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Thursday 29 September 2016
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Mastering your QOF domain

Insight: Finance

The organisational indicators of the Quality and Outcomes Framework (QOF) have remained among the most stable over the years as the rest of the QOF has changed. Some indicators, which took only a relatively small number of points, have been removed.

There were 184 points in 2004, 164.5 this year and 160.5 next year. That is more than any single clinical area and more than all of the Quality and Productivity indicators. There have been few new indicators and none have been added for the last four years.

Very often these indicators are taken for granted by practices. However, significant effort is still needed to ensure these are achieved. While they may not contain as many points as previously, they are among the indicators most easily verified by primary care trusts (PCTs) and are often the focus of QOF inspections.

The official guidance is particularly helpful with regards the organisational domain and usefully contains examples and numerous links to sources of advice and guidelines.(1) There is much more detail than I am able to go into here and it should be essential reading when writing new procedures or policies.

The indicators are split into several sections. While this made some sense in 2004, these indicators overlap quite a bit now. As indicators have been withdrawn they have been increasingly unevenly spread. The patient communication section now has only one indicator. A more useful system would perhaps be to group the indicators according to the actions required, as set out below.

Achievement
The first group contains indicators that measure achievement by the practice. These can be measured from searches of the patient records.

The indicator relating to recording smoking status is effectively a clinical indicator. It awards points in a graded fashion from 40-90%, where smoking status has been recorded in the previous 27 months. This information would usually be recorded in the clinical consultation but could also be from the notes of newly registered patients or patient questionnaires. From 2013 this will move into the clinical smoking area, along with a new indicator requiring smoking cessation advice over the same period.

The remainder of the indicators are all or nothing. Either all the points are awarded or none. A number of these indicators relate to records that can be extracted from the patient notes. Four indicators relate to note summarisation. Three of these relate to different levels of achievement of no summarisation through the practice at 60%, 70% and 80%. Fifty-five points are available for reaching 80%. This is by far the largest area in the organisational domain. Once the top threshold has been reached it is relatively easy to maintain this in future years. If the computer record is updated in consultations the next summary will continue to be updated.

Two graded indicators relate to blood-pressure measurements in patients aged 45 or older at the end of the QOF year. The indicator is purely for the measurement – no particular level of blood pressure needs to be achieved. These work in a similar way to the notes summarisation, with thresholds at 65% (10 points) and 80% (a further five points). These will largely be picked up during clinical consultations.

All the indicators so far are extracted automatically from practice systems and uploaded to QMAS (the Quality Management and Analysis System) or equivalent. The rest of the indicators must be entered manually. They are all simple ‘yes’ or ‘no’ indicators merely requiring a box to be ticked. There is no reason to delay in putting these in (and it is as well to make sure you can remember your password from last year) and enter as much as you can as early as possible. Ideally, the hyper-organised could do so in April but for now QMAS is generally not open until October.

There is a separate indicator for the summarisation of new patient records within eight weeks of receipt, carrying seven points. This is also crucial to maintaining the general level of summarisation as patients come and go from the practice. Note that this is set to eight weeks after notes have been received by the practice, and not by the date of registration. If the records are not received, this indicator would not apply. While the main note summarisation codes are automatically extracted by QMAS or its equivalent, this indicator needs to be manually entered.

There are two similar indicators for medication reviews. The first relates to medication reviews for all patients with repeat medications. A separate indicator relates to patients with more than four repeat prescription items. Prescriptions without an active ingredient, such as emollient creams or dressings, are not included in this indicator.

A further indicator requires a clear indication for medication to be entered into the record. Some practice systems have a specific field on the prescribing screen where this can be entered. While that is by far the simplest way to verify this, a simple entry in the notes coinciding with the start of the medications would be sufficient. The threshold for this indicator is 80%, which is likely to be fairly easy to achieve in most practices.

Actions completed
The second group of indicators are for specific actions that the practice should have completed during the course of the QOF year.

A meeting must be arranged with the prescribing adviser of the PCT and three areas for improvement should be agreed. This is worth four points and there are a further four points for evidence of change. These are in addition to the areas agreed for this year’s QP 1-5.

Other actions required by the practice include a review of complaints and significant events. The significant event indicators are split into two. Six points are available for three significant event reviews in the past year and there are a further four points for 12 reviews in the past three years. The events that should be included in these reviews are specified in the guidance.

The review of complaints is worth three points and should include any learning points shared with the practice team.
Four indicators relate to practice staff. These divide into clinical and non-clinical staff; the requirements are similar but timescales vary. All staff should have an appraisal with evidence of a personal development plan for the employed clinical staff. Five points are available for the appraisal of clinical staff and three points are available for the appraisal of non-clinical staff.

An additional pair of indicators relates to cardiopulmonary resuscitation training. All clinical staff should have had an update within 18 months (four points). The timescale for non-clinical staff is 36 months (three points). Practically it may be simplest to update the whole practice staff at one session, particularly as the 18-month indicator will be dropped from 2013.

Practice procedures
The final group of indicators relates to policies and procedures within the practice. An inspection may ask for the procedures as well as evidence these are being followed. In all of these areas there is considerable scope to share between practices. As the object of the policies will be the same for all practices, only minor local alterations are likely to be required.

One effective method of producing policies is for a group of local practices to share out their development. Each practice may only have to produce one or two policies of their own and simply adopt those that others have developed.

In the majority of cases, writing a policy will simply involve the documentation of what is currently happening, although this exercise can also be useful to show any current gaps in procedures.

Typically, only one or two points are available for each indicator. A larger chunk of points are for the turnaround of repeat prescriptions. If this normally happens within 72 hours, three points are gained with an additional six points for a turnaround of less than 48 ‘working’ hours.

Three points are available for having the practice open at least five mornings and four afternoons a week. The practice leaflet will be examined for evidence of this, and for the repeat prescription turnaround times, so it is important to keep this up-to-date.

Good communication with the out-of-hours service is a requirement of a small cluster of indicators. There is a single point for a system looking at information coming from out-of-hours and a further two points for a system informing of out-of-hours patients who are likely to die at home.

Anaphylaxis drugs should be held within the practice (two points) and there should be a system for checking their expiry and that of other injectables (two points). Three points can be gained for an efficient system for calibration of equipment – both clinical and office.

A further two points are available for a policy of giving written information and therapy to patients who wish to stop smoking. Often this is done as part of a larger programme and that is perfectly acceptable here.

Work that is carried out for the organisational domain of the QOF, more than for any other part, can be rolled forward from one year to the next. It is unlikely that practice managers will be coming from a standing start. A little bit
of work can ensure points are awarded for several years into the future.

Dr Gavin Jamie is a full-time GP in Swindon with an interest in health informatics. He has been a QOF assessor and runs the QOF Database website (www.gpcontract.co.uk), publishing data and analysis from throughout the UK.

Reference
1. British Medical Association. QOF guidance, Fourth revision 2011-2012. London: BMA; 2011. Available from: http://www.bma.org.uk/employmentandcontracts/independent_contractors/qua...