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Investing in general practice

February 2003

Annex A: Quality indicators - Summary of points

Secondary Prevention in Coronary Heart Disease
All minimum thresholds are 25%

Indicator	Points	Maximum threshold
Medical records
CHD 1. The practice can produce a register of patients with coronary heart disease	6
Diagnosis and initial management
CHD 2. The percentage of patients with newly diagnosed angina (diagnosed after 01/04/03) who are referred for exercise testing and/or specialist assessment	7	90%
Ongoing Management
CHD 3. The percentage of patients with coronary heart disease, whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status need be recorded only once	7	90%
CHD 4. The percentage of patients with coronary heart disease who smoke, whose notes contain a record that smoking cessation advice has been offered within the last 15 months	4	90%
CHD 5. The percentage of patients with coronary heart disease whose notes have a record of blood pressure in the previous 15 months	7	90%
CHD 6. The percentage of patients with coronary heart disease, in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less	19	70%
CHD 7. The percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months	7	90%
CHD 8.The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the last 15 months) is 5 mmol/l or less	16	60%
CHD 9. The percentage of patients with coronary heart disease with a record in the last 15 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindication or side effects are recorded)	7	90%
CHD 10. The percentage of patients with coronary heart disease who are currently treated with a beta blocker (unless a contraindication or side-effects are recorded)	7	50%
CHD 11. The percentage of patients with a history of myocardial infarction (diagnosed after 1 April 2003) who are currently treated with an ACE inhibitor	7	70%
CHD 12. The percentage of patients with coronary heart disease who have a record of influenza vaccination in the preceding 1 September to 31 March	7	85%
Subset – Left Ventricular Dysfunction
LVD 1. The practice can produce a register of patients with CHD and left ventricular dysfunction	4
LVD 2. The percentage of patients with a diagnosis of CHD and left ventricular dysfunction (diagnosed after 1/4/03) which has been confirmed by an echocardiogram	6	90%
LVD 3. The percentage of patients with a diagnosis of CHD and left ventricular dysfunction who are currently treated with ACE inhibitors (or A2 antagonists)	10	70%

Stroke or transient ischaemic attacks
All minimum thresholds are 25%

Indicator	Points	Maximum threshold
Records
STROKE 1. The practice can produce a register of patients with stroke and TIA	4
STROKE 2. The percentage of new patients with presumptive stroke (presenting after 01/04/03) who have been referred for confirmation of the diagnosis by CT or MRI scan	2	80%
Ongoing Management
STROKE 3. The percentage of patients with TIA or stroke who have a record of smoking status in the last 15 months, except those who have never smoked where smoking status should be recorded at least once since diagnosis	3	90%
STROKE 4. The percentage of patients with a history of TIA or stroke who smoke and whose notes contain a record that smoking cessation advice has been offered in the last 15 months	2	70%
STROKE 5. The percentage of patients with TIA or stroke who have a record of blood pressure in the notes in the preceding 15 months	2	90%
STROKE 6. The percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in the last 15 months) is 150/90 or less	5	70%
STROKE 7. The percentage of patients with TIA or stroke who have a record of total cholesterol in the last 15 months	2	90%
STROKE 8. The percentage of patients with TIA or stroke whose last measured total cholesterol (measured in the last 15 months) is 5 mmol/l or less	5	60%
STROKE 9. The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken (unless a contraindication or side-effects are recorded)	4	90%
STROKE 10. The percentage of patients with TIA or stroke who have had influenza immunisation in the preceding 1 September to 31 March	2	85%

Hypertension
All minimum thresholds are 25%

Indicator	Points	Maximum threshold
Records
BP 1. The practice can produce a register of patients with established hypertension	9
Diagnosis and initial management
BP 2.The percentage of patients with hypertension whose notes record smoking status at least once	10	90%
BP 3.The percentage of patients with hypertension who smoke, whose notes contain a record that smoking cessation advice has been offered at least once	10	90%
Ongoing Management
BP 4.The percentage of patients with hypertension in which there is a record of the blood pressure in the past 9 months	20	90%
BP 5. The percentage of patients with hypertension in whom the last blood pressure (measured in last 9 months) is 150/90 or less	56	70%

Diabetes Mellitus (Diabetes)
All minimum thresholds are 25%

Indicator	Points	Maximum threshold
Records
DM 1.The practice can produce a register of all patients with diabetes mellitus	6
Ongoing Management
DM 2.The percentage of patients with diabetes whose notes record BMI in the previous 15 months	3	90%
DM 3. The percentage of patients with diabetes in whom there is a record of smoking status in the previous 15 months except those who have never smoked where smoking status should be recorded once	3	90%
DM 4. The percentage of patients with diabetes who smoke and whose notes contain a record that smoking cessation advice has been offered in the last 15 months	5	90%
DM 5. The percentage of diabetic patients who have a record of HbA1c or equivalent in the previous 15 months	3	90%
DM 6. The percentage of patients with diabetes in whom the last HbA1C is 7.4 or less (or equivalent test / reference range depending on local laboratory) in last 15 months	16	50%
DM 7. The percentage of patients with diabetes in whom the last HbA1C is 10 or less (or equivalent test / reference range depending on local laboratory) in last 15 months	11	85%
DM 8. The percentage of patients with diabetes who have a record of retinal screening in the previous 15 months	5	90%
DM 9.The percentage of patients with diabetes with a record of presence or absence of peripheral pulses in the previous 15 months	3	90%
DM 10. The percentage of patients with diabetes with a record of neuropathy testing in the previous 15 months	3	90%
DM 11. The percentage of patients with diabetes who have a record of the blood pressure in the past 15 months	3	90%
DM 12. The percentage of patients with diabetes in whom the last blood pressure is 145/85 or less	17	55%
DM 13. The percentage of patients with diabetes who have a record of micro-albuminuria testing in the previous 15 months (exception reporting for patients with proteinuria)	3	90%
DM 14. The percentage of patients with diabetes who have a record of serum creatinine testing in the previous 15 months	3	90%
DM 15. The percentage of patients with diabetes with proteinuria or micro-albuminuria who are treated with ACE inhibitors (or A2 antagonists)	3	70%
DM 16.The percentage of patients with diabetes who have a record of total cholesterol in the previous 15 months	3	90%
DM 17.The percentage of patients with diabetes whose last measured total cholesterol within previous 15 months is 5 or less	6	60%
DM 18.The percentage of patients with diabetes who have had influenza immunisation in the preceding 1 September to 31 March	3	85%

Chronic Obstructive Pulmonary Disease (COPD)
All minimum thresholds are 25%

Indicator	Points	Maximum threshold
Records
COPD 1.The practice can produce a register of patients with COPD	5
Initial diagnosis
COPD 2.The percentage of patients where diagnosis has been confirmed by spirometry including reversibility testing for newly diagnosed patients w.e.f. 01/04/03	5	90%
COPD 3.The percentage of all patients with COPD where diagnosis has been confirmed by spirometry including reversibility testing	5	90%
Ongoing management
COPD 4. The percentage of patients with COPD in whom there is a record of smoking status in the previous 15 months	6	90%
COPD 5. The percentage of patients with COPD who smoke, whose notes contain a record that smoking cessation advice has been offered in the past 15 months	6	90%
COPD 6. The percentage of patients with COPD with a record of FeV1 in the previous 27 months	6	70%
COPD 7. The percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked in the preceding 2 years	6	90%
COPD 8. The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March	6	85%

Epilepsy
All minimum thresholds are 25%

Indicator	Points	Maximum threshold
Records
EPILEPSY 1. The practice can produce a register of patients receiving drug treatment for epilepsy	2
Ongoing Management
EPILEPSY 2. The percentage of patients age 16 and over on drug treatment for epilepsy who have a record of seizure frequency in the previous 15 months	4	90%
EPILEPSY 3.The percentage of patients age 16 and over on drug treatment for epilepsy who have a record of medication review in the previous 15 months	4	90%
EPILEPSY 4. The percentage of patients age 16 and over on drug treatment for epilepsy who have been convulsion-free for last 12 months recorded in last 15 months	6	70%

Hypothyroidism
All minimum thresholds are 25%

Indicator	Points	Maximum threshold
Records
THYROID 1. The practice can produce a register of patients with hypothyroidism	2
Ongoing Management
THYROID 2. The percentage of patients with hypothyroidism with thyroid function tests recorded in the previous 15 months	6	90%

Cancer
All minimum thresholds are 25%

Indicator	Points	Maximum threshold
Records
CANCER 1. The practice can produce a register of all cancer patients defined as a ‘register of patients with a diagnosis of cancer excluding non-melanotic skin cancers from 1 April 2003’	6
Ongoing Management
CANCER 2. The percentage of patients with cancer diagnosed from 1 April 2003 with a review by the practice, recorded within six months of confirmed diagnosis. This should include an assessment of support needs, if any, and a review of co-ordination arrangements with secondary care	6	90%

Mental Health
All minimum thresholds are 25%

Indicator	Points	Maximum threshold
Records
MH 1. The practice can produce a register of people with severe long term-mental health problems who require and have agreed to regular follow-up	7
Ongoing Management
MH 2. The percentage of patients with severe long-term mental health problems with a review recorded in the preceding 15 months. This review includes a check on the accuracy of prescribed medication, a review of physical health and a review of co-ordination arrangements with secondary care	23	90%
MH 3. The percentage of patients on lithium therapy with a record of lithium levels checked within the previous 6 months	3	90%
MH 4. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months	3	90%
MH 5. The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months	5	70%

Asthma
All minimum thresholds are 25%

Indicator	Points	Maximum threshold
Records
ASTHMA 1. The practice can produce a register of patients with asthma excluding patients with asthma who have been prescribed no asthma-related drugs in the last twelve months	7
Initial Management
ASTHMA 2. The percentage of patients age eight and over diagnosed as having asthma from 1 April 2003 where the diagnosis has been confirmed by spirometry or peak flow measurement	15	70%
Ongoing Management
ASTHMA 3. The percentage of patients with asthma between the ages of 14 and 19 in whom there is a record of smoking status in the previous 15 months	6	70%
ASTHMA 4. The percentage of patients age 20 and over with asthma whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status should be recorded at least once	6	70%
ASTHMA 5. The percentage of patients with asthma who smoke, and whose notes contain a record that smoking cessation advice has been offered within last 15 months	6	70%
ASTHMA 6.The percentage of patients with asthma who have had an asthma review in the last 15 months	20	70%
ASTHMA 7. The percentage of patients age 16 years and over with asthma who have had influenza immunisation in the preceding 1 September to 31 March	12	70%

 

A. Records and information about patients
Records 1 1 point	Each patient contact with a clinician is recorded in the patient’s record, including consultations, visits and telephone advice
Records 2 1 point	Entries in the records are legible
Records 3 1 point	The practice has a system for transferring and acting on information about patients seen by other doctors out of hours
Records 4 1 point	There is a reliable system to ensure that messages and requests for visits are recorded and that the appropriate doctor or team member receives and acts upon them
Records 5 1 point	The practice has a system for dealing with any hospital report or investigation results which identifies a responsible health professional and ensures that any necessary action is taken
Records 6 1 point	There is a system for ensuring that the relevant team members are informed about patients who have died
Records 7 1 point	The medicines that a patient is receiving are clearly listed in their record
Records 8 1 point	There is a designated place for the recording of drug allergies and adverse reactions in the notes and these are clearly recorded
Records 9 4 points	For repeat medicines, an indication for the drug can be identified in the records (for drugs added to repeat prescription with effect from 1st April 2004). Minimum standard 80 per cent
Records 10 6 points	The smoking status of patients age 15 – 75 is recorded for at least 55 per cent of patients
Records 11 10 points	The blood pressure of patients age 45 and over is recorded in the preceding five years for at least 55 per cent of patients
Records 12 2 points	When a member of the team prescribes a medicine other than a non-medicated dressing, topical treatment or OTC medicine there is a mechanism for that prescription to be entered into the patient’s general practice record
Records 13 2 points	There is a system to alert the out-of-hours service or duty doctor to patients dying at home
Records 14 3 points	The records, hospital letters and investigation reports are filed in date order or available electronically in date order
Records 15 25 points	The practice has up-to-date clinical summaries in at least 60 per cent of patient records
Records 16 5 points	The smoking status of patients age 15 – 75 is recorded for at least 75 per cent of patients
Records 17 5 points	The blood pressure of patients age 45 and over is recorded in the preceding five years for at least 75 per cent of patients
Records 18 8 points	The practice has up-to-date clinical summaries in at least 80 per cent of patient records
Records 19 7 points	80 per cent of newly registered patients have had their notes summarised within eight weeks of receipt by the practice

 

B. Patient communication
Information 1 0.5 points	The practice has a system to allow patients to contact the out-of-hours service by making no more than two telephone calls
Information 2 0.5 points	If an answering system is used out of hours, the message is clear and the contact number is given at least twice
Information 3 1 point	The practice has arrangements for patients to speak to GPs and nurses on the telephone during the working day
Information 4 1 point	If a patient is removed from a practice’s list, the practice provides an explanation of the reasons in writing to the patient and information on how to find a new practice, unless it is perceived such an action would result in a violent response by the patient
Information 5 2 points	The practice supports smokers in stopping by a strategy, which includes providing literature and offering appropriate therapy
Information 6 0.5 points	Information is available to patients on the roles of the GP, community midwife, health visitor and hospital clinics in the provision of ante-natal and post-natal care
Information 7 1.5 points	Patients are able to access a receptionist via telephone and face to face in the practice, for at least 45 hours over 5 days, Monday to Friday except where agreed with the PCO
Information 8 1 point	The practice has a system to allow patients to contact the out-of-hours service by making no more than one telephone call

 

C. Education and training
Education 1 4 points	There is a record of all practice-employed clinical staff having attended training/ updating in basic life-support skills in the preceding 18 months
Education 2 4 points	The practice has undertaken a minimum of six significant even reviews in the past three years
Education 3 2 points	All practice-employed nurses have an annual appraisal
Education 4 3 points	All new staff receive induction training
Education 5 3 points	There is a record of all practice-employed staff having attended training/ updating in basic life support skills in the preceding 36 months
Education 6 3 points	The practice conducts an annual review of patient complaints and suggestions to ascertain general learning points which are shared with the team
Education 7 4 points	The practice has undertaken a minimum of 12 significant event reviews in the past three years which include (if these have occurred): · any death occurring in the practice premises · two new cancer diagnoses · two deaths where terminal care has taken place at home · one patient complaint · one suicide · one section under the Mental Health Act
Education 8 3 points	All practice-employed nurses have personal learning plans which have been reviewed at annual appraisal
Education 9 3 points	All practice-employed non-clinical team members have an annual appraisal

 

D. Practice Management
Management 1 1 point	Individual healthcare professionals have access to information on local procedures relating to child protection
Management 2 1.5 points	There are clearly defined arrangements for backing up computer data, back-up verification, safe storage of back-up tapes and authorisation for loading programmes where a computer is used
Management 3 0.5 points	The Hepatitis B status of all doctors and relevant practice employed staff is recorded and immunisation recommended if required in accordance with national guidance
Management 4 1 point	The arrangements for instrument sterilisation comply with national guidelines as applicable to primary care
Management 5 3 points	The practice offers a range of appointment times to patients which as a minimum should include morning and afternoon appointments five mornings and four afternoons per week except where agreed with the PCO
Management 6 2 points	Person specifications and job descriptions are produced for all advertised vacancies
Management 7 3 points	The practice has systems in place to ensure regular and appropriate inspection, calibration, maintenance and replacement of equipment including: · a defined responsible person · clear recording · systematic pre-planned schedules · reporting of faults
Management 8 1 point	The practice has a policy to ensure the prevention of fraud and has defined levels of financial responsibility and accountability for staff undertaking financial transactions (accounts, payroll, drawings, payment of invoices, signing cheques, petty cash, pensions, superannuation etc)
Management 9 3 points	The practice has a protocol for the identification of carers and a mechanism for the referral of carers for social services assessment
Management 10 4 points	There is a written procedure manual that includes staff employment policies including equal opportunities, bullying and harassment and sickness absence (including illegal drugs, alcohol and stress) to which staff have access

 

E. Medicines Management
Med 1 2 points	Details of prescribed medicines are available to the prescriber at each surgery consultation
Med 2 2 points	The practice possesses the equipment and up-to-date emergency drugs to treat anaphylaxis
Med 3 2 points	There is a system for checking expiry dates of emergency drugs at least on an annual basis
Med 4 3 points	The number of hours from requesting a prescription to availability for collection by the patient is 72 hours or less (excluding weekends and bank/local holidays)
Med 5 7 points	A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed four or more repeat medicines (excluding OTC and topical medications): Standard 80 per cent
Med 6 4 points	The practice meets with the PCO prescribing adviser at least annually and agrees up to three actions related to prescribing
Med 7 4 points	Where the practice has responsibility for administering regular injectable neuroleptic medication, there is a system to identify and follow up patients who do not attend
Med 8 6 points	The number of hours from requesting a prescription to availability for collection by the patient is 48 hours or less (excluding weekends and bank/local holidays)
Med 9 8 points	A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines (excluding OTC and topical medications): Standard 80 per cent
Med 10 4 points	The practice meets with the PCO prescribing adviser at least annually, has agreed up to three actions related to prescribing and subsequently provided evidence of change

Patient experience
PE 1 Length of Consultations
The length of routine booked appointments with the doctors in the practice is not less than 10 minutes. [If the practice routinely sees extras during booked surgeries, then the average booked consultation length should allow for the average number of extras seen in a surgery session. If the extras are seen at the end, then it is not necessary to make this adjustment.]
For practices with only an open surgery system, the average face to face time spent by the GP with the patient is at least 8 minutes.
For practices that routinely operate a mixed economy of booked and open surgeries should report on both criteria. 30 points

PE 2 Patient Surveys
The practice will have undertaken an approved patient survey each year 40 points

PE 3 Patient Survey
The practice will have undertaken a patient survey each year, have reflected on the results and have proposed changes if appropriate 15 points

PE 4 Patient Surveys
The practice will have undertaken a patient survey each year and discussed the results as a team and with either a patient group or Non-Executive Director of the PCO. Appropriate changes will have been proposed with some evidence that the changes have been enacted 15 points

Additional Services

CS	Additional - Cervical Screening
CS1 11 points	The percentage of patients aged 25 to 64 years (in Scotland 25-60 years) whose notes record that a cervical smear has been performed in the last three to five years. (Standard: 25 to 80 per cent)
CS2 3 points	The practice has a system to ensure inadequate/abnormal smears are followed up
CS3 2 point	The Practice has a policy on how to identify and follow up cervical smear defaulters Patients may opt for exclusion from the cervical cytology recall register by completing a written statement which is filed in the patient record (exception reporting)
CS4 2 points	Women who have opted for exclusion from the cervical cytology recall register must be offered the opportunity to change their decision at least every five years
CS5 2 points	The practice has a system for informing all women of the results of cervical smears
CS6 2 point	The practice has a policy for auditing its cervical screening service, and performs an audit of inadequate cervical smears in relation to individual smear takers at least every two years
CHS	Additional - Child Health Surveillance
CHS1 6 points	Child development checks are offered at the intervals agreed in local guidelines and problems are followed up
MAT	Additional - Maternity Services
MAT1 6 points	Ante-natal care and screening are offered according to current local guidelines
CON	Additional - Contraceptive Services
CON1 1 point	The team has a written policy for responding to requests for emergency contraception
CON2 1 point	The team has a policy for providing pre-conceptual advice