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How to review your practice's policies

CQC registration means all practices will need to have up-to-date policies in place, writes Professor Ruth Chambers

Chaperone policy: provide training for any team members who act as chaperones, or who may be needed if the usual chaperones are absent (Photograph: J H Lancy)
Chaperone policy: provide training for any team members who act as chaperones, or who may be needed if the usual chaperones are absent (Photograph: J H Lancy)

With the increasing emphasis on quality and standards in general practice, now is a good time to check that your practice's policies are up to date.

Do you have the full range of policies that the Care Quality Commission (CQC) will expect when your practice registers with it?

Compare policies and quality benchmarks
Your practice manager could start by downloading (from www.cqc.org.uk) all 16 essential standards of quality and safety that the CQC expects of providers of healthcare, to check that the practice has up-to-date policies that match.

Or ask your primary care organisation (PCO) which practice policies it expects in relation to a practice's core contract - for example, to do with employment (Criminal Records Bureau checks, equality and diversity), premises (disabled access, data protection) or delivery of care (confidentiality, chaperones, clinical management of specific conditions).

Identify missing policies
If you find gaps - policies that you have not got but should have, or ones that are out of date - agree a practice plan to add or update them quickly.

You cannot predict when a patient complaint or quality review will make the quality and consistent application of a particular practice policy central to an investigation. Make the task easier by adopting or adapting a policy already developed by another practice or that your PCO recommends.

Encourage the practice team to view policies as useful resources that enhance the quality and safety of care you provide for all your patients, rather than bureaucratic nuisances that can be safely ignored.

Check fitness for purpose
Assuming you already have a practice policy or can adopt or adapt another practice's, start by reviewing whether it is fit for purpose:

  • Is the policy up to date?
  • Does it apply to the nature of your practice?
  • Has the policy been adapted to apply to your practice team or the service provided?
  • Do all team members to whom it is relevant consistently adhere to it?

The secret to making a policy workable is to involve everyone in reviewing and participating in any necessary training or up-skilling. Any training undertaken should meet their needs without forcing them to repeat learning time after time.

If there have been any adverse events associated with the policy under review, highlight them so the team can see why the policy is relevant and why it must minimise the likelihood of that significant event recurring.

Get revised policy right
Include everyone to whom the practice policy applies in gathering information about how the particular policy is working. Talk to other team members who may well have observed how consistently clinicians adhere to the policy or who hear patients' comments.

When you have updated the policy to take account of everyone's suggestions and what is needed to make it fit for purpose, pick a good time to present the revised policy to all the clinicians in the spirit of up-skilling.

  • Have there been any significant events, such as a patient complaint about how an intimate examination was undertaken?
  • Are there any situations when it is difficult to apply your policy, such as when a GP or practice nurse does a solo home visit?
  • Are patients generally happy for a trained chaperone to be alongside a male or female GP when they undertake an intimate examination? Does your chaperone policy apply equally to GPs (male or female) and practice nurses (male or female)?
  • To what extent do all clinicians adhere to the chaperone policy in the surgery and on home visits? Do they record the presence or absence of a chaperone in the patient's medical records?
  • Is the policy up to date? Is there any new legislation that is relevant to a chaperone policy, or has there been a change in public opinion about the necessity of chaperones or their acceptability?
  • Do clinicians give patients informed choice or, as a personal, defensive tactic, always insist on a chaperone being present?
  • Are there prominent notices with easy-to-read and understandable text in every consulting and treatment room advising patients about the availability of chaperones?
  • Invite and encourage suggestions from all team members on revising the policy.

In relation to the chaperone example policy review (see box, above), provide training needed for any practice team members who act as chaperones, or who may be called on in a crisis when the usual chaperones are not available. Ensure any resources necessary for the policy to be applied consistently are in place.

Set a date for when the policy should next be reviewed.

  • Professor Chambers is a GP in Stoke-on-Trent and honorary professor at Staffordshire University

 These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • If you have good practice policies, run a learning session for local practices to share and discuss them.
  • Undertake significant event audits in relation to a practice policy; feed back findings to your practice team and agree action.
  • Review and update a different practice policy that is relevant to your role in the practice.

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