Continuing our focus on CQC inspections and the key lines of enquiry (KLOEs), in this article we concentrate on the ‘effective’ element.
The effective KLOE is all about being good at showing how the practice employs evidence-based outcomes that enable patients to experience a good quality of life. There’s also an underlying theme of making checks to ensure sustained care and improvement. Effectiveness is demonstrated now more by outcomes rather than inputs, but processes are still important both to show planning takes place and that there’s a clear and common approach to how things are done in the practice.
Consent and the legal frameworks
There will be no surprises that ensuring the practice sticks to its legal requirements is an area for inspection. Staff knowing how they should be providing a service to people with mental health issues that fits the legislation (Mental Capacity Act or the legalities of the Children’s Acts) will always be inspected. The consent and treatment issues involving patients who don’t have the capacity to make decisions are far too complex to go into any great detail here, but staff all need to know whether what they do is in the best interests of that patient. While process is not necessarily the main focus of the new inspection regime, this is one area where having a clear process, understood by all staff and the ability to demonstrate its use in practice is very important.
The ability of staff (especially clinical staff) to recognise a patient whose liberty is being restricted outside the legal framework and who lacks mental capacity, is highlighted for inspection, as is a system to avoid the need for physical restraint. It is likely that this latter issue will not be regularly encountered in most GP surgeries. The increase, however, in residential facilities that practices will be called on to cover, because conditions such as dementia are on the rise, may well lead practice clinicians to encounter these issues outside the practice premises. Take a look at the Consent and Mental Capacity Act policies [PLUS] for further guidance.
Each of the KLOEs has some aspect of staffing contained within it and Effective is no exception. A practice that assesses training needs, recognises that staff development increases effectiveness and makes an investment in time at the very least, promoting involvement across the board, internally and externally, should be able to easily show how it is becoming more effective.
In a previous article on KLOEs it was mentioned that assessing staff skills as they stand now and matching them to both what the health economy want and developing practice personnel to meet those needs was the way forward. This KLOE reinforces that simple position. Having staff who are able to deal with patient needs using the right skills that have been planned in the light of need is effective in terms of outcomes and cost – the best practices will be able to show this across all the KLOES and gain the best inspection feedback.
Management (back to well-led again!) has to manage – and that means monitoring what staff do, assessing if it is the right thing they need to do and acting to correct deviation from the required standard is what effective is all about. Appraisals and revalidation have to be taken seriously to achieve effectiveness, supported and encouraged by the partners/board and embraced throughout the practice at every level. Nobody ever said that practice management was easy and clearly it is becoming more professional day-by-day – a fact that PMs are all acutely aware of. Indeed, the best practices acknowledge this right up to partner level. MRCGP is not a management qualification, no matter how hard it tries to be. So, for example, persuading partners to shut the door to staff who try to by-pass the PM when they don`t like being managed can only improve effectiveness and demonstrate leadership. The Appraisals Document [PLUS] is a useful template which can be adopted by practices. Also, take a look at this blog post: Appraisals – expected and needed.
Finally under staffing – have you realised that the proper use of volunteers in practice is now governed under this KLOE? Practices have started to make the use of volunteers in much the same way that secondary care has sought to support its services with well-meaning unpaid volunteers. The recruitment, training and support of volunteers needs to be at no less a standard than a good practice would give to its own employees and has to be evidenced for the CQC inspection.
Delivering effective care
This is probably an area where GPs might seek to stand on professional ground and sideline the PM? Have none of it. The average PM can recognise effective care, for no other reason than they deal with the complaints, grumbles and legal fallout that result from there being no effective care given. It`s sometimes important to be able to make the GPs and nurses see outside their own sphere and realise that they operate in a wider setting.
The PM can scan the environment to pick up on effective technology that will provide better care and support for patients and enable them to retain independent, which of course costs less in terms of appointment time and practice finance. The use of innovations such as e-Consult or similar online systems, as well as PC-connected ECGs or imaging systems that make it quicker and easier to reach the right diagnosis, are important characteristics looked for in effective practices. Plus, don’t forget that `technology` does not necessarily mean digital innovation, but also ways of working such as holistic care that spans multiple disciplines of physical, mental and social issues. Effective standards apply everywhere.
The treatment of patients who have communication problems, particularly when dealing with the relief of pain, mean that their assessment and management requires special attention under this KLOE. The practice has to demonstrate that it tries to ensure consistency across the various organisations involved in patient care and that co-ordination is as important as communication. The minutes of, for example, MDT meetings can show that the practice takes co-ordination seriously and challenges any views expressed that conflict with what practice clinicians think to be the best options or courses of action.
Effective support for patients
Effective support for patients is probably the most extensive section of this KLOE. Support as a topic for inspection spans several of the main areas and looks to the practice to:
- monitor the outcomes of patient care against what was intended,
- provide help and support to patients both in recognising the implications of their condition and what needs to be done should their health deteriorate
- benchmark itself against the support given by other practices and organisations – not an easy task!
Patients must be encouraged along the path of self-help, as well as those with long-term conditions becoming involved in regular checks at the practice to ensure they make the best of what is available that can assist them to improve their own health. How a practice manages to make a horse led to water to drink remains an imponderable, but looking at QOF exception rates between practices in the same CCG or locality can give some idea. Therefore, be prepared to answer why, for example, your diabetic foot-checks in QOF exclude twice as many patients as the practice next door or your mental health exclusion rate is twice the national average!
Does the practice provide extra support and assistance to those with complex conditions? Does the practice contribute to patient support by involvement in meaningful audits or research? Perhaps the easiest to show is the success you have supporting national and local initiatives such as stop-smoking, obesity or exercise programmes and perhaps substance or alcohol abuse programmes. Now that online gaming addiction has been recognised alongside gambling, has the practice put itself one step ahead and begun to look at that issue? It raises the question of how much involved the practice is in its local community, working with local schools or community organisations to support patients with social health that impacts on their physical and mental well-being.
Special categories of patients are expected to receive demonstrable support under this KLOE – those in the 12 months to end of life, those at risk of long-term conditions and those who care for those patients. This is an area often specifically addressed in inspections and the inspection team will look for practices both identifying those categories and giving that bit more support. You have been warned!
Missed part of the series? Catch up with the rest of “The inspection insider” series here.
Helpful document for your CQC inspection: CQC guidance
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