered most years but not every year.
    • The patient had had 3 admissions during the previous 18mths with aspiration pneumonia.
    • There was no evidence of any discussion or recording of advance care planning in the notes.
    • The patient had been seen by 6 different healthcare professionals in the practice in the last 12 months.

    Actions from learning:

    • The practice to audit quarterly whether health check action plans are created at the health check.
    • The individual performing the health check to set a digital review date for actions on the plan.
    • The practice to create a system starting on 1st September every year to ensure that all on the learning disability register are offered a flu vaccinations and that those with no capacity to consent have a best interest decision made and recorded about whether to administer the jab. Uptake of flu vaccinations in the LD population to be monitored monthly from end September to end December.
    • The practice to nominate a healthcare professional to review the 50 patients on the LD register to determine which if any were at highest risk of premature mortality or of death within the next 12 months. Advance care planning then to be considered for this cohort and discussion at palliative care meetings if appropriate.
    • The practice to review methods of improving continuity of care for those at highest risk on the LD QOF register.

    Implement and embed:

    Audit of notes, performed by the practice audit clerk at each quarter end, showed the number of those who had had a health check and had an action plan created rose from only 30% in the first 2 quarters to 80% by the third quarter.

    By the end of December, 70% of all those on the LD QOF register had received a flu jab – an increase from 50% the previous year.

    The review of patients on the register revealed 5 people with serious complex co-morbidities who also had evidence in the record of poor continuity of care. Each patient was allocated to a GP in the practice to take overall responsibility for ongoing care management including advance care planning if appropriate.

    The learning about life expectancy, morbidity, and premature mortality for people with a learning disability was shared with the team at the Palliative care meeting.

    Sustain and spread:

    The practice shared its enhanced understanding of the LeDeR programme with the network. It also shared the death review process that it had used. The network decided to organise network wide learning from the LD team about premature mortality in people with a learning disability.

    What the practice did next:

    The practice maintained the monitoring processes established after the review in order to ensure better continuity of care for complex patients, better care planning and improved outcomes.

    What evidence did the practice provide for QOF payment:

    The contractor completed the annual QOF QI domain self-declaration. They kept a copy of the action from learning plan and the clinical audits performed following the review for future payment verification if needed, as well as evidence for future CQC inspections and to support individual clinicians in their annual appraisal.

     

    Early diagnosis of cancer

    How can your practice undertake quality improvement activity focused on early diagnosis of cancer?

    How can your practice undertake quality improvement activity focused on early diagnosis of cancer? (PDF file 78.1 KB)

    Plain text of document (infographics not included):

    Why is early cancer diagnosis important?

    More than 310,000 people received a first treatment for cancer in England in 2019. Due to the pandemic, this fell to over 280,000 people in 2020 (NHS England 2021). For most cancers survival is much greater at both one and five years if detected at stage one - highlighting the need for early diagnosis (Hawkes 2019; Crosby et al 2020).

    Why is it important for general practice?

    General practice plays a crucial role in the timely diagnosis of cancer, with almost 68% of people with cancer first reporting their symptoms at their GP surgery (Swann et al. 2018). Whilst other providers deliver screening services for bowel and breast cancer, actions taken in general practice can increase uptake of national cancer screening programmes (Hewitson et al. 2011). Cancer screening programmes have been shown to improve patient outcomes.

    1. Evaluate

    Actions

    Step 1 - Start with an assessment of the current quality of care your practice provides, including both:

    a) An assessment of practice screening programme update rates compared to local or national baselines e.g. PHE's fingertips, CRUK's 'Expected vs Actual' tool.

    b) An assessment of current referral practice via participation in the National Cancer Diagnosis Audit OR other retrospective audit of recent cancer diagnoses.

    Top tips
    • Undertaking an LEA or SEA
    • SWOT analysis
    • Seeking views of patients and carers
    • Auditing & focusing on safety netting around suspected diagnoses
    Practice example

    "Involvement in the NCDA highlighted avoidable delays in the diagnosis of cancer in several of our patients. As a team we then process mapped the ideal patient journey from presentation through to the referral being received by the hospital"

    2. Create

    Actions

    Step 2 - Focus QI activities on outcomes such as:

    1. An increase in the follow-up and informed consent / refusal of screening for cervical, breast or bowel cancer.
    2. A reduction in equitable uptake of screening in population groups identified by the practice.
    3. An increase in the proportion of cases where cancer diagnoses are reviewed and learned from.
    4. A decrease in the time from presentation to referral.
    5. An increase in the proportion of suspected cancer referrals where a demonstrably robust practice-wide system for safety-netting is used.
    Practice example

    "We aimed to reduce the number of appointments needed from patient presentation to referral from 2 to 1, over the course of 9m. We used a fishbone diagram to identify areas of weakness and to plan our changes"

    Top tips

    Once you have identified your area/s for improvement, teams should clarify SMART aims.

    Aims: What will be achieved?

    Measures: How will they know if a change improves things?

    Changes: What different ways of doing things will be tested?

    3. Implement

    Actions

    Consider using PDSA (Plan, Do, Study, Act) cycles, frequently reviewing changes. Multiple small tests of changes are recommended.

    Aim to involve patients, the whole practice team and external stakeholders i.e. local practices, public

    Practice example

    "Realising we were under-referring and were lacking confidence in knowing full guidance we introduced several small changes - we all agreed to attend educational event on cancer referral and recognition; we adapted our website homepage and added new videos to the waiting room loop; we installed a link to NG12 to our practice intranet (and read and discussed this at a team meeting), and created mouse mats outlining red flags for 2ww cancer referrals"

    4. Review

    Two (or more) meetings to share learning across networks

    Meeting 1:

    • To share and compare audit & baseline research outputs
    • To validate each other's improvement plans
    • To align with local and wider priorities and activities

    Meeting 2:

    • To celebrate and share successes, changes and learning
    • To discuss and plan embedding and sustaining
    Practice example

    "1 of the neighbouring practices hadn't yet used the NCDA. They had found the baseline audit difficult and opted to join next year due to the helpful summary reports. 2 sites agreed to work together to try to boost their smear numbers - particularly in the under 35 age range. We shared some successes we had achieved from a project we had undertaken in 2015.

    "At the second meeting we shared our outputs - namely that we had managed to refer to patients more quickly and reduce the mean number of consultations taken. We flagged that we had also increased our total number of referrals by 50%, and total prevalence also went up. We borrowed ideas from our adjoining surgery, who had bolstered their safety-netting practices, and agreeing on the importance of continuing the work in the future, made further plans to exchange more detailed suggestions."

    5. Monitoring

    Self-declare activity completion and attendance at 2+ PCN peer reviewing meetings.

    Case study – bowel cancer screening

    QOF QI Early diagnosis of cancer case study: Bowel cancer screening (PDF file, 259 KB)

    Plain text of document (infographics not included):

    Practice details: 6,500 patients, 2.8 WTE GPs (1 partner), inner-city practice – lower quartile deprivation index.

    The project team focused on ways to improve the uptake of cervical screening, using evidence-based interventions.

    They used the RCGP QI wheel for general practice (available in RCGP’s How to get started in QI guide for advice).

    Culture and context:

    In preparation for the QOF QI domains, 2 GPs, 2 administrators and the HCA had undertaken online QI learning modules. The practice had also elected to take up the offer of QI training offered by the CCG. The senior administrator and a salaried GP took on the lead clinical and non-clinical roles.

    At a weekly practice meeting, on the background of a recent late bowel cancer diagnosis and death, the project team invited the room to undertake a brief SWOT (strengths, weakness, opportunities and threats) analysis in relation to both cancer diagnosis and screening. It was recognised that cervical screening rates had gone up over the past 5 years – coinciding with a local enhanced service. They realised that having weekly clinical meetings meant that certain equivocal cases were often held over and discussed there, and sometimes led to delays in referral. A low uptake of the national bowel cancer screening programme uptake was recognised as a key area for attention.

    Diagnose:

    The practice used searches found in Macmillan’s Quality Improvement Toolkit, along with Fingertips data. They identified the practice as being in the lowest decile nationwide.

    Plan and test:

    Plan and test: The project team then used this data to inform their next actions and set a clear plan. They agreed a SMART outcome aim (what the project wanted to achieve and by when), a measure (how they will know if anything is changing), and the change itself (what will people do differently):

    Aim:

    The practice team aimed to increase the uptake of patients who default on bowel screening by 5% over the next 12 months, (and thereby to move out of the lowest decile).

    Measure:

    The project used relatively limited information held within GP registers – subject date of birth and screening result codes. The lead administrator created searches and measured monthly:

    a. The percentage of eligible non-participants at four months who were contacted by letter and telephone

    b. The proportion of eligible subjects receiving opportunistic discussion with the GP

    Change:

    The team participated in an initial peer review meeting with their Primary Care Network colleagues, where practice data was shared, ideas for measurements and changes generated, and learning from each other took place. They undertook the following changes:

    a. Letters were sent from the practice and telephone calls made to those subjects who had not returned their gFOBt or FIT kit within four months of the BCSP invitation

    b. Opportunistic discussion of bowel screening for those patients consulting their GP for other reasons, who had not been screened within the past two years, was undertaken - including coding on the practice operating system (8CAY READ code / XaPyB - “Advice given about bowel cancer screening programme”).

    Implement & embed:

    The GP had recently attended a GP Cancer Update Course, and this included several proposals for improving the uptake of patients who default or decline bowel screening. The proposals included increasing awareness amongst all clinicians – including the project team and practice staff – and actively seeking out the target population to encourage uptake by direct contact from the practice. These actions are in process at present and bowel screening uptake will be monitored at practice level and through PHE’s Fingertips tool to evaluate impact in future.

    Outcome:

    The practice was able to show a small improvement on their internal searches. They placed a run chart on the wall of the practice and used it to display the progress of uptake against their SMART aim. It was updated monthly and used to check that they were on track to meet their goal when full (annual) data would be available. They found it helpful to visualise both the increase in communications from the practice, and numbers of additional opportunistic discussions, also using run charts.

    Sustain and spread:

    The practice also now has a heightened awareness and management plan for all clinicians, i.e. upon notification of a ‘declined’ bowel screening invitation, a pathway has been devised whereby these are highlighted and reviewed, and appropriate decisions are made on an individual basis. The project lead attended the 2nd peer review meeting with colleagues from the local Primary Care Network (PCN) to share the team’s progress and raise suggestions for next year’s focus. The practice, along with others in the PCN, is now looking for patient champions to encourage enhanced uptake of screening through patient activation and intends to use an expert patient to move forward with this process.

    What the practice did next:

    There is evidence that the strategy of additional GP based reminders for those not participating by four months is effective. Approximately one additional person was estimated to participate for every 7 successful DNA telephone calls. In addition, the project team intends next year to initiate letters and telephone calls direct from the practice promoting bowel screening for those subjects approaching their 60th birthday, with details of when the first invitation by the BCSP would be sent.

    What evidence did the practice provide for QOF payment:

    The contractor completed the annual QOF QI domain self-declaration. They kept a copy of the QI monitoring template and clinical audits for future payment verification if needed, as well as evidence for future CQC inspections.

    Case study – cervical screening

    QOF QI Early diagnosis of cancer case study: Cervical screening (PDF file, 233 KB)

    Plain text of document (infographics not included):

    Practice details: 4,500 patients, 2.7 WTE GPs, inner-city teaching practice – lower decile deprivation index.

    The project team focused on ways to improve the uptake of cervical screening, using evidence-based interventions.

    They used the RCGP QI wheel for general practice (available in RCGP’s How to get started in QI guide for advice).

    Culture and context:

    In preparation for the QOF QI domains a GP, a practice nurse, a HCA and an administrator undertook the online RCGP QI learning module and created a QI project team.

    At a practice cancer review meeting a case was discussed involving a 32-year-old patient who had recently been diagnosed with cervical cancer. At a routine GP consultation, she presented with vaginal discharge and post-coital bleeding. Her cervix appeared abnormal on examination. She was referred urgently. It was realised that she had never attended for a cervical smear. This prompted a review of smear uptake.

    It was noted that there had been a reduction in the number of cervical screens performed following a practice nurse leaving and this was an area for attention.

    Diagnose:

    Using the PHE Fingertips data, the GP reviewed the cervical screening rates for the practice and compared these to local surgeries and other CCGs nationally. He also used EMIS searches to compare this data to previous years, and to drill down further to identify any inequality within the practice. He also reviewed uptake rates for groups who may experience barriers to accessing services. The data demonstrated that total practice cervical screening rates in all eligible patients had decreased over the previous 2 years. Uptake had dropped from a stable 72% to 66% to 63% in 2 years. Rates for women aged 25-34 were notably low, as were rates for female patients without English as a first language.

    The data was presented at the next whole team practice meeting. Reasons for the decline were proposed and included the change in the practice nurse rota – resulting in fewer appointments available after 4pm, along with changes in administration staff. Plus, a general lack of understanding about the process and significance of testing was acknowledged.

    Plan and test:

    It was agreed that the busy team would consider upping screening rates as a priority and, with clinicians, administrators and reception staff working together, consider how they would approach the challenge, and how they would support each other.

    The team used the Model for Improvement to plan their project. They devised SMART aims (what the project wanted to achieve and by when), some practical measures (to understand what had changed) and brainstormed together a range of changes they would be happy to try out. They used a driver diagram to help focus their list of changes.

    Aim: Over the next 10 months, the team aimed to increase the total uptake of cervical screening by 8% to reach the national average, and with a ‘stretch target’ of 12% - to enter the top quartile.

    Changes were introduced gradually and reviewed formally at two monthly meetings and the question of ‘How are things going?’ was raised on a weekly basis informally.

    The team attended an initial peer review meeting with their Primary Care Network Colleagues to share both the data they had collected, and ideas of how to improve their performance.

    Measures:

    i) Proportion of eligible patients screened adequately within the specified period (25-49 years last 3.5 years, and 50-64 years old in last 5.5 years)

    ii) Proportion of eligible patients with a) 1st, b) 2nd, and c) 3rd reminder letters

    iii) Proportion of eligible patients with text message reminders sent the day before iv) Average level of confidence across both clinical and nonclinical team members (self assessed from 1-10) in having conversations with patients about screening.

    The search was repeated monthly to measure changes.

    Change: From a suggested team list of 22 possible improvement changes, the team agreed on the following ideas to work on:’ to ‘ideas to work, which include education, system change and access.

    Education:

    A teaching update for the clinical team on cervical screening and the role of HPV.

    - All clinicians agreed to consider opportunistic screening when possible, especially for those women who had been harder to engage in the screening programme.

    Practice learning sessions for the administration team including basics of screening, clinical importance and how to approach patients – making the most of each contact.

    - All receptionists were made aware of how to check the records of women attending the practice for appointments, and to discuss the option of arranging an appointment for screening at a time that was convenient for them.

    System change:

    Women were encouraged to bring a friend along with them to the appointment if they thought that would be helpful – in the invitation letter, at reception, and opportunistically.

    A text message was sent on the day prior to the appointment to remind the woman to attend.

    Leaflets in different languages were placed in the waiting room for the benefit of the practice’s hard to reach cohort.

    Access:

    Flexibility was introduced to provide cervical smear testing immediately if a patient identified she was ready to have the test (e.g. at baby clinic).

    The rota was revised to allow 2 focused late afternoons and evenings per week. 

    Outcome:

    In the first 6 months, the proportion of women attending for cervical screening increased by 3% compared to last year. By 12 months, it had increased by 10%. Comments, collected from women who attended about why they had not done so previously, were used to further promote attendance. The project was advertised on, and some of the feedback attached to, a newly created ‘Women’s Health’ board in the waiting area. Improved internal communication – including informal chats, a standing item at practice meetings, and returning the focus frequently to smears, meant that the confidence of receptionists, administrators and clinicians when discussing smears also increased. Numbers of opportunistic smears also went up.

    A monthly chart of uptake was shared internally via email, and also posted to the wall for patients to see.

    Implement and embed:

    A better understanding and empowerment of the team helped contribute to the practice’s success. Several clinicians went on to undertake the NHS cervical screening module programme on eLfH. The practice nurse agreed to start work on a plan for next year, taking into account evidence-based suggestions via Gov.uk Screening. Methods to identify those who had failed to attend for screening, via the practice system, were modified as the project progressed, and the reception team felt empowered by recognising their role as part of the solution.

    The QI administrator contacted Jo’s cervical cancer trust and arranged for a delivery of free resources to display. The project outcomes and progress were shared in detail with other PCN members at the second meeting.

    Sustain and spread:

    They acknowledged, however, that they needed to improve the robustness in ensuring all three recall reminders were sent appropriately. Plans were made to make modifications to the patient record – to better identify those overdue, and to allow an easier offering of appointments. Reception staff resolved to regularly provide a leaflet about the importance of screening to women who were overdue.

    The project team attended the next PCN network meeting and shared the learning with local practices. Tips were also picked up at the PCN meeting from practices taking a different approach. There were wider discussions about poor uptake of bowel and breast screening programmes and plans to work with other members of the PCN on projects to improve uptake of screening more generally was agreed. One practice committed to a more frequent (monthly or so) discussion with QI leads in the following year as they recognised they were experiencing very similar problems to the practice that had made changes.

    What the practice did next:

    The content of ‘the script’, and manner in which verbal invitations were given to women opportunistically were honed – based on feedback actively elicited.

    The GP lead agreed to further modify the letter sent to eligible women, and agreed to compare ours to other in the PCN and using resources online. The NHS Easy guide to cervical screening was also attached to the letter.

    Further work to improve the cervical screening offer to women with physical or learning disabilities is planned in the next phase of the project – since this was the next notable group with low attendance rates. The practice are looking to work closely with the patient participation group to understand the main barriers and concerns for women and their carers.

    What evidence did the practice provide for QOF payment:

    The contractor completed the annual QOF QI domain self-declaration. They kept a copy of the QI monitoring template and clinical audits for future payment verification if needed, as well as evidence for future CQC inspections.

    Case study – early diagnosis of cancer based on NCDA outcomes

    QOF QI Case study: Early diagnosis of cancer based on NCDA outcomes (PDF file, 328 KB)

    Plain text of document (infographics not included):

    Practice details: 12,000 patients, 5.5 WTEs, suburban practice.

    The team decided to focus on reducing both the primary care interval – i.e., the time in days between first presentation to referral from primary care, and the number of consultations prior to referral, to improve early cancer diagnosis.

    They used the RCGP QI wheel for general practice (available in RCGP’s How to get started in QI guide for advice).

    Culture and context:

    One of the salaried GPs had attended a regional QI training course, and a health care assistant (HCA) had completed online QI modules. A core team was created to lead the project, made up of the GP, the HCA and an experienced administrator.

    A significant event analysis was undertaken at a practice multidisciplinary clinical team meeting following a complaint relating to a delayed referral. Learning from it highlighted that the patients with vague symptoms took several GP visits before referral to the correct specialty was made.

    Diagnose:

    The surgery had participated in the National Cancer Diagnosis Audit in the previous year, and the team reviewed the annual feedback analysis report. They recognised that they had a relatively long primary care interval (time in days between first presentation to referral from primary care) compared to local and national figures, and the median number of GP consultations prior to referral was 2 compared to the local and national figure of 1.

    Plan and test:

    The project team then used this data to inform their next actions and set a clear plan. They agreed a SMART outcome aim (what the project wants to achieve and by when), a measure (how they will know if anything is changing), and the change itself (what will people do differently).

    Aims:

    The practice team set 2 aims:

    a. To reduce the primary care interval by 25% over the next 12 months

    b. To reduce the median number of consultations prior to referral from 2 to 1 over the next 12 months.

    Measure:

    On a monthly basis the administrator created a list of all new cancer diagnoses. The primary care interval was calculated for each new case by electronic notes review – with first presentation and referral date having been documented in the notes. The number of consultations prior to referral was counted by the HCA.

    Change:

    The team participated in an initial peer review meeting with their Primary Care Network colleagues and were able to share both data and ideas. Learning from their nearest practice colleagues they decided to:

    a. Discuss the new cancer diagnoses at more regular intervals – by creating dedicated new multidisciplinary cancer diagnosis discussion meetings (administration team were also invited) every month. These were previously happening quarterly. They ensured dissemination of minutes across the team and invited more active feedback from colleagues.

    b. Generate quarterly in-house cancer education sessions and agreed changes to the rota that allowed all GPs and practice nurses to attend at least one of the wider CCG cancer events throughout the year.

    Outcome:

    It was reassuring to find that the median number of consultations prior to referral had reduced from 2 to 1.5 (the new range being 0-5 compared with to 0-8 previously) over the course of the project, whereas the primary care interval showed a modest improvement of 10%. The figures were plotted on run charts in the waiting room each month so that both the whole practice team and patients could observe progress.

    Implement and embed:

    The administrator left the practice after 2 months, providing the opportunity to retrain a new colleague in search and list creation. The HCA oversaw the primary care interval calculation. To ensure a good mix of clinical colleagues could attend, the team realised they needed to vary the day of the cancer meetings and change the frequency to 6-weekly to keep attendance high. They realised that not all the clinicians were aware of the latest changes to NG12 (Suspected cancer: Recognition and referral) guidelines1, so this was the focus of the first team educational session. Session changes meant that some GPs were able to attend more educational sessions than in previous years.

    Sustain and spread:

    By calculating and reviewing the primary care interval themselves on a monthly basis, they felt better able to visualise any changes. They found that an increasing number of the admin team attended the meetings. The project lead also attended the 2nd peer review meeting, where they shared the team’s work with colleagues from the local primary care network, wider system issues were recognised and ideas for next year’s collective efforts were suggested.

    What the practice did next:

    They agreed that they would continue to contribute to the NCDA. Also, that the QI cancer lead would rotate between 2 of the junior GPs who both showed increased interest following the cancer education sessions. They intended to concentrate next year on safety netting 2 Week Wait referrals to ensure patients consistently receive an appointment within 2 weeks and agreed to invite members of the PPG to join in planning discussions for future QI work.

    What evidence did the practice provide for QOF payment:

    The contractor completed the annual QOF QI domain self-declaration. They kept a copy of the QI monitoring template and clinical audits for future payment verification if needed, as well as evidence for future CQC inspections.

    QOF QI hub

    The QI domain was introduced to QOF to encourage practices to focus on these important areas of care. The QOF QI hub on QI Ready contains additional practical resources and case studies, with examples of how practices can approach their quality improvement activity.

    The resources support practices to improve through the development and implementation of a quality improvement plan, as well as sharing their learning across their network.

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