General practice faced a number of challenges in 2013, with the development of CCGs and disbandment of PCTs, alongside the introduction of the CQC registration process. As all practices will now be registered with the CQC, the challenge for 2014 is ensuring your practice team is fully prepared for a CQC inspection.
MPS conducts Clinical Risk Self Assessments (CRSAs) to identify and address potential risks in practices that may have an impact on patient and staff safety. This article will focus on the top five risks that were identified in assessments across more than 150 practices in 2013.
It will demonstrate how to address each risk area, how to meet the relevant CQC standard and provide practical tips to help your practice prepare for an inspection.
Table of potential risks from CRSA visits undertaken by MPS during 2013:
% of practice visited with this potential risk
Health and safety
1. Poor communication
Fundamental to patient care is communication – between all members of the practice team, the healthcare team and the patient. Better communication between staff and patients is a priority for improving patient safety.
The risks identified during CRSAs relating to communication are split into two categories, both of which correspond to regulations laid out by the CQC: internal communication (outcome 6, regulation 24) and communication with patients (outcome 1, regulation 17).
Ensure staff understand the role of the CQC and what may happen during an inspection, it may be useful to include CQC as a standing agenda item in the practice meetings.
(i) Internal communication
- Ensure the minutes of key practice meetings are kept, signed by the chair, dated and reviewed for both accuracy and ‘matters arising’ at the next meeting. It is possible that CQC will regard the quality of minutes as an indicator of managerial standards generally within a practice.
- Discourage interruptions to the doctors when they are in surgery. Interruptions may inadvertently cause the doctor to lose his/her train of thought and may also result in a breach of confidentiality. Provide guidelines for administrative staff detailing the reasons when interruptions are acceptable and when they are not ensure that interruptions are always kept to a minimum.
- Use an internal messaging protocol such as an electronic message system.
- Discourage the use of sticky notes and pieces of paper, which can easily get lost.
- Consider having a daily 90 second update to discuss the day ahead including any challenges and staffing arrangements (eg locums). You may find the mnemonic BRIEF useful:
- Brief Introductions
- Rota and staffing
Forecast (or format of the day)
- Ensure there are effective systems in place for communicating with district nurses, health visitors and other members of the multidisciplinary clinical team.
- Ensure all contacts from the out-of-hours service are reviewed by a clinical staff member and action taken as applicable.
(ii) Communication with patients
Consider how the practice communicates with patients.
- Ensure information included in leaflets and websites is up to date – for example, the details of the practice services, opening times and so on.
- Consider how to encourage patients to be involved in how services are run, for example through a patient reference group (PRG). In MPS experience, those practices that have undergone a CQC inspection have reported that the inspectors have spoken with patients about the services the practice provides.
You may wish to consider preparing your PRG or perhaps display a poster in the waiting room advising patients of CQC’s role, which is available on its website www.cqc.org.uk.
- Consider whether there is a need to publish practice leaflets in other languages.
- Ensure the needs of visually and hearing-impaired patients are adequately met – for example, with audio loops.
- Only send text messages to those patients where consent has been recorded for you to undertake this form of communication.
Ensuring a service user’s privacy and dignity are upheld are important elements of CQC outcome 1, regulation 17 (respecting and involving people who use the services).1
The GMC states in its Confidentiality guidance, paragraph 13 : ‘You should not share identifiable information about patients where you can be overheard – for example, in a public place or an internet chat forum. You should not share passwords or leave patients’ records, either on paper or screen, unattended or where they can be seen by other patients, unauthorised healthcare staff or the public.
- In 78% of practices MPS visited, there was a possibility that patients may be able to overhear conversations at the reception desk. Consider reviewing the layout of the reception, reposition the computer screen or move the telephones away from the front desk to help to reduce the risk of breaching confidentiality. Perhaps have a queuing system, as in a bank, or confidential electronic booking-in systems.
- Half of practices sometimes leave patient-identifiable information on consulting room desks. This can be read if a patient is left alone in the consulting room. It is good for a patient to see the computer screen when it is a matter concerning them, but be careful when a patient comes in with a relative, the patient may not wish them to see other medical history detailed on the screen.
- In the majority of practices visited, staff had signed a confidentiality statement. It is wise to consider a clause in the contract relating to after employment, as not all the statements we looked at had one.
Also consider a clause on social networking as it is not appropriate for staff to discuss the practice or staff members on Facebook or Twitter. Members of the practice patient reference group, whether a virtual or face to face group, should also sign a confidentiality statement.
- Many staff live in the area in which they work, so it is important to reinforce the need to keep information confidential. Patient information gathered during the course of professional duties should be treated as confidential.
- All members of staff should be trained in confidentiality issues, and the message to respect and maintain patient confidentiality regularly repeated.
3. Health and safety problems
Practices must provide a safe environment for both patients and staff in order to comply with the Health and Safety at Work Act 1974. www.legislation.gov.uk/ukpga/1974/37/contents
The CQC will be looking to see whether the provider has suitable arrangements in place to ensure people receive care in and work in, or visit, safe surroundings that promote their wellbeing (outcome 10, regulation 15.1
Many practices have incurred unnecessary expense by replacing fixtures, fittings and flooring. The CQC will expect the practice to have taken reasonable measures to ensure compliance with this particular standard.
- Nominate a designated and trained health and safety lead for the practice and have a documented health and safety risk assessment.
- Ensure safe-keeping and disposal of sharps and waste.
- Boost security through introduction of panic alarms and staff training in dealing with violence and aggression.
- Emergency equipment and procedures must be readily available.
4. Prescribing risks
Medication errors contribute to a large number of mostly preventable errors in general practice. Common examples include wrong dose, inappropriate medication and failure to monitor for toxicity and side-effects.
The CQC will be looking to see whether a practice has suitable arrangements to ensure that patients have their medicines when they need them and in a safe way (outcome 9, regulation 13). www.cqc.org.uk/sites/default/files/media/documents/essential_standards_of_quality_and_safety_march_2010_final_0.pdf
- Discuss and draw up a comprehensive repeat-prescribing protocol that formalises prescribing systems.
- The practice may wish to consider mapping out the repeat prescribing journey, this allows all members of the practice team to identify any flaws in the system and ensures that all practice staff manage repeat prescriptions in a consistent way.
- Ensure staff are trained in procedures and have access to the protocol, which should be dated and regularly reviewed.
- Best practice indicates that medication added to the prescription list should be done by the GP. If medication is added to the computer or changed by administration staff, it must be closely checked by the doctor afterwards.
- Considerable care needs to be taken to ensure all details are correct and have been added to the correct patient record. The GMC states, in paragraph 31 of Good Practice in Prescribing Medicines – guidance for doctors: ‘It is important that any system for issuing repeat prescriptions takes full account of the obligations to prescribe responsibly and safely and that the doctor who signs the prescription takes responsibility for it.’ If generating a prescription for new patients, ensure the patient sees the doctor for a review of their medication.
5. Record keeping
In outcome 21, regulation 20, the CQC will be looking to see that service users are protected against the risks of unsafe and inappropriate care, and treatment arising from a lack of relevant information.
- Complete records, made at the time, are essential for good quality patient care and are needed if a complaint or claim is made. In the case of a claim, some courts take the quality of the record as an example of the care provided to the patient.
- Ensure all patient contacts including telephone calls, consultations at the surgery, home visits and actions on behalf of the patient are documented in the computer record.
- Ensure letters scanned onto a computer are saved in the correct record.
- Ensure both clinicians and summarisers are adding allergies in the correct way to the medical record.
- Ensure summarising is done by someone with a clinical background and who is suitably trained.
- Draw up a protocol for summarising.
- Julie Price and Kate Taylor are clinical risk managers at the Medical Protection Society (MPS).