The problem
What quality means has been confused by the demands of QOF, CQC, scorecards, and more recently Primary Medical Service Assurance Framework reports. We are not convinced that any of these indicators for performance management and remuneration are good enough measures of overall quality.
The RCGP Quality Practice Award evolved out of the FBA and started in 1996 and is awarded for five years. QPA is the highest attainable award available from the RCGP and covers large clinical and organisational components and an assessment of patient experience. The practice has to demonstrate reflective learning resulting in a quality initiative that is a holistic process of quality improvement.
There are over 10,000 GP practices in the UK. By April 2013 283 practices had achieved QPA (2.8% of all practices). Of these 283, 46 had re-accredited a second time (16% of the 2.8%) and only four (including Horfield) had done it for a third time. QPA can’t totally assure quality and probably nowhere near good enough to address all quality issues, but we felt that it’s the best we could do now.
Getting started
As a practice we have been on our quality quest for many years through Charter Mark awards, Investors in People, and previous cycles of QPA - so we are not novices. We know QPA is a daunting undertaking. It needs about two years of preparation and costs about £30,000 in extra time and effort from most of the doctors and staff. QPA changes and improves itself each year. It also seems to get harder each year with new and more exacting criteria and standards.
The first step is to look at the criteria and standards for the current version of QPA on the RCGP website. The next step is to consider if this is something that most of your practice want to do and will help with. It can’t be done just by one or two people, it’s a team effort.
What we did
Undertaking the Quality Practice Award requires practices to submit a portfolio of written evidence set against a number of standards covered in six modules. When a practice’s written evidence is complete, a full-day assessment visit is conducted by a panel of three, which comprises a combination of an experienced GP, nurse and manager.
Our senior partner had led the two previous QPA submissions and also led this third cycle; this leadership role is key to success. The main effort for the lead involves doing the lion’s share of the work and allocating the rest, collating results, sending it off to the facilitator in a steady trickle for about 18 months, correcting anything that needed to be improved, and prompting, reminding and encouraging everyone to make their contributions.
The RCGP website describes how to get started but the key issues are planning carefully for a few months how the work will be led, supported, delegated, timetabled, prompted (and prompted again), documented, reviewed internally (and externally by a QPA facilitator) before it’s bundled into a finished document that is sent off to the three external assessors before the deadline for completion.
Challenges
The hardest part of the QPA is trying to get busy doctors and staff to do this extra work, but as long as we gave ourselves plenty of time a rhythm eventually developed and tasks that had seemed impossible at first became easier. We also set aside dedicated admin resource to help support the contributors in their task.
Outcomes
Aiming to achieve the QPA was like a massive spring-cleaning of our practice systems. We thoroughly reviewed, reflected-upon and documented all the criteria and standards of the QPA. Many of the criteria were new to us and the standards higher than previously.
Positive organisational changes were extensive and included restructuring our document storage on our practice intranet into a simpler and more accessible format, consistently linking all employee objectives to our annual business plan, and developing an up-to-date IT strategy including use of social media.
The work helped us prepare for our CQC application and made us fit for the next few years.
Achieving the award was a morale booster for everyone and the helpful feedback comments and suggestions from the QPA assessment team are now incorporated into our planning processes to help us further improve.
In addition to the direct costs to the RCGP it probably cost us at least an extra £30,000 in doctor and staff time over 18 months. This was the cost in terms of staff time, and in our experience if the practice can’t spare the time, it shouldn’t attempt to achieve the QPA.
The future
We don’t have to revisit QPA until 2018 but that means we will have to start planning to do it in 2017. In the meantime we will continue to build upon the benefits of having gone through and survived this accreditation process, ensuring that this remains a great place to work and that we continue to provide excellent patient care in an organised and professional environment.
Dr Terry Kemple is the senior partner and Carolyn Plows the practice manager and business partner at Horfield Practice, Bristol.
