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

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

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

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

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

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

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

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

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)

CGPSAT uptake figures All Wales Clinical Governance Practice Self Assessment Tool (CGPSAT) 2010/11 2011/12 2012/13 Total number of suggested matrices to be completed 11 20 Number of practices in Wales 494 483 478 % practices in Wales submitting the full recommended number of matrices 45% (221) 49% (236) 39% (137) % practices in Wales engaged with the CGPSAT (ie those who completed and submitted the recommended number plus those who were in progress with but did not submit) 64% (314) 70% (338) 78% (374) Primary Care Quality

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

As at 3rd March 2014 Primary Care Quality (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

As at 3rd March 2014 Primary Care Quality (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

CGPSAT uptake 2013_2014 (as at 3rd March 2014) Health Board Closing date 30th April 2014 Practice progress – number of matrices completed No of submissions Total Practices Not started -<10 10-20 21-30 31-40 41-50 51 <50 Abertawe Bro Morgannwg 1 4 2 8 18 16 3 23 77 Aneurin Bevan 9 14 7 15 91 28 Besti Cadwaladr 29 49 119 Cardiff and Vale 6 68 48 Cwm Taf LHB Hywel Dda 19 57 5 Powys 12 17 Primary Care Quality

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

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

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

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

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

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

CGPSAT – Team Engagment Primary Care Quality

Standard for Healthcare 2 - Equality, Diversity and Human Rights CGPSAT Matrix 3.1 Equity of Access Primary Care Quality

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

Standard for Healthcare 18 - Communicating Effectively CGPSAT matrix 17.1 Communication systems 2010/11 2012/13 Primary Care Quality

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

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