What is a quality account?
Quality accounts are a holdover from the Darzi era, where they were introduced as part of Lord Darzi's NHS Next Stage review. The aim of quality accounts is to ensure that providers – such as GP practices – are held accountable for improving quality, and they are given the same status as financial accounts. Starting next year, all GP practices will have to produce an annual quality account, which will be sent to the Department of Health and published on the NHS Choices website.
We were keen to show our patients we were continuing to improve the quality of our care, so we decided to take part in a pilot of quality accounts in our area during 2010.
It is easy to be cynical about these kind of reports, and we were concerned that the exercise would be a considerable additional workload without any added value for the practice.
After completing the pilot we still have some reservations about their usefulness, but on balance, the exercise of reviewing our services and coming up with a plan to improve them has been a useful one.
Here, we detail our experience and give some tips about how you can ensure your experience of preparing these accounts is a positive one.
What it involves
There are some sections that are mandatory to include – such as an overall statement of quality, a review of quality performance over the previous year, priorities for improvement and evidence stakeholders have been engaged (see box, below) – but on the whole the contents are pretty much up to you to decide. In principle this is a good idea, but pilots in general practice have found the quality of accounts varies and that many GP practices needed a lot of guidance to complete them.
The first requirement is to identify someone to make the statement on quality. We discussed this at our practice meeting. Our executive GP partner provided the statement on quality, but this reflected the vision for the whole practice.
Next, you have to analyse your current position and benchmark yourself against other practices. We found this was the most time-consuming activity as there are not really any standard national measures for quality improvement, and there is significant clinical variation within and across practices for various reasons.
We had help from our PCT, the NHS Institute for Innovation and Improvement, the RCGP and the Quality Observatory, but the lack of national benchmarks curtailed our ability to identify areas for improvement. We ended up focusing on data such as that from the patient survey, feedback from our patient forum, QOF data and patient complaints.
Practices are required to identify at least three priorities for improvement. We went beyond this, with nine clinical and administrative priorities. We chose three indicators in each of the three key domains of quality – patient safety, clinical effectiveness and patient experience – as recommended in DH guidance . Unfortunately, we were constrained to only those areas that had existing quality measures and were not able to work on the areas we would have wished to.
We undertook a review of the information, discussed this at practice meetings and developed a long list of areas we wished to focus on. We then worked with staff and patients to agree a shorter list, which enabled us to have a mix of areas we were good at and those we could improve.
Existing clinical leads undertook to review, audit and implement action plans for each of the clinical areas identified. They worked with the practice manager to co-ordinate staff and patient involvement. The practice manager had responsibility for non-clinical indicators, documentation and completion of the report.
Staff leading on this work had to free up capacity, and this did create staffing problems at times. But it can be worked through if you plan carefully.
The development of quality accounts is a complicated process, although less onerous than we had feared. Right from the start we developed a clear engagement plan to ensure that all practice staff were involved in implementation of quality improvements.
One valid criticism is that all the time spent preparing a written report is unlikely to improve anything.
The potential audience for the quality accounts is too wide. It was challenging to produce a document that could be used by commissioners, other stakeholders and patients – different audiences with different needs, that need information presented in different ways. We would like to see the audience for the report made more specific. But we have found that engaging staff in a formal programme of quality improvement has been very beneficial.
Staff valued the opportunity for involvement and we used practice meetings and educational sessions to engage staff in the changes we wanted to make. These conversations have continued with positive feedback from practice staff.
The whole team is becoming used to a culture of change and actively identifying areas for improvement.
Anonymised patient complaints and untoward incidents are now routinely shared with staff and patients and used to inform improvements. We achieved clinical buy-in by linking quality improvement to personal development plans and GP appraisals.
The accounts also provided an opportunity for patient engagement. We used our existing patient forum, website, newsletter, telephone interviews and informal contacts to gather the information we included in the accounts.
We placed a brief overview of quality accounts on our website and patient screen in the waiting room. This helped us to get patients involved. We used our patient forum to raise awareness and get patient feedback on their experience of using our services and develop a shortlist of priorities.
It was gratifying to receive consistent reports of high satisfaction for the services patients received. However, disappointingly, patients seem rather less interested in the quality accounts than we were.
In a survey we carried out, patients did not perceive value in a written report and most said they would not read it. Although advertised on our website, Christmas newsletter and through copies available in the waiting room, we have not yet had a request for a copy.
Preparing the accounts and following up on their progress is now a core role for the practice manager, and this will be a key part of becoming commissioning-ready (or fit for purpose as a provider) so we can succeed in an open market with increasing economic challenges.
What we changed
Preparing quality accounts has enabled us to use a structured approach to implement our plans for improvement. We now have our priorities for 2011/12 and some ways of measuring our progress based on evidence.
The practice had already planned to integrate our administration and reception functions to save costs, and being involved in the pilot meant we were clearer about the objectives and expected outcomes, and could get some much-needed support from external organisations at a local and national level to do this.
As a result of the changes we made, we have been able to reduce waste and increase patient and staff satisfaction and practice profits. ‘Lean methodology' has been used to review nurse triage of home visits and the baby clinic. This has further reduced waste in our system and had a positive financial impact.
We still have a long way to go, but this pilot has helped us to change our practice culture to ensure that continuous quality improvement will become an organisational norm.
We have a better understanding of each other's roles and the contribution we all make to provision of high-quality, effective, efficient services. More importantly, we have a better understanding of our individual roles in enhancing patient experience and outcomes.
We are currently working with the Primary Care Northern Deanery to develop quality indicators for mental health and osteoporosis as a result of our problems with benchmarking in the pilot scheme.
We will also be using the clinical dashboard and risk stratification tool for clinical benchmarking data through our commissioning consortium.
We had some worries that the accounts could become another mechanism for performance management – although this was not borne out in the pilot phase – but we remain uncertain and cautious about the use of this document for commissioning purposes.
Dr Paul Grainger is executive partner and Sheinaz Stansfield is practice manager at the Oxford Terrace Medical Group in Gateshead
What you must include in a quality account
• Overall ‘statement on quality' from a senior GP partner certifying the document is accurate
• Review of quality performance over the previous year, including certain mandatory statements on quality of NHS services provided
• At least three priorities for improvement and how progress will be measured
• Who you have involved and engaged with to produce the account
• Any statements from the PCT, LINks or OSCs.
Source: Department of Health
1. Department of Health. Quality Accounts Toolkit 2010/2011.