Improving Together: A National Framework for Quality and GP Clusters in Scotland

National Support for Improving Quality in GP Clusters

The quality framework for General Practice developed by Royal College of General Practitioners in Scotland and Healthcare Improvement Scotland provides a useful reference for the aspects of quality that GP clusters may need support from national organisations. ^[7] The framework is based on the Juran Trilogy processes of:

• Quality Planning
• Quality Improvement
• Quality Control

The framework outlines the activities in each of these processes that General Practice could be supported to undertake as follows:

Quality Planning

Quality Planning is a structured process for designing and organising services that meet new goals and ensure that patient needs are met There are various steps which include: setting the aim, identifying the practice population, identifying patient and carers needs, developing a process to meet the need, and developing checks to ensure that the aim is met.

Through this process General Practice will be supported to:

• Set quality improvement goals
• Identify strategies, infrastructure and resources required
• Build interest, motivation and ownership
• Align with existing national and local quality initiatives

Quality Improvement

Quality Improvement can be defined as a set of processes within general practice which includes training in specific improvement methods and approaches, the creation of improvement teams, data feedback, tailored facilitation and support. This ensures that the individuals who provide care have the necessary skills in improvement techniques and are able to adopt various approaches including improvement tools, self-reflection and benchmarking in order to understand and address the reasons for variations in quality, and to identify areas where acceptable quality can be improved further. They can then implement corrective measures, and devise new approaches to improve quality of care (Kings Fund 2011).

The Institute of Medicine conceptualised quality as having six dimensions: safety, timeliness, effectiveness, efficiency, equity and patient centeredness - sometimes referred to as the STEEP acronym ( IOM, 2001).

Through this process General Practice will be supported to:

• Understand and use the appropriate quality improvement tools / methodologies
• Define improvement projects: What parts of the process are not working?
• Diagnose the problem: What is the root cause of the problem?
• Identify the changes required to address the problem
• Confirm that the change was effective
• Communicate and share best practice.

Quality Control

Quality Control is a process for meeting quality aims by measuring actual performance and planned performance and taking action on the difference. Quality control encompasses a range of activities across a number of levels from national oversight and inspection through to local practice / practitioner evaluation and peer group review. This level of local data collection and monitoring instils a strong degree of ownership and helps promote a practice culture of continuous quality improvement. Through this process General Practice could be supported to:

• Undertake self-evaluation and take part in peer group review of quality and safety in the practice
• Measure current performance and its variance from expected or intended performance
• Describe variability in processes, understanding and interpreting that variability, reducing or eliminating unnecessary or inappropriate variation, and expanding or maximising positive variation
• Provide feedback comparing actual performance to intended, achievable outcomes.
• Use data to manage the process, evaluate effectiveness, maintain quality improvement gains, and facilitate further planning and improvements.

Within the context of this quality framework there are several national organisations that will contribute to supporting GP clusters including:

• Healthcare Improvement Scotland
• NHS National Education for Scotland
• NHS National Services Scotland
• Scottish School of Primary Care
• The Royal College of General Practitioners

Healthcare Improvement Scotland

Healthcare Improvement Scotland provides support across Health and Social Care through the following functions:

• Evidence
• Improvement
• Quality Assurance
• Scottish Health Council

Staff from across the organisation will work together, and where appropriate with other agencies and organisations, to support CQLs and leaders across primary care apply the quality framework outlined above in two ways:

• Design and deliver national improvement programmes that address common challenges across Scotland (testing and spreading at scale)
• Provide tailored and responsive improvement support to enable the health and social care system to deliver against key local improvement priorities

National improvement programmes

HIS will continue to support the development and delivery of improvement programmes that will enable GP practices, GP Clusters and primary care services to work together across Scotland on common issues and challenges

The design of the programmes will be done in partnership with CQLs and leaders in primary care services to ensure that:

• The issues being addressed are informed by local priorities emerging from the new GP cluster arrangements as well as national priorities that will emerge from the developing evidence base and policy from national organisations and Scottish Government.
• The scale of testing is suited to the issues being addressed so that small scale proto-typing is considered when exploring new issues and scale and spread is adopted when appropriate.
• There is sufficient and appropriate flexibility for GP clusters to choose local improvement priorities from national programmes.
• The method for working collaboratively is suited to a distributed workforce but makes use of, and where necessary supports development of, local quality improvement infrastructure including GP clusters to enable efficient and effective collaboration from practice to national level.

This will build on HIS experience of running improvement programmes for a distributed workforce such as the Scottish Patient Safety Programme in Primary Care.

Tailored and responsive improvement support

GP clusters are intended to enable practices to work together on common issues and challenges, eg. through national or local improvement programmes, whilst also recognising there will be variation in the challenges different clusters and practices will face.

HIS will play an important role in supporting CQLs and leaders in primary care services to develop their role in supporting improvement in GP clusters whether through extensive programmes across several or all clusters to individual initiatives in one cluster or perhaps practice. To do this HIS will need to understand the needs of CQLs, leaders and primary care and respond to this in a tailored way. This will include:

• Providing development support in relation to specific needs of each board/partnership and its GP clusters (as described below)
• Bespoke support through providing skills, expertise and/or resources to address specific problems identified by board/partnership and GP clusters

To do this effectively will require strong relationships and good on-going communication between HIS and CQLs and leaders in primary care.

Core quality support functions

HIS will provide support to GP clusters through national improvement programmes and tailored responsive support. The detail of the support available is given below:

Building the knowledge and skills to do the work of improvement

HIS will work closely with NHS Education for Scotland to:

• Support the design and delivery of a range of resources that facilitate the development of the knowledge, skills and competence in leading and doing the work of improvement with a focus on developing the capacity of CQLs and leaders in primary care services to support GP clusters to;
  • apply improvement methodology to redesign and continuously improve services
  • participate in highly effective strategic commissioning
• Support implementation of change and improvement methods through coaching, facilitating, mentoring and providing consultancy support to CQLs and leaders in primary care services.
• Provide 'faculty' to support delivery of national improvement training focussed on CQLs and leaders in primary care services and local improvement training focussed on GP clusters and delivered by CQLs and leaders in primary care services.
• Support a range of networks and communities of practice involving CQLs, PQLs and leaders in primary care services which are focused on improvement.

Providing expertise in evidence, evaluation and measurement for improvement

The partners contributing to the supporting infrastructure will:

• Conduct rapid reviews of evidence for CQLs and leaders in primary care services to inform improvement work locally.
• Conduct rapid reviews of evidence on topics emerging at national level from GP clusters and partnerships/boards.
• Provide advice and support to CQLs and leaders in primary care services on how to pragmatically embed evaluation across improvement work including support for developing the business case for improvement.
• Developing the capacity of CQLs and leaders in primary care services to use and facilitate use of data (qualitative and quantitative) in GP clusters to identify opportunities for improvement and to understand whether changes are leading to improvement. As part of this provide advice and guidance on using data to better understand population need.*

* This would draw on SPIRE and analytical support provided by National Services Scotland

Innovation and Horizon scanning

• Support work to design and test innovative solutions to common improvement challenges emerging from GP clusters, localities and boards/partnerships that involve primary care services.
• Develop tools and guidance to support the work of improvement to suit the needs of GP clusters.
• Horizon scan to identify promising practices across Scotland and internationally that are relevant to GP clusters and primary care services.
• Convene experts and frontline staff from across the system to provide 'thought leadership' to GP clusters and primary care services as required.

Creating the Conditions for Improving Outcomes

• Work with partners to identify and remove any national level barriers and to enhance national level enablers for GP cluster working.
• Provide a 'boundary spanning' function across GP cluster, localities, boards/partnerships and national organisations to support improvement in outcomes.
• Support CQLs and leaders in primary care to develop and run campaigns focused on building social movements for change in context of primary care services and GP clusters.

Clinical Guidelines

Working with other agencies where appropriate, HIS will respond to the emerging needs of GP clusters to prioritise and develop clinical guidelines in formats that support them in delivering the quality framework.

Quality Assurance

HIS will work with national organisations and GP clusters to develop proportionate quality assurance that is based on the principles and values of this framework. Quality assurance may include a combination of internal and external mechanisms to ensure that GP clusters, health boards and health and social care partnerships are able to understand and review the quality of care, both independently and with the support of others, to drive quality and improvement with GP clusters.

National Services Scotland