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Key performance Indicators chosen and agreed by the patient participation group
On Monday the 19th of May 2014, the PPG (Patient participation Group) were invited into the practice to discuss potential key performance indicators. These
are additional services that would be offered to the patients at the practice. The doctor’s choices were mainly based on what they were able to deliver and also
what would be of benefit to the majority of the patients. Below are the chosen KPI’s and the reasons for choosing them.
Present
Dr S Sivasinmyananthan
Nisha Singh
Trudy Do
Kate Poh
Naomi Allotey
Anita Rani
Mr EN
Mrs RN
Mr KA
Mrs BR
Mr RG
Mr PR
Mr EC
Mr GW
Mrs MW
Mr GH
Mr HW
Ms RG
Mr CA
1
Indicator
Infant Feeding
2
Smoking in pregnancy
3
Smoking and mental health
4
Health Checks
5
Alcohol
6
Mental Health
Performance requirement
% of infant feeding status (ie breastfed or artficial
feeding) recorded as % of total CHS 6-8 week
checks. Must be included on template
% pregnant women recorded as smoker, smoking
discussed, referred to stop smoking
% patients with newly diagnosed mental health
problems including depression recorded as a
smoker, smoking discussed, referred to stop
smoking services, and followed up on the next
visit
% of eligible population offered health check
%of adult population screened for alcohol use
using Audit- C, and where over 15 referred to
specialist
% patients on register for long term conditions
other than those indicated in QOF screened for
Comments
The PPG agreed that this was an appropriate service to
offer as it is important to promote breastfeeding
The PPG agreed that it is important to offer support to
mother who smoke during their pregnancy
The GP explained to the PPG that although this service is
available to anyone who smokes it is difficult to target
patients with mental health difficulties. However, the
practice has decided to continue to offer this service.
This service is currently offered to patients aged between
40 and 70. The practice has to complete 20% of the
practice eligible population. These checks are for patients
who do not have any pre-existing conditions
This service is currently provided by the practice. All new
patients over the age of 15 is screen for alcohol use when
they register at the practice
The PPG felt that the services offered should be targeted
at the wider practice population
depressed
% of adults with BMI recorded over 30 referred to
weight management services and followed up on
the next visit
% of children with BMI in the 91st centile referred
to weight management services. In order for
practices to receive payment 1 nominated should:
1. Attend public health commissioned childhood
obesity 3 hours brief intervention training. 2.
Attend the 1 day childhood obesity training to give
appropriate advice and information to families.
The nominated clinician should clinician should
then feedback to the rest of the practice team via
an education session.
Practice offers the choice of phlebotomy facilities
to any patient that can have blood taken in the
community setting
7
Obesity: Adults
8
Obesity: Children
9
Phlebotomy
10
Over 65’s medication review
Percentage of over 65’s on 4 or more meds
receiving 6 monthly medication review
11
Practice opening hours
12
Clinical availability
Practice is to open at least 52.5 hours per week
and able to take calls over lunch time
Clinical appointments available total at least 16.5
hours per 1000 per week
13
Patient participation group
14
Learning disabilities
Patients have influenced service redesign through
the practice PPG, been involved in discussion
with the practice about the development and
selection of KPI’s for 2014. Practice to publish its
KPI’s for 2014. Practice to publish the KPI’s in the
surgery waiting room and on the practice website
to engage the PPG in monitoring its KPI
achievements
Percentage of patients on the learning disabilities
The PPG feel it is unnecessary to offer this service as a
KPI as we have a dietician at the practice.
Support is offered to children however, it is felt that the
KPI’s should target a wider practice population
The PPG did not feel it was necessary to offer this service
to patients as it is currently available at The Laurels, North
Middlesex Hospital and Lordship Lane Health Centre.
However, the GP’s and practice staff explained that it
would be provided twice a week from 7:30-9:30 AM and it
would be appointment based. This means that patients
would know what time they would be seen and would not
have to wait. The PPG agreed that this service may work
for the working patients and parents
The PPG agreed that the GP’s should provide this service
as it is important to monitor patients taking several
medications and the elderly may need closer monitoring.
The PPG were happy with the opening hours
The PPG felt it is necessary to offer 15 minute appointment
as the previous 10 minute slot sometime is not enough for
patients
The practice felt it was necessary to involve patients in the
choice of KPI’s as the services would be provided to the
patients.
Everyone agreed that this would be a suitable service to
15
Hepatitis B and C screening
16
Hepatitis B vaccination
17
Looked after children
18
Looked after children
19
BP Monitoring
20
Nursing Home
21
Special patient notes
22
15 minute appointment times
23
MMR invitations for teenagers who
were not fully immunised as a child
24
Atrial Fibrillation screening
25
Diabetes Testing
register who are given a consultation with a
clinician for an annual health needs assessment
(Template to be developed)
Percentage of adults injecting or former injecting
drug users offered screening for blood borne virus
Percentage of adults injecting or former injecting
drug users offered vaccination for hepatitis B
Establish a register and ensure an annual health
check if offered
Annual health check delivered (template to be
developed)
Practice to offer 24hr blood pressure monitoring
to all who need it.
Weekly ward round and monthly meeting with
geriatrician with report provided to demonstrate
Special patient notes for 111/ out of hours as
percentage of palliative care register
Practice offers 15 minute appointment times for
routine booked appointments.
Note: KPI 22 and 27 cannot both be selected)
Regular quarterly search of practice population to
identify 16-18 year olds who have not been fully
immunised (consider copying parents in as
appropriate)
Letters sent informing them of vaccination status
enclosing leaflets about MMR and recommending
vaccination.
Appointment slots made available with clinician
for vaccination and also for advice for patient and
family as required.
DNAs to be followed up with second letter after
one month, 2nd round DNA phone contact or
letter one month later
Initial AF screen through initial pulse rhythm
check followed up by ECG (either in house or
through referral)
Screen patients in at risk groups for diabetes on
offer
The practice does not have any patients which inject so the
practice is unable to do.
Every 6 weeks the practice has a meeting with the health
visitor to discuss children under 5yrs. The practice is
unsure how we would be able to provide evidence for these
KPI's as the practice already does these.
The practice is not looking to do this KPI as machines tend
to go missing; they break down and are very expensive.
There is already a facility for this at Lordship Lane Health
Centre.
The practice is unable to do this KPI as the practice does
not cover any nursing homes.
The practice already does this indicator. Resuscitation is
often discussed as an appropriate action if the patient is on
the palliative care register.
The practice provide 15 minute appointment times for all
routine booked appointments
This service is provided by the practice
The Practice feel the patients will benefit from this service
The practice will attempt to do this but it will be difficult as
26
Complex cases and families
27
Extended appointments for nonEnglish speakers
28
Diabetes Care 1- year of care
29
Diabetes care 2 pregnancy
30
Diabetes care 3- diabetes control in
primary care
31
Diabetes care 4 type 1 diabetes
32
Diabetes care 5- insulin initiation
33
Diabetes care 6- GLP1 for
appropriate patients as per
an annual basis with a fasting blood glucose test
with one or more of the following criteria:
Patients with obesity
Patients with IHD
Patients with CVA
Patients with hypertension
Patient with a 10 year CVD Risk >20%
Practice to offer Multi-disciplinary intervention for
complex families and challenging patients for
patients and/ or families that present with complex
physical and social issues. Meetings to be held
every other month, 6 times pa, involving clinicians
and other practice and primary care staff. Must
include a GP trained in supervision of MDTs and
evidence must be provided of these skills. Local
authority must be linked in as appropriate for
complex families
Extended appointments for non- English speakers
(based on 2000 extended appointments/ year) All
patients booked must contacted the day before to
remind them of their appointment
Practice to offer ‘gold standard’ diabetic year of
care treatment to all patients with type 2 diabetes.
With this method of management, all types 2
diabetes should expect to receive the 15 diabetes
UK expectations of care (as appropriate)
All diabetes of child bearing age to be offered
annual education about pregnancy if appropriate
(similar to epilepsy and Qof)
Type 2 diabetic on insulin to been seen in house
for their diabetic control unless other
complications (such as CKD3b or above ) mean
hospital management is indicated
Type 1 diabetics who do not wish to got to
hospital are offered an appointment at least twice
yearly for diabetic review
Initiate insulin for appropriate patients as per
NICE guidance
Initiate GLP1 for appropriate patient as per NICE
the risk tools are different.
It will be difficult to provide evidence for this indicator and
to meet the criteria.
The practice is unable to do this indicator as the
appointments have increased from 10 minute slots to 15
minutes.
The diabetes indicators would be difficult to measure.
The practice is unsure what the uptake would be and is
concerned what topics would be discussed. As the practice
already has an arthritis group, it is better to have volunteers
rather than to be forced.
34
guidance
Patient educational sessions
35
Annual Health checks for patients
aged 75 years and over
36
Identification of mental health
patients requiring psychotropic
depot injections
37
Child protection identification and
monitoring in primary care
Practice to offer 6 meetings PA on a specific topic
facilitated by members of the practice and others,
on topics such as obesity, smoking, diabetesRamadan, mental health, COPD.
Practice should work in networks where possible,
opening the session on neighbouring practices.
Patient feedback forms on the sessions must be
collected to determine their views on the session
and what they would differently as a result.
Practice should undertake:
-search to identify patients 75 years and over –
invite patients in for check
Check to consist of:
-medication review by pharmacist or GP
- Testing for long term conditions
-Hearing
-vision
-Mobility
Identify patients on mental health register who
require psychotropic depot injections. Keep track
of compliance. Use a rick analysis by the
psychiatrist to define the list. This will also take
account of patient’s choice. Includes carrying out
an audit of how many patients on the register with
details of treatment. Keep up to date phone
numbers and key workers detail to follow up nonattendance.
Identify patients on the child protection register at
every opportunity when interact with primary care
and to discuss with attached HV on a regular
basis. Includes carrying out an audit of how many
patients have warning when electronic notes are
accessed for a child or a member of the family
that has a child on a child protection register.
The practice already does this indicator and there is high
percentage uptake as it is beneficial to patient.
The practice is unable to do this indicator as it is difficult to
keep track of compliance as it is out of the practice control.
The practices have regular meetings with the health visitor
to discuss any issues. These meetings discuss anything
unusual and A&E attendances.
Each KPI represents a specific number of points. The total amount of points offered by the practice is 111. The practice need to offer at least 100 points in
total. The PPG and staff agreed to offer health checks and alcohol screening as part of a KPI however, as these services are already provided by the practice
we are unable to offer these as part of the KPI’s. These have been replaced by the Smoking and mental health KPI.
As a result of this meeting, the practice and PPG have chosen different KPI’s to what was submitted in April 2013. The meeting helped decide which KPI’s
would be beneficial to the patients but also which KPI’s the practice are able to offer.