Clinical Governance Practice Self Assessment Tool (CGPSAT) update

1. Clinical Governance Practice Self Assessment Tool (CGPSAT) update Thursday 20th March 2014 Primary Care Quality and Information Service Laura Jones, Team Lead Primary Care Quality

2. Primary Care Quality Public Health Wales* Assists Health Boards, practice teams and individual primary care practitioners to improve the quality of the care that they deliver by: Providing access to evidence-based quality improvement guidance and tools Encouraging review, reflection and revision *Previously known as (PCQIS) Primary Care Quality and Information Service

3. Primary Care Quality Public Health • aims to encourage and support primary medical care teams to examine the care they provide, reflect on their services and try different approaches as necessary to improve • Improved systems can help deliver safe care in a more comprehensive and effective way to patients Primary Care Quality

4. Clinical Governance Practice Self Assessment Tool (CGPSAT) • Encourages practices to bridge the gap between understanding and thinking about their governance systems and completing the actions needed to improve them • The on-line maturity matrix style CGPSAT was made available to all Welsh General Practices in 2010 and was designed to be completed via programme of self assessment and review Primary Care Quality

5. CGPSAT background • Based on the Standards for Healthcare Services in Wales • Over the past 3 years it has become the favoured tool • In conjunction with a quality review visit and collation of other pieces of information available to health boards • Helping to assure that General Practices are delivering safe care in a comprehensive and effective way Primary Care Quality

6. CGPSAT • A practice’s engagement with the CGPSAT can provide evidence for revalidation that its GPs are working in a governanced environment. • The Wales Postgraduate Deanery recommends that GP appraisers encourage GPs to complete the tool as evidence for their appraisal • Publication of ‘Francis Report’ and in Wales the Welsh Government recommendations from the ‘Robert Powell investigation’ have highlighted the need for Health Boards to have primary care quality assurance processes in place Primary Care Quality

7. CGPSAT Objectives To be used by practices to review progress made in the development of governance processes within their practices To provide assurance to Health Boards of the same That it can be referred to by inspecting bodies (such as HIW) as evidence that appropriate clinical governance activity is occurring in practices That can support revalidation

8. CGPSAT Principles Voluntary Standardised model across Wales Developed by practitioners and other stakeholders Endorsed by GPC Wales & RCGP Wales Designed to help practices review, monitor & improve systems within their practice Completed by practice team

9. Roll out of CGPSAT 2010_13 • Due to considerable changes in 2010, Primary Care Quality ‘suggested’ the CGPSAT be completed over 3years (51 matrices) • Year 1: 2010/11 – complete 11 matrices (year 1) • Year 2: 2011/12 – complete 20 matrices (and review previous matrices in year1) • Year 3: 2012/13 – complete 20 (and review previous matrices completed in year1 and year2)

10. CGPSAT uptake figures Primary Care Quality

11. CGPSAT 2013_14 • Left unchanged, agreed that practices have an extra year to review fully completed CGPSAT to make improvements • Closing date 30th April 2014 • Monthly uptake reporting sent to health boards • Completed and submitted • In progress • Not started Primary Care Quality

12. As at 3rd March 2014 (adjusted for practices known to be closed ; complete is completed all 51 & submitted ; s prefix is started or in progress ; yellow are completes but less than 50 matrices ) Primary Care Quality

13. As at 3rd March 2014 (adjusted for practices known to be closed ; complete is completed all 51 & submitted ; s prefix is started or in progress ; yellow are completes but less than 50 matrices ) Primary Care Quality

14. CGPSAT uptake 2013_2014(as at 3rd March 2014) Primary Care Quality

15. CGPSAT 2014_15 • Plans to update the content of the CGPSAT put on hold until 2015/16 • From 1st April 2014: GMS contract in Wales, QOF QP domain has been replaced with a new Local Service Development Domain • to support cluster/network development and provide some focus for improvement activity • Completion of the CGPSAT is part of the Local Service Development domain Primary Care Quality

16. CGPSAT – learning for practice and locality development • How can Practices learn from the CGPSAT and use this for practice and locality development to strengthen the local health care in Wales? • Collation of information entered in the CGPSAT and included in the Practice Development Plan will help inform the needs assessment and priorities for development in the GP cluster/network • This may identify some learning or training needs or support needed for some practices that may not be as “mature” as others Primary Care Quality

17. Practice Development Plans within the CGPSAT • The current version of the CGPSAT does not have a single PDP area but each matrix has its own text area which can be amalgamated into a report • Practice development • Practice constraints • Practices need to use the print function to print a PDP report (see CGPSAT tutorial) Primary Care Quality

18. CGPSAT a useful experience for your practice team • Completion as a whole team will encourage fuller discussion, review and understanding of processes in the practice, encourage wider involvement (and ownership) in development and improve generation of ideas • Do not attempt to complete the tool all in one sitting. You will get better value if you give yourselves time to reflect on the issues • Be honest. It is preferable to assess your practice at a lower level and plan how to improve than to overestimate your level of maturity and have difficulty proving it • The CGPSAT provides supporting information boxes to advise you on what evidence you might be able to produce to demonstrate how you have achieved the level assessed. These are examples only and won’t be applicable to all practices Primary Care Quality

19. CGPSAT 2014_15 • As there are still a lot of practices who have only partially completed the 2010-13 version of the CGPSAT, it has been left unchanged for 2014/15 • Practices that completed the tool in 2013/14 or earlier should now review their answers (and update if appropriate) and make a new Practice Development Plan • A new submission (all 51 matrices completed) is required to obtain the QOF payment by 31st March 2015 Primary Care Quality

20. Health Board CGPSAT Reporting • Monthly uptake figures (October – April) • June – CGPSAT annual reporting (spreadsheet) of practices submissions and CGPSAT level responses • Cross referencing the CGPSAT to Standards for Healthcare in Wales • Quality Improvement in Primary Care: Learning from the CGPSAT Primary Care Quality

21. CGPSAT – Team Engagment Primary Care Quality

22. Standard for Healthcare 2 - Equality, Diversity and Human RightsCGPSAT Matrix 3.1 Equity of Access Primary Care Quality

23. Standard for Healthcare 7 - Safe and Clinically Effective CareCGPSAT Matrix 14.1 Patient Safety and Reporting 2010/2011 2012/13 Primary Care Quality

24. Standard for Healthcare 18 - Communicating EffectivelyCGPSAT matrix 17.1 Communication systems 2010/11 2012/13 Primary Care Quality

25. Developments • 2015/16 CGPSAT content will be updated (working group meetings) • Discussions around a better IT platform for 2015/16 • 2014 - Health Inspectorate Wales (HIW) primary care reference group set up • Summer 2014 piloting a general medical practice inspection model • Planning to use a selection of CGPSAT areas to avoid duplication Primary Care Quality

26. CGPSAT support to practices and health boards • CGPSAT web pages being update. more user-friendly with access to: • Tutorial • CGPSAT checklist • Hints and tips • Background documents • http://howis.wales.nhs.uk/sitesplus/888/page/CGPSAT Primary Care Quality