How do you build a high performing practice?

GPFUQ #213 How do you build a high performing practice?

High quality high performing practices do not happen by accident. Bodenheimer & colleagues in The 10 Building Blocks of High-Performing Primary Care (Ann Fam Med 2014;166-171. doi: 10.1370/afm.1616.) have looked at what seems to be the important building blocks and linked the blocks with Starfield's 4 pillars of primary care. 

1. Engaged leadership - fully engaged un the process of change
2. Data driven Improvement - monitoring the progress towards objectives
3. Empanelment - linking each patient with a care team and named GP 
4. Team Based care - A good team means one GP can do more
5. Patient-Team partnership - includes addressing what matters to the patient and shared decision making 
6. Population Management - having teams to match the needs of different patient groups
7. Continuity of Care - 1 of Starfield 4 Pillars of Primary Care 
8. Prompt access to care - 1 of Starfield 4 Pillars of Primary Care
9.Comprehensiveness and Coordination -2 of 4 Starfield Pillars of Primary Care
10. Template for the future - Offer patients choices for what they need with a team that can share the care

GPFUQ #214 How do you build a health care team with good structure (anatomy or hardware) and good culture (physiology or software)?

In the Anatomy and Physiology of Primary Care Teams (JAMA Internal Medicine January 2019 Volume 179, Number 1 p 61-2) Bodenheimer reviews how primary care flourish by creating teams that share the care, with well-trained and empowered team members taking on functions that do not require a medical degree. Evidence is accumulating that primary care teams can improve care, reduce health care costs, and make inroads in the problem of clinician burnout. But not any team will do. To be effective, teams must be stable, build a positive team culture, and share the care. 

Team structure has 2 facets: (1) who is on the team and (2) how stable is the team. Team culture also has 2 components: (1) how team members work together and (2) how teams share the care.

Teambuilding has 3 phases: planning, adoption, and routinized phases of team building. Routinized practices have at least 6 years of team-based care with standardized workflows.

For clinicians, the emotional exhaustion component of burnout was high when team culture was low. When team culture was high, emotional exhaustion was significantly lower for clinicians working with the same medical assistant compared with clinicians

without a stable team.

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Should non-clinical performance standard should be set for GPs?

GPFUQ #208  What non-clinical performance standard should be set for GPs?

If GPs do not set agreed personal non clinical standards with feedback on performance then improvement is much more difficult. Examples of simple and measurable performance measures include  1. Personal List Continuity - the achievable standard is about 55% 2. Timeliness- each GP sees patients within 15min of booked appoingtment time - the achievable standard is >95%. A common problem is that sometimes the doctor does not start a session of booked appointments on time. 3. Team Building - each GP attends a common lunchtime break 12.15-12.45 - standard 100% 4. Portfolio responsibilities and Business plan- each GP writes a short report (100 words) each year on their portfolio responsibilities in time for the practice’s annual business meeting each year - standard 100% 5. Availability of appointments. Patients should be able to book an appointment with their personal GP within 5 working days - standards 100% 6. 360 Multi Source feedback completed each year both as reporter and reported on - standard 100% 7. Peer review - each GP participates in a programme of observed consultations - everyone observes everyone else for a one hour session every 3 years, and gives a feedback sheet about observations- standard 100% 8. Each GP has a in house appraisal (1hr) with practice manager and another GP of their choice- standard 100%.

GPFUQ #209 What data determines what you need to do in the future? 

There is no data for the future

GPFUQ #210 What’s the main thing missing in quality improvement in the NHS?

You need a Closed-loop system – that's one that’s designed to automatically achieve and maintain the desired output by comparing it with what actually happens. It does this signalling the difference between the input and the expected output. The NHS tries to do this with a hopeless tangle rather than a closed loop. All doctors interested in learning and improvement should view @MaryDixonWoods RCP November 2018 Harveian Lecture https://www.rcplondon.ac.uk/events/live-streaming …. Starts at 37m & it lasts 60m.

GPFUQ #211 What the best way to lead? 

Keep going until you are apprehended.

GPFUQ #212 What do good leaders need to do? – lead from the front with clear vision, solid objectives and processes to proceed

1.    Prepare the journey

2.    Fund the journey

3.    Reinvent for the future

4.    Organise for sustained performance