1. 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

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
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

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 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

13. 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

14. 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

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 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 Rights CGPSAT Matrix 3.1 Equity of Access
Primary Care Quality

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

24. Standard for Healthcare 18 - Communicating Effectively CGPSAT 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
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
Primary Care Quality