How do we overcome wasteful and unnecessary bureaucracy associated with poorly designed accreditation and reaccreditation courses?

#GPFUQ 194 How do we overcome wasteful and unnecessary bureaucracy associated with poorly designed accreditation and reaccreditation courses.  The challenge is to provide appropriate learning for each learner. Not too little and not too much.

GPs are often expected by third parties to have initial accreditation in a task that the GPs want or need to do, and once accredited they may be expected to reaccredit their knowledge and competence at regular intervals. Many of the standards for accreditation may not be truly fit for purpose because

1.              There is poor linkage between the GPs learning needs or gaps and the learning objectives; poor linkage between the learning objectives and the content of courses: poor linkage between the content and the outcome questions about performance or patient outcomes; and poor linkage between the outcome questions and the learning objectives.  As a result a danger is that the content of the course is either poor quality or over engineered and wasteful of the time of the learner, and/or the outcome of the course in that the learners performance is not determined so there is no feedback to the learner or the course designer on the success or failures of the course.

2.              The proliferation of poor quality accreditations and re accreditations is an expensive misuse of scarce NHS resources (eg GP time).

3.              Poorly designed accreditation and re accreditation courses contribute to the unnecessary bureaucracy that make GPs feels overwhelmed.

All GPs need to give robust feedback to accreditors that the quality of accreditation and reaccreditation processes must be improved following the best quality improvement and learning principles and processes.

Principles of Quality Improvement and Learning suggest

1. What are you trying to achieve? All learning starts with a problem. You always need to describe the problem that needs to be solved. For example with cx sampling in the National Screening programmes: Is it the quantity of samplers (ie not enough to run the programme), or the quality of samples that is a problem (ie too many poor quality samples).

2.What do you know about this problem?

When you know the problem conduct a learning needs analysis, describe the gap analysis, write learning objectives, develop the content for the course and then write the assessment of outcome questions.

The needs assessment and gap analysis may need a literature review, quality performance data review, and expert interviews. This might be either interrogating the data to see if it's a general problem (affects all areas and samplers) or a specific problem (areas and samplers who have the problem can be identified). Has anyone else has the problem and solved it already?

You should identify the needs/gaps by outcomes like knowledge, confidence, competence, performance and patient outcomes

3. What are you able to do with the available resources? You should include the costs you are passing onto others (eg the learners time, and opportunity costs associated with that). You should aim for the ‘good enough’ solution. You don’t want to over engineer the solution. For example if there is a cheap, fast, reliable way to fix the problem (eg gets Cx samplers to watch a You tube video) you should use that solution in preference to anything that is more expensive or slower.

4. How are you going to measure success? What are the success criteria? You will need to have success criteria based on outcomes that are linked through the learning objectives and process to the initial needs assessments. There must be a clear connection for the structure and process of learning between the needs assessment and the outcomes. If there are any broken or weak links they must be identified and removed or repaired

and finally

5.How and when will you review what you are doing?

Examples of questions to ask are given in Appendix A- Linkage of Learning Objectives to Outcomes levels and questions

I have used Cx sampling accreditation and re accreditation as an example to test these principles and practices – see appendix B.

Appendix A

Linking (ref Derek Dietze- Linkage of Learning Objectives to Outcomes levels and questions: A practical solution for Optimal results)

1.Linking Identified Needs/gaps to Learning Objective. Do the objectives

•      Address the identified needs/gaps?
•        Reflect and deliver on the level of desired/promised outcomes?
•        Seem achievable given the nature of the intervention?

2.Linking Learning objectives to Content. Does the content

•       Specifically address each learning objective?
•       Prepare the learner to achieve the desired outcome?

3.Linking Content to Outcomes Questions. Are the outcome questions

• answered in the content and is sufficient time spent on the areas being measured?
• Asked at  the right time/place (ie in follow up for performance and patient questions)? 

4.Linking Outcome Questions to Learning Objectives. Is each outcomes question

• specifically designed to assess achievement of a specific learning objective?
• Designed to assess the level of outcome indicated in the learning objective it is linked to?

Appendix B

Good practice guidance for cervical  sample takers

A reference guide for primary care and community settings in the NHS Cervical Screening Programme

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/469962/CSP_GPG2_uploaded_211015.pdf

SECTION FOUR

Sample taker training

The resource pack for trainers of sample takers

represents best practice and is available at

www.cancerscreening.nhs.uk

A competency framework has been developed by Skills for Heath relating to Cervical Cytology Sampling CH37 and can be found at

www.skillsforhealth.org.uk

Organisation of training

Training for sample takers should be in two parts; a theoretical course followed by a period of practical training. Practical training should take place in the practice or clinic where the trainee is based. It should be supervised bythe mentor (see Criteria for Sample Taker Mentoring below).

Trainees should keep a record of their training.

Theoretical course

A theoretical training course should cover the following the NHSCSP, its background and context equality of access to cervical screening understanding test resultsanatomy and physiology of the pelvic organs practical aspects of taking cervical samples.

Update training

Sample takers should undertake a minimum of one half day's update training every three years. E-learning update modules may be used if they fulfil both the national and local requirements. Whatever form it takes, update training must cover all of the following areas

current developments in the NHSCSP, nationally and locally

recent literature relevant to sample taking, sampling devices and women's needs

changes to local screening policies and procedures

personal learning needs

qualitative assessment of 20 recent consecutive samples produced by the sample taker.

Criteria for sample taker mentoring

Trainers

Trainers should have good teaching and communication skills, and ideally hold a relevant teaching qualification. They should undertake regular update training and maintain awareness of developments in the NHSCSP. They must be practising sample takers who are able to demonstrate continuing competence in taking samples for cervical screening with particular reference to

transformation zone sampling

sampling technique

equipment and sample preparation

audit of results, including adequacy rates

effective communication awareness of developments in the NHSCSP

Practical training

For the first practical session/s the trainee should be accompanied by the training mentor and should

identify training needs in discussion with the mentor

observe at least two samples being taken

take a minimum of five samples under supervision.

The mentor and trainee should then decide whether the student may proceed without further direct supervision. Once this is confirmed, the trainee should arrange to take and document a minimum of 20 unsupervised samples. Easy access to a trained colleague is essential throughout this period.The trainee should visit both the cytology laboratory and the colposcopy clinic, documenting the visits

in the training record book

Final assessment

Both mentor and trainee are expected to maintain regular contact and to discuss progress towards meeting identified training needs and any problems. They should meet for a final evaluation session, which should include a final clinical assessment. The trainee must have completed a minimum of 20 cytologically adequate samples before the final evaluation session. All training should be completed within a nine month period.

Maintaining competence

To help to ensure continued competence in accordance with their professional codes of conduct, sample takers should conduct continuous self evaluation. They should audit and reflect on their individual rates of inadequate tests and abnormal test results compared with the rates reported by the local laboratory.

What’s the weakest link in the chain of care?

#GPFUQ 193 What’s the weakest link in the chain of care? Attempts to reduce emergency hospital admissions should focus on all the people (patients, their carers and clinicians) at high risk. If better care is available outside of hospitals the rising demand for the care of patients with chronic conditions is hard to understand. It’s the weakest link in a chain of people at risk that’s important. The links are weak and the risk of emergency admission high when patients, their carers and clinicians each has to struggle to cope with a mix of complex medical and social conditions, the plethora of services available, perverse guidelines and incentives that confuse best practice, and the lack of effective feedback loops to inform their choices about care. The weakest link can be anywhere in the chain of people and services.

For example one of the many factors in the mix is the GP. A series of studies of GP Out of hours services in Bristol (Reference 1) showed a marked (a four fold) variation in emergency referrals between the top and bottom quartiles of referrers and a ten fold difference between the top ten and the bottom ten referrers. A low `tolerance of risk' by the GP seemed to be the weak link that predicts emergency referrals. Strengthening this weak link and each weak link in the chain by making the differences in behaviour visible by better feedback to the patients, carers and clinicians might reduce variation in performance and improve quality. Better knowledge and understanding of risk needs to be shared with out patients when making decisions about their care. 

Reference

Risk taking in general practice: GP out-of-hours referrals to hospital

Authors: Ingram, Jenny; Calnan, Michael; Greenwood, Rosemary J; Kemple, Terry; Payne, Sarah; Rossdale, Michael

What is connection culture?

#GPFUQ 189 What is the unintended consequence culture?

Its when in modern health care every possible approach to improving health care can have an unintended and unwanted consequence. For example improving health seeking opportunities for patients may enable either their dependency or self-care; transforming the interactions with patients may increases the opportunities for greater risk or reassurance and reconfiguration of 'work' practices may cause more burden or empowerment for patients.

#GPFUQ 190 What is connection culture?

It’s when you shift from using ‘I’ and ‘you’ to ‘we’ in your language and heart. If you can connect with someone you can talk about anything. If you are disconnected from someone its what you do next to get connected that’s important. When we are disconnected we feel different from the experience of others and this limits our ability to empathise and understand, to problem solve and manage risk. Seeking connections with people helps us respect different points of view and cultural diversity. We learn to be curious and more tolerant.

#GPFUQ 191 What is entitlement culture?

In British society everyone usually feels entitled to something. This sense of what we’re entitled to changes with the times, and seems to get stronger with each generation. The problems occur when sense of entitlements clash. For instance government and public may feel entitled to have an 8 till 8, 7 day a week routine NHS, but until the rest of the country works exactly similar hours the NHS staff feel entitled to have a roughly 9 to 5, 5 day a week routine NHS. The clash continues when patients believe they are reasonable to want faster access to more services for more of their problems, whilst GPs feel overwhelmed by the increasing workloads fueled by what they consider unreasonable expectations.

#GPFUQ 192 What is reality culture?

This is the Trilemma dilemma. Whilst we want fast accurate and cheap solutions to problems we can only ever usually achieve two out of the three. For example the answer to the Government rhetoric that its manifesto pledges it to push for increased access to GP services via 'seven day working' is that we already have a fast and cheap GP service  24 hours a day seven days a week  that is working  via our GP Out of Hours services. If we want to extend the routine five/six day services (that are already are under extreme pressure) quickly so that the seven day service is more ‘accurate’ or ‘routine’ we can’t do it with the present resources. It must be more expensive, or will take a very long time to bring about.

What do patients remember most and longest about their doctor?

#GPFUQ 185 What’s special about being a GP? A GP is a specialist in the health of the whole person who understands risk, solves problems and can fairly access the finite resources of the health service. In addition a GP is an advocate for patients a teacher, a leader, a business person, and an innovator. Being a GP is a challenging, difficult and highly skilled specialty requiring a breadth of knowledge and the ability to deal with ever increasing complexity and new challenges. Its never routine. GPs care for people not organs and have a continuity with their patients that simply cannot be replicated in secondary care. Patients are people and managing their needs entails not only basic medical management but also the added complexity of dealing with their personality, values and beliefs, their wider family and friends and everything in between. It's the difference between being any doctor and someones GP.

#GPFUQ 186 What do patients remember most and longest about their doctor? They only remember how their doctor made them feel not what their doctor said.

#GPFUQ 187 What the biggest problem to overcome in healthcare? Sometimes when things go wrong it leaves a legacy of unresolved anger and mistrust that is difficult to overcome.

#GPFUQ 188 What are the main obstacles to transparency in health care? Fear of litigation, fear of media criticism, and fear of damage to reputation. It needs compassion and bravery to overcome these obstacles?

How often will GPs see a condition that statistically they will never see?

#GPFUQ 181 How often will GPs see a condition that statistically they will never see?  About once every ten years.

#GPFUQ 182 Can GPs increase patients self treatment and reduce the need for medical involvement?

If GPs don’t do the work – will GPs lose their special relationship with their patients? General Practice can be like being a good parent it involves not just quality time but also routine stuff so being a good GP means being available for the minor worries, coughs and travellers' diarrhoea as well as for major physical and psychological pathology. By dealing with the former GPs can build the relationships they need to be able to help with the latter. However many minor ailments could be self managed. IMS Health survey Dec 2007 shows 57m GP consultations annually involve minor ailments, (51.4m involve minor ailments alone), 18% GP workload is for minor ailements, 50% Minor ailment consultations are for 16-59yr olds, costs to NHS £2b pa (80% are for GP time), averages 1hour/day for every GP http://www.pagb.co.uk/information/research.html#tns

Suggestions for action

·               GPs should develop a strategy for promotion of self-treatment of minor ailments, and a triage process. Setting up self-treatment facilities and advice.

·               RCGP should script Video and podcasts for use on the practice website and in the waiting room that tell patients how to look after minor ailments. Use the same RCGP script in different practices but with the local GPs as the ‘actors’ to promote local interest and validity. The video and podcast are accompanied by a printed handout on the management of minor ailments. You can have video added to video broadcasts in waiting room

·               Set up an ‘Avoid the queue, self manage your illness’ area in the practice to advise on initial best management for the following conditions which are the commonest minor ailments back pain, dermatitis, heartburn and indigestion, nasal congestion, constipation, migraine, cough, acne, sprains and strains, headache, earache, psoriasis, conjunctivitis, sore throat, diarrhoea, haemorrhoids, cystitis, hay fever, warts, nail infections, colds.

·               Produce an evidence-based handout on How to manage your minor ailment for each of the common minor ailment conditions.

·               Identify patients who have presented with minor ailments from the consultation records of the electronic health record and after the consultation mail the patient the information sheet How to manage your minor ailment for the relevant conditions- invite patients to return feedback sheet to enter into a prize draw

·               Gain greater value from previously under-utilised sources. This may include: enabling patients, carers and communities to manage and improve their own health and/or contribute to the process of healthcare; empowering members of the healthcare team whose contribution is at present limited owing to lack of training for example; and/or removing barriers that are standing in the way of obtaining full value from all members of the healthcare team eg ‘practice to the limit of the licence’

·               Triaging, consulting and prescribing for common benign conditions without red flags e.g cold, sore throat, UTIs in women, acne minor skin problems etc. Transfer most care of minor illnesses to triage by others and taught self care

·               Getting experienced staff to deliver some of doctors duties, i.e writing prescription for minor illness

·               Use local newspaper adverts about management of minor ailments

·               Provide more information for patients to record and track their symptoms and signs eg A one page leaflet to record and track symptoms of pain

·               The RCGP should publish a template for best practice

#GPFUQ 183 How should GPs assess their professional networks? Ask can you find and spread best practice any faster? The success of social networking websites shows how quickly networking tools spread. A ‘spread strategy’ is being part of an effective network of knowledge that works for you. Networking in one shape of form seems the most usual way that GPs already spread ideas. Formats include any professional meeting, peer group discussion and social events in practices and other group meetings and discussion in the wider world  (e.g. focus groups, internet groups, site visits, conferences, educational meetings, email communications, the media medical press, networks like CHAIN, doc2doc, Resilient GPs on Facebook, other social networking, chiefs meetings, champions, GP cooperatives, practice visits, annual appraisal, study groups, and on-line discussion groups). Most of these meetings are part of the professional and social fabric of the world we live in, and the networking is mostly unstructured and informal. However although it is clear that this networking connects almost everyone,  it may need improvement to make it more efficient and effective e.g. keeping up to date knowledge on any clinical topic like diabetes will be more robust if you can link with more than one network source about diabetes. Many of these networks have become prescribed with the formative processes involved in annual appraisals, and the various practice inspections (e.g. trainers reaccreditation) and provide a regular process of checking that every GP is part of a functioning professional network. Modern general practice where we work in groups and often have special responsibilities for certain clinical areas in the practice favour a networked approach to learning and being clear how each of us is connected to these networks for updating our knowledge and skills.

Suggestions for action

·           Map out your main networks and document them (who they are and what they link you to) for your next NHS appraisal. At your appraisal discuss whether there are any important clinical or business gaps in your links. What can you do to improve the efficiency and effectiveness of your networks? Circuit testing your learning networks at an annual appraisal process is a simple way to check up on the networks that each GP relates to. Whilst its too difficult to document all the networks, its is reasonable to test and trace the networks with hypothetical questions like how would you be confident that you would learn about and discuss a new innovation in practice management or new evidence in a treatment

·               Meet regularly with local colleagues to discuss difficult cases or to reflect on where they are and what can/must be improved

·               Buddy up with another practice to share expertise and resources

·               Look outside medicine and learn from business colleagues and friends

·               Have a relationship with secondary care colleagues- so that you can resolve local problems easily

·               Meet with wider social care/community nurses regularly to discuss patient referrals

·               Visit neighbouring practices to see what works well then discussing it at practice meetings to see whether the practice could learn from this

·               Continue any regular meetings with other GPs that has an agreed task of say support and sharing good ideas – and clear achievable and measurable aims eg Balint groups / Learning groups / Co mentoring

·               Undertake an evidence-based journal club weekly for 1 hour

·               Encourage all staff to attend practice meetings, not just partners. Involving them means they're more engaged with the practice.

·               RCGP should promote network groups- Unofficial groups abound, particularly among recent CCT holders. Make a census so they're known about.

·               The RCGP should publish a template for best practice

#GPFUQ 184 How do you improve GP? You need the feedback you can get either from a mirror or from a village

Whats wrong with the regulators?

#GPFUQ 177  What’s wrong with the regulators? A paradox of the new regulation of professionals like GMC Revalidation and the Care Quality Commission (CQC) that aims to reduce unacceptable variations in their performance is that the regulation itself can create unacceptable variations in regulation with poor quality assurance of both the structure and process of regulation creating variable outcomes. 

#GPFUQ 178  When is it the best treatment to stop medicines? If it improves patient outcomes. Risk can outweigh benefit when too many medicines are prescribed in patients with too many co-morbidties. Reducing and stopping drugs can then become the best treatment. There are 5 steps (1) check  all drugs the patient is taking and the reasons for each one; (2) consider the overall risk of drug-induced harm in individual patients before a  deprescribing intervention; (3) assess each drug in regard to its current or future benefit potential compared with current or future harm or burden potential; (4) prioritize and agree with the patient the drugs for discontinuation that have the lowest benefit-harm ratio and lowest likelihood of adverse withdrawal reactions or disease rebound syndromes; and (5) implement a discontinuation regimen and monitor patient  for improvement in outcomes or onset of adverse effects.

#GPFUQ 179  What’s the problem recording shared-decision making (SDM)? The use of electronic templates to gather data for whatever reason has shifted consultations from being patient-centred to computer-centred. The paradox is that the more time we spend recording SDM, the less time we have to actually do it.

#GPFUQ 180 When shouldn’t we ask for extra money for health care? If we are already spending money doing something pointless, or if we are looking for technical solutions to existential problems.