Are the measures used to assess GP clinical performance valid?

GPFUQ #207 How do you assess the validity of a clinical performance measure?

In "Time Out — Charting a Path for Improving Performance Measurement" http://www.nejm.org/doi/full/10.1056/NEJMp1802595, 

Catherine H. MacLean 

and Amir Qaseem assessed and reviewed the appropriateness of measures used to assess a doctors performance. They found that only about a third of measures met  the  

criteria developed by the Performance Measurement Committee (PMC) of the American College of Physicians (ACP) to assess the validity of performance measures.  For each measure, the committee rated validity with respect to five domains: importance, appropriateness, clinical evidence, specifications, and feasibility and applicability.

DOMAIN 1. IMPORTANCE

·       Meaningful clinical impact: Implementation of the measure will lead to a measurable and meaningful improvement in clinical outcomes.

·       High impact: Measure addresses a clinical condition that is high-impact (e.g., high prevalence, high morbidity or mortality, high severity of illness, and major patient or societal consequences).

·       Performance gap: Current performance does not meet best practices, and there is opportunity for improvement.

DOMAIN 2. APPROPRIATE CARE

·       Overuse: Measure will promote stopping use of a test or treatment in general population or individuals where the potential harms outweigh the potential benefits.

·       Underuse: Measure will encourage use of a test or treatment in general population or individuals in whom the potential benefits outweigh the potential harms.

·       Time interval: Time interval to measure the intervention is evidence-based.

DOMAIN 3. CLINICAL EVIDENCE BASE

·       Source: Evidence forming the basis of the measure is clearly defined with appropriate references.

·       Evidence: Evidence is high-quality, high-quantity, and consistent and represents current clinical knowledge.

DOMAIN 4. MEASURE SPECIFICATIONS

·       Clarity — numerator and denominator clearly defined: • For process measures, numerator includes a specific action that will benefit the patient, and denominator includes well-specified exclusions. For outcome measures, numerators detail an outcome that is meaningful to the patient and under the influence of medical care. Denominator includes well-specified and clinically appropriate exceptions to eligibility for the measure.

·       Clarity — all components necessary to implement measure clearly defined

·       Validity: The measure is correctly assessing what it is designed to measure, adequately distinguishing good and poor quality.

·       Reliability: Measurement is repeatable and precise, including when data are extracted by different people.

·       Risk adjustment: Risk adjustment is adequately specified for outcome measures.

DOMAIN 5. MEASURE FEASIBILITY AND APPLICABILITY

·       Attribution: Level of attribution specified in the measure is appropriate (measure ties the outcomes to the appropriate unit of analysis) and is clearly stated.

·       Physician’s control: Performance measure addresses an intervention that is under the influence of the physician being assessed.

·       Usability: Results of the measure provide information that will help the physician to improve care.

·       Burden: Data collection is feasible and burden is acceptable (low, moderate, or high)

What makes a great teacher?

GPFUQ #206 How do you recognise a great teacher?

Usually they are

1. Good natured and approachable, professional but not aloof, can be funny and not always take themselves or their subject too seriously
2. Prepared - they take teaching well seriously and know it does not happen by accident
3. Motivated - they have a passion for their subject and enthusiasm for their students
4. Demanding but not unkind. They are comfortable with themselves and allow discussions54. More interested in questions that can't be answered than answers that can't be questioned.
5. Willing to entertain new ideas and try new things.
6. Natural - they make teaching look easy

Designing a Utopian Training Programme?

GPFUQ #205 What’s the vision for the future of general practice?

Background – The Work Role crisis?

We know we have a UK NHS workforce and workload crisis but we also have a work role crisis. What is the role of the GP in the future and what do we need to change in training do to provide for the next generation of GPs? What’s the vision for the future and how are we going to get there?

The Bristol Trainers Day theme on 7^th March 2018 was ‘Futuristic Training’. This is a summary of the ‘Designing a Utopian Training Programme’  led by Shabi Nabi and Terry Kemple. There were about 70 trainers present.

How do we facilitate Continuous Quality Improvement?

The 5 questions to ask and answer before you start any changes

•What are we trying to achieve?

•What is already known about this change?

•What will success look like – what are our success criteria?

•What can we actually do with the limited resources that are available?

•How and when will we review this improvement plan?

What are we trying to achieve in health care?

The Triple Aim (2008) (US Institute for Healthcare Improvement)

1. enhance patient experience

2. improve population health   

3. and reduce costs  

Plus, one extra aim to make the Quadruple Aim adds (2014)

4. improve the work life of health care providers, including clinicians and staff 

What are we trying to achieve in primary health care?

Barbara Starfield showed:

Improved population health outcomes are associated with larger, stronger and more integrated primary care system

Her 4Cs of Primary care are:

•First Contact access,

•Continuity,

•Comprehensiveness, and

•Care coordination

Arguably all 4 have been undermined in current general practice

What’s the Vision for Primary Care and General Practice and how does it fit with everything else we need to plan and do?

  

Where are we going? What do we aspire to achieve? What are our hopes and ambitions for General Practice and GP training?

This is a summary of the vision for General Practice in the future. We will have:

·      Super practices (unless in a rural or remote location) that are the first contact for primary and holistic NHS care with

·      A sufficiency of GPs who are experts in undifferentiated symptoms and multimorbidity who are resourced to lead a happy multidisciplinary team that share the vision for health care via

·      Patient friendly efficient and effective Human and/or Artificial Intelligence triage processes  that leads into  either

·      Community based Hubs for urgent care and more local routine patient care with

·      All appointments sensitive to the needs of the patient both in length and with rapid access to right person at right time in the right place providing

·      Assured continuity of, comprehensiveness of and coordinated personal care when it’s important for a person’s best care and

·      Helping most patients to be excellent at self-care who whenever possible are responsible for their own notes and follow up providing

·      Good relations and integration with secondary care and other services, with more of secondary care services based in the community in

·      Buildings that are fit for purpose with

·      IT that is also fit for purpose where there is a

·      Work life balance for clinicians that facilitates improved productivity in optimal length working days provided by

·      GPs and other health care staff who enjoy flexible working and portfolio careers where

·      The financial disincentives to working as a GP have been removed (e.g. the costs of medical indemnity, pension capping,

And our GP training schemes ensures that

Every foundation doctor

·      experiences a high-quality GP post followed by

·      more flexible and bespoke options for GP training (e.g. matched to learning needs or circumstances with switching from other specialities without repetition of experiences, better accommodation of less than full time training)

Every doctor on completion of GP training

·      can cope with multiple care providers

·      understands all the benefits and risks of different employment status (partner, salaried, sessional GP)

·      appreciates and values the rights and responsibilities of having a rewarding professional role, rather than a rigidly boundaried job.

·      understands value of primary care to prevent over medications and over treatment

·      Knows the essential skills to be business partners and leaders to continuously improve health care

·      Can make time for continuing improvement creative thinking

·      Has had exposure to good continuity – a strong usual doctor/MDT who really knows the patient

·      Has had specific training for any enhanced roles ( e.g.GPSI, leadership both clinical and non-clinical)

·      Has had training packages in IT and other project organisation

·      Know how to nurture adaptable open and honest resilient teams

·      Can cope with optimal loads of information, bureaucracy and regulation and avoid the perils of their excess.

·      Can find an appropriate mentoring scheme in and after their GP training for continuing support

·      Can readily adapt to any necessary improvements in any aspects of health care (e.g. evidence-based medicine, IT developments, the way the multidisciplinary team works)

·      Is comfortable with less face to face contact with patients and more leadership in multidisciplinary teams

·      Has good time management skills