preparing for cqc registration dr jack nagle · preparing for cqc registration dr jack nagle ceo,...

Preparing for CQC Registration

Dr Jack Nagle

CEO,

Alpha Primary Care

01 Dec 2011

• Presentation and discussion today based

on work undertaken in collaboration with

the NHS Alliance PM Network;

• Most of the information presented here will

be available to NHS Alliance members;

OVERVIEW

• Some key messages,

• Quality in Practice

• CQC Registration

• Myths & Realities

• Case study – what it looks like

• Summary

Some Key Messages:

• Process for GP Practice Certification will be much more

streamlined and easier than that for dentists

• Don’t panic – continue with the day job!

External Environment

GP Practice 1

CCG

GP Practice

Practice Group ?

Clinical Commissioning

GP Practice 2

CQC Registration

Competition

Financial Constraints

Primary Care Developments

Performance Indicators

Why ?

• GP Practices can no longer work in isolation;

– Core focus on practice service delivery;

– Support to practice group;

– Perform to norms, standards of CQC;

• All practices must register & comply with CQC

• Practices must:

– Prepare for this new environment;

– Put in place all necessary new systems & guidelines;

– Learn to work more collaboratively;

Certified to ISO 9001

(Significant?) Change is happening..

Quality & TQM ?

• Quality – is it going to really impact on general practice?

• A philosophy!

– Focus on the patient,

– Focus on preventing problems rather than having to fix them,

– Relentlessly eliminating waste and inefficiencies,

– Involving all staff,

– Benchmarking and sharing best practice,

– Monitoring and reviewing performance,

• Key Enabler for :

– QIPP

Practice Response ?

• Most practices focusing on improvements

• Practice Business Management

• TQM,

“VAC” value Added Care

• Setting practice standards,

• CQC

– Essential Standard to be met – baseline;

– Majority of practices operating above this level,

– but think of ongoing compliance – maintaining standards,

CQC Registration & Compliance

• Develop up 195 procedures;

• Establish audit system;

• Implement procedures and document control;

• STOP !! – this is not what CQC is focusing on !!

CQC Registration & Compliance

• Focus on outcomes;

• Looking at evidence;

• Practices will self declare;

• If not compliant in an area – show plan and

timescale to become compliant;

• Premises – if problems show how practice will

overcome ( doesn’t mean knocking down the

building!)

CQC Registration & Compliance

• “Essential standards” that all practices must meet;

• APC in association with the NHS Alliance PM

Group

– “CQC with no tears”!

– Readiness assessment;

– Planning & execution – to meet requirements;

– Do plan, prepare and use time to April 2013 wisely

• “Don’t panic”

“CQC with no tears”

CQC's Essential Quality & Safety Standards

Practices must meet these standards:

•OUTCOME 1: Regulation 15: Respecting & Involving people who use the services

•OUTCOME 2: Consent to care & treatmentInvolvement & Information

•OUTCOME 4: Care & welfare of people use use the services

•OUTCOME 5: Meeting nutritional needs

•OUTCOME 6: Co operating with other providers

Personalised Care Treatment & Support

•OUTCOME 7: Safeguarding people who use services from abuse

•OUTCOME 8: Cleanliness & Infection Control

•OUTCOME 9: Management of medicines

•OUTCOME 10: Safety & Suitability of premises•OUTCOME 11: Safety, availability and suitability of equipment

Safeguarding & Safety

•OUTCOME 12: Requirements relating to workers

•OUTCOME 13: Staffing

•OUTCOME 14: Supporting workers

Suitability of staffing & Suitability of Management

•OUTCOME 16: Assessing & monitoring the quality of service provision

•OUTCOME 17: Complaints

•OUTCOME 21: RecordsQuality & Management

“CQC with no tears” Alpha Primary Care Process Map - 'CQC Essential Standards'

CQC•Alpha: Complete Assessment on current Practice Systems & Documentation.

CQC•Alpha: Highlight areas of non conformance and conformance - relating to the stipulated CQC essential standards for Quality & Safety (ESQS).

CQC•Alpha: Develop & Implement Action Plan to achieve compliance.

CQC

• Alpha: Introduce protocols & systems in areas of non conformance, providing the necessary evidence to prove compliance, to include Clinical Governance, Audit, HR & Quality Assurance.

CQC

•Alpha: Engage with Management & Staff - Support & train in all processes, create a culture of 'continuous quality improvement and development'.

CQC•Alpha: Establish long term strategy for ongoing Quality Assurance.

CQC •Alpha: Full implementation of Quality Management Processes & System - "Full compliance with CQC regulatory requirements".

CQC•Alpha: Monitoring continued compliance against CQCs essential standards.

A Case Study –London Practice

• Using assessment tool reviewed “Essential standards –

16 outcomes” with practice manager and clinical lead,

• Review and discussion;

• Prepared summary (“Setting the Bar”);

• Discussed & developed action plan,

• Practice compliant with minor and moderate

improvement areas to work on over the next year,

• Discussions, summary and improvement plan all done

over a few days!

A Case Study Compliance Section Outcome Regulation Compliance Minor Moderate Major

Respecting and

Involving Patients

who use the Services

1 17

√

2 18 √

Personalised Care,

Treatment and

Support

4 9 √

Meeting Nutrional

Needs

5 14 √

6 24 √

Safeguarding &

Safety

7 11 √

8 12 √

9 13 √

10 15 √

11 16 √

Suitability of

Staffing

12 21 √

13 22 √

14 23 √

Quality &

Management

16 10 √

17 19 √

21 20 √

Some Myths & Facts • Myths:

– Practice must hire more staff to meet essential standards;

– You need special compliance systems and special software;

– Non compliance will lead to providers being shut down!

– CQC will close down your premises or will necessitate significant

increase in capital expenditure

• Facts:

– Most practices operating to these essential standards,

– Providers can declare “non-compliance” and demonstrate a plan

and timescale to compliance,

– Providers can demonstrate how they will address premises

criteria Reference Sources: Direct discussions with CQC ; CQC Guide – “An Introduction to registration to CQC”

“ CQC with no tears” • Majority of practices will meet most of CQC essential standards;

• Focus on outcomes – not procedures and processes,

but:

• Assumes practice is running to reasonably good standards;

• There will be some practices ( small number) that will have major

non compliances:

– Outline plan & timescale to move to compliance;

• Absolutely essential – ongoing focus on Quality and compliance,

So to recap - Some Key Messages

• Process for GP Practice Certification will be much more

streamlined and easier than that for dentists

• Don’t panic – continue with the day job!

but

• Do use the time wisely,

• Review, plan for improvement, introduce over time,

“ CQC with no tears” & ongoing compliance!

Thank you for your attention.

For Further Information

Contact:

Kaye Locke Karen Bradley

kaye@nhsalliance.org kbradley@alphaprimarycare.com

www.nhsalliance.org www.alphaprimarycare.com

Reference Documents:

• “CQC – Essential standards of Quality & Safety, March 2010”

• “CQC –Setting the bar –guidelines for inspectors Sept 2010”

• “CQC Registration – Setting the bar November 2010”

• “CQC An introduction to registration with CQC”