developing continuous quality improvement...

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DEVELOPING

Continuous QualityImprovement Activities

from a quality perspective

Measuring the care you practice provides

Using the quality cycle to continually improve performance

How to get your continuous quality improvement credits

DEVELOPING

Continuous QualityImprovement Activities

from a quality perspective

Measuring the care you practice provides

Using the quality cycle to continually improve performance

How to get your continuous quality improvement credits

��

Acknowledgements

The RNZCGP hopes you will find this resource a useful introduction to the concept of quality improve-

ment. It replaces the Practical Guide to Audit and is the result of feedback from trials and workshops

during 1998/9.

Dr Keith Carey-Smith, Dr Jim Vause, Dr Wellingham, Dr Tony Hanne, Dr Dean Millar-Coote, Maureen

Gillon, Lynn Saul.

ISBN: 0-9582176-1-0

© The Royal New Zealand College of General Practitioners, New Zealand, 2000. Reprinted 2009

The Royal New Zealand College of General Practitioners owns the copyright of this work and has

exclusive rights in accordance with the Copyright Act 1994.

In particular, prior written permission must be obtained from the Royal New Zealand College of General

Practitioners for others (including business entities) to:

• copythework

• issuecopiesofthework,whetherbysaleorotherwise

• showtheworkinpublic

• makeanadaptationofthework

as defined in the Copyright Act 1994.

Contents

This resource is designed for individual GPs, practice staff, IPAs and other primary

care groups. It outlines the RNZCGP framework for designing and undertaking a

College approved quality improvement activity.

Introduction ................................................................................................................. 4

SECTION 1: Quality improvement .............................................................................. 6

1.1 Quality improvement ....................................................................................... 6

1.2 Measuring quality ............................................................................................ 6

1.3 The role of feedback in improving quality ....................................................... 7

1.4 Setting markers for improvement .................................................................... 7

SECTION 2: Introducing the RNZCGP quality cycle .................................................. 9

2.1 A six step guide to designing your own quality improvement process ........ 10

1. Topic selection ................................................................................... 10

2. Plan .................................................................................................... 10

3. Data .................................................................................................... 11

4. Check ................................................................................................. 13

5. Act ...................................................................................................... 14

6. Review ................................................................................................ 15

2.2 Sample quality improvement cycle ............................................................... 16

SECTION 3: Suggested quality improvement topics ............................................... 18

Glossary .................................................................................................................... 24

Appendix 1 ................................................................................................................ 27

Appendix 2 ................................................................................................................ 29

References ................................................................................................................ 30

4 © THe Royal New ZealaNd College of geNeRal PRaCTiTioNeRs / Developing CQI Activities

Introduction

The Mission statement of the RNZCGP is:

‘To improve the health of all New Zealanders through high quality general practice’

The College has produced this document as another tool to help GPs progress fur-

ther along the path of achieving high quality general practice. The aim of this tool is

to provide a way of taking any aspect of general practice and to formulate a plan to

improve it. It focuses on how you can establish where you are now, where you want

to go and how to get there. It can be used together with the many other tools already

published by the College.

Quality general practice will mean different things to different people depending on

which aspect of a subject is being discussed. However there are two key concepts

that are useful in thinking about improving quality.

Quality can and must be measured. To know where you are now, and how well you •

are making progress towards the goals you want to achieve, a measure of some

sort must be used. Sometimes it is not easy to measure the qualitative aspects of

practice and to improve we must be able to measure that improvement.

Quality is not a static state. Circumstances and parameters change so that what-•

ever you are doing, it can always be done better. This is often called Continuous

Quality Improvement (CQI) and can be expressed in the form of quality cycles.

Therefore, this document is a guide to implementing CQI in general practice.

CQI in general practice is concerned with the assessment of the quality of medical care,

the efforts to improve the provision of care and the procedures to ensure that good

quality is maintained. Undertaking a quality improvement process reflects the desire

and commitment of the team to find out, “Are we doing what we should be doing?”

and, “How can we do better”. In defining where you want to go, it is important that a

process is planned and asks the right questions in order to find the answer.

© THe Royal New ZealaNd College of geNeRal PRaCTiTioNeRs / Developing CQI Activities 5

One term for this is a gap analysis. For example:

“Imagine yourself on a yacht in the middle of the Pacific with no engine or modern naviga-

tional equipment. A logical question would be, “Where am I?” Using a sextant allows you

to put a cross on the map. Only then can another cross be marked at where you want to

go before making the next step about how to get there.

“The assumption behind the approach to quality measurement is that unless we learn at

least something about what we are doing, it is highly unlikely that we will know what needs

improving, or how to improve. It is generally agreed that the most effective way to learn is

to ask the right questions. The key is to establish a baseline to enable you to know where

you stand in relation to where you want to go.” (Tony Hanne, Goodfellow Unit, 1999)


SECTION 1

Quality Improvement

1.1 Quality improvement

Quality improvement in general practice is concerned with the assessment of the quality

of medical care, the efforts to improve the provision of care and the procedures to ensure

that good quality is maintained. Undertaking a quality improvement process reflects

the desire and commitment of the team to find out, “Are we doing what we should be

doing?” and “How can we do better”1, 2. In defining where you want to go, it is important

that a process is planned and asks the right questions in order to find the answer.

1.2 Measuring quality

There are two aspects to improving quality.

The measure: “Look at where you are”.•

The change: “Getting where you want to be”.•

To put audit in the context of quality:

Quality Improvement Process

AUDIT: The Measure ‘Look at where you are’

IMPROVEMENT: The Change ‘Getting where you want to be’

project-based •

aims to examine a specific problem•

mainly retrospective •

emphasis on data collection and feedback•

provides an accurate picture of the quality •of care

a baseline for comparison and improvement•

identifies positive aspects of care, as well •as negative

stimulates discussion, critical reflection •and proposals for improvement strategies3

continuous activities•

continuous change•

mainly prospective•

emphasis on colleagues’ •support


1.3 The role of feedback in improving quality

Practice staff meetings or peer group discussion provide the best opportunity to dis-

cuss audit results. Planning responses and implementation strategies that are more

likely to produce a change in behaviour then depends on the level of commitment by

the practice team. If used properly, feedback provides a basis for modifying behaviour,

and is fundamental to the learning process3.

1.4 Setting markers for improvement

Identifying ‘where you are’ and setting markers for improvement ‘where you want to

be’ involves three steps:

Choosing indicators1.

Developing criteria2.

Setting the standard 3.

STEP 1: Choosing indicators of best practice from the information available(see Appendix 1 for different ways of classifying evidence)

Indicators are markers that provide points along the way to meeting a standard. They

are measurable elements of practice performance for which there is evidence or con-

sensus that it can be used to assess quality, and produce a change in the quality of

care provided4. The basis for regarding an element of performance, as an indicator

should be explicitly stated, where possible using published evidence e.g.

INDICATOR

The smoking status of adult patients is identified and recorded in the patient notes.

Source: National Health Committee. Guidelines for smoking cessation. NZ: National

Advisory Committee on Health and Disability; July 1999.

Note: The example of smoking status is used throughout this document.


STEP 2: develop criteria to measure the indicator

Criteria are the elements of care that can be counted or measured in order to assess

the indicator. They are discrete, definable, measurable and explicit. In other words, it

needs to be precisely defined2 e.g.

CRITERIA

• Smokingstatusisrecordedinthenotesofadultpatients.

• Smokingstatusisupdatedregularly.

STEP 3: setting the standard

The standard is essentially a mark of success in achieving an indicator and specifies

the acceptable level of care3. Therefore, the standard is the level of performance that

you want or expect to achieve. It may be a precise target level of performance or that

which you identify e.g.

STANDARD

Smoking status is recorded in 80% of adult patient notes.


SECTION 2

Introducing the RNZCGP Quality Cycle


2.1 A six step guide to designing your own quality improvement process

1. TOPIC SELECTION

Are we doing what we should be doing?

e.g. Smoking Cessation

Choosing a topic

What do you want to review?•

Keep it relevant, it should be a practice problem, and/or have common or serious •

consequences.

It should be clearly defined.•

Benefit the health status, well-being or satisfaction of patients.•

Have important cost implications.•

Have relevant scientific findings which show a connection between the process •

and desired outcome5.

Choose a topic where you can change the outcome. If you can’t, don’t try.•

Suggestions

Development/improvement can be done as a peer group activity.•

It may be easier to use an existing resource developed by the RNZCGP.•

KISS Theory• …Keep It Short and Simple.

2. PLAN

Where are we going?

Develop the indicator/marker/area to review.

Where are we going? Are there any evidence-based guidelines or other resources

available that outline best practice e.g.

Guidelines for smoking cessation• 6.


INDICATOR

The smoking status of adult patients is identified and recorded in the patient notes.

Develop criteria to measure the indicator.

Criteria are precisely defined to enable you to measure the indicator.•

CRITERIA



What is the standard you want to achieve?

STANDARD


3. DATA

Where do I go to find it?

Consider

WHO • willbeinvolved–individuals,practiceteamorGPgroups?

• willtakeresponsibilityforplanning,implementation,evaluation,

organisation, communication, coordination?

WHAT • datawillbecollected?

• methodwillbeusedtocollectdata?

• samplesize?

– Willitreflectwhatishappeninginthepractice?

– Isitamanageablesample?

• sampletype?e.g.random.

• datawillestablishwhetherthestandardshavebeenmet?


WHERE • willthedatabecollectedfrom?

Possible sources of data:

– age/sex/diseaseregisters

– surveys/questionnaires

– practiceactivityanalysis

– recordreview

– observation7

WHEN • willtheaudittakeplace?–developtimelines.

HOW • willthedatabeanalysed?

DO • datacollectionmethodsneedmodification?

• objectives/indicators/standardsneedmodification?

Example of data collection sheet:

Patient number:

Criteria 1 2 3 4 5 6 Total

Smoking status is recorded

in the notes of adult patients

Smoking status is updated

regularly

Note: Group data collection

The benefit of group data collection for groups of GPs is the possibility of further

quality initiatives to improve patient outcomes. Some primary care organisations

have developed information systems to collect data in key health outcome areas to

audit care provided.


4. CHECK (COMPARE)

What is the gap between data results and your own expectations?

Analysing the results

This step involves comparing data with the standards set for the indicators and crite-

ria, (although some may be doing better than expected, it is more common for most

practices to find that their audit results are not as good as expected8).

Review the data and compare with your expectations (the standard you set)

Where are the gaps between your expectations and your data results?•

Where are the gaps small, i.e. where are you doing well?•

Where are the gaps large, i.e. where is there room for improvement?•

Which gaps do we want to close?•

Note: Before developing an action plan, prioritise the problem to solve and choose

solutions.

EXAMPLE

• If the standard for recording the smoking status was set at 80% and

you achieved 40%, then you would have a baseline for identifying improvement.

• Theremightbeanumberofareasthatyoucouldidentifyasbeingpotentialsources

for improvement e.g.

– Routinelyaskingpatientsaboutsmoking.

– Developingawarningiconforthecomputer.

– Usingcolouredstickersforsmokingstatus.

• Oncethelistisdevelopedthebestoptionscanbechosenbythepracticestaff.


5. ACT

What changes can be made to improve patient care?

Taking action

Once the team has identified priorities for change, the next step is to ensure everyone

knows what needs to be done, by whom, and by when. Include the practice team in

the planning and decision making.

Problem solving process

What is the problem or underlying problem(s)?•

Change it to an aim.•

What are the solutions or options?•

What are the barriers? How can you overcome them?•

Overcoming barriers

Identifying barriers can provide a basis for change3.

Whatisachievable–findoutwhattheexternalpressuresonthepracticeareand•

discuss ways of dealing with them in the practice setting.

Identify the barriers? •

Develop a priority list. •

Choose one or two achievable goals e.g.•

Barriers list Options Selected options

1.

2.

3.

Effective interventions3

No single strategy or intervention is more effective than another, and sometimes •

a variety of methods are needed to bring about lasting change.

Interventions should be directed at existing barriers or problems, knowledge, skills •

and attitudes, as well as performance and behaviour.


Action – A framework for change

Below is an example of an action plan for identifying and organising change:9

Action plan for improving the recording rate of patients who smoke

Action required

Person responsible

Resources required

Establish timeline

Priority Procedure

PRESENT THE RESULTS – PLAN CHANGES

Develop ways to change the result to a more positive solution15.

• Whatistheunderlyingproblem?–Doesthepracticeseeanyareasitwishes to improve?

• Whatareyouaimingtoachieve?–Prioritisethegapswhichthepracticewishestoclose and choose one, two or three topics.

• Whatoptionsarethereforachievingtheaims?–Developactionplans.

• Whichoptionswouldbebest?–Useproblemsolvingtechniques.

• Whatbarrierswillpreventyouachievingthese?–Howwillthepracticeensureplansare carried out?

• Howwillyougetpastthebarriers?–Who/what/how/when?

• Whenwillyoureviewthisagaintoseehowfaryouhavegot?–diaryit!

• Planafeedbacksessionusingafacilitator.

6. REVIEW

Were the goals for improvement achieved?

Monitoring change and progress

Review the action plan, e.g. 3/12, 6/12, 9/12, 12/12 against the timeline.•

Evaluatetheoutcome–istheprocessworking?•

Were the goals for improvement achieved?•

Have the goals changed as a result?•

Do you need to develop new tools to achieve the goals that have been set?•

Determine whether a second audit should be done.•


Undertaking a second cycle

It is recommended that the second cycle be commenced at stage 3 (Data).

Was the information you collected appropriate for the questions asked?•

Did you meet the expectations as outlined in the first cycle?•

Was the whole process beneficial?•

Keeptheworkloadmanageable!•

Gaining credits

MOPS (Maintenance of Professional Standards) credits may be gained from complet-

ing continuous quality improvement activities that have been endorsed by the College

(see Appendix 2).

2.2 Sample Quality Improvement Cycle – Smoking Cessation6

This activity was developed using the Guidelines for Smoking Cessation.

TOPIC SMOKING CESSATION

Consider are we doing what we should be doing?

PLAN Where are we going?

Are there any evidence-based guidelines or other resources avail-

able that outline best practice?

National Health Committee. Guidelines for smoking cessation. NZ: National

Advisory Committee on Health & Disability; July, 1999.

1. Which indicators will you choose from the information available?

The smoking status of adult patients is identified and recorded in the

patient notes.

2. Identify the criteria to measure the indicator.



3. What is the standard you want to achieve?



DATA Collect data – Where do you go to find it?

• Identifyapatientsample,e.g.computergeneratearandomsample

of 50 records, or check the records of the next 50 patients who walk

through the door.

Who should be involved?

• Staffwhohavedirect clinical contactwith patients, e.g. practice

nurse, GP.

CHECK What is the gap between data results and your own expectations?

e.g. 80% of patients audited have had their smoking status recorded, and

we wanted 80%.

40% of patients who quit last year have taken up smoking again, and we

wanted 80%, so therefore, the gap = 40%.

What are you doing well?

Recording of smoking status.

What needs improving?

Could try and reduce the relapse rate.

ACT Make changes – What changes can be made to improve patient care?

• Discussthefindingsatapracticemeeting,e.g.problem:

relapse rate.

• Brainstormsolutions,e.g.thepracticenursecouldfollowuppatients

who are having difficulty giving up smoking.

• Identifystaffmemberswhoaremotivatedtoimplementsolutions.

• Patient recordswithoutsmokingstatusrecorded in the lastyear

have a sticker to remind GP to ask patient or icons flashing on

computer screen.

REVIEW Were the goals for improvement achieved?

(undertake a second audit)

• Repeattheauditinsixmonthstimewithadifferentgroupof

patients.


SECTION 3

Suggested Quality Improvement Topics

There are two frequently used classifications that describe the functions of a

practice:

Structure, process, outcome• 10.

Patient, professional and management quality• 11.

The most difficult part of a quality improvement activity can be choosing the topic.

Below is a list of suggested topics under the above classifications.

Structure (management quality)

The buildings, personnel, equipment and protocols that facilitate the process

of care.

Patient confidentiality in public parts of the practice is often difficult. Does the prac-

tice layout enhance patient privacy in the reception and waiting rooms12?

Are there adequate safeguards in the reception area to ensure confidentiality of •

information?

Do arrangements exist for private discussion with patients?•

Can phone calls in the reception area be heard by patients in the waiting room?•

Can reception staff observe patients in the waiting room whilst maintaining privacy •

of interactions and information?

Is there a phone available for private patient telephone conversations when •

needed?

Does your practice have a vision? Strategic planning is a participative process that

includes the whole practice team9. Successful planning is based on practical ex-


periences and contributions from all staff. Their ideas and opinions can contribute

in a practical way. For example, the reception staff may have noticed that patients

are distressed at the time they have to wait to see the GPs and have suggested a

better appointment system. The practice team can work together to develop the

best approach for all concerned.

What is the problem?•

Where is the practice now?•

Where do you want to be in the future?•

How will you get there?•

What are the goal posts?•

Good practice systems are important to the smooth functioning of the practice. Are

patient records and documents filed safely and securely12?

Are patient records and documents visible in public areas?•

Are patient records and documents visible in occupied consulting rooms?•

Are non-lockable files in staff areas only?•

Are practice staff aware of the practice policy on the storage and safety of documents?•

Are files secure or password protected when not in use?•

Emergency work is an important part of GP work. They must be ready and equipped

to administer first line treatment for medical emergencies. Therefore, it is important

that the contents of the doctors bag are current and complete12 .

Are you aware of the standard for a doctors bag?•

Do you have a list of the contents?•

Who is the person responsible for updating the contents of the bag?•

How regularly is the bag checked?•

Is there a system for checking?•

Is the bag kept in a place that is secure?•

Does each doctor have their own bag?•


Process (professional quality)

Concerned with the technical aspects of medical care, activities of a health system

or practitioner in the provision of care.

Do the records in your practice contain enough information to identify the

patient and to document the assessment, management, progress and out-

comes sufficiently for another doctor to carry on management12?

Is there sufficient information to identify the patient?•

Was the last consultation recorded adequately?•

Was the doctor making the entry easily identified?•

Are all current medications listed?•

Are problems and risk factors identified?•

Is there an adequate record of preventive services and options given?•

Coordinating care for patients who require cardiac rehabilitation13 – the primary

care setting often means GPs have to communicate with other health professionals

to ensure their patients have access to the care they need.

Can you identify the team members for coordinating cardiac care?•

Do each of the team members have a defined role that is understood by others?•

Is there a plan for care?•

How are the reporting structures defined?•

How does the feedback loop work?•

The incidence of tuberculosis in New Zealand is increasing14. Are you familiar with

the management principles for the treatment of tuberculosis?

What are the investigations needed to identify the organism and its sensitivity pattern?•

Can you identify patient compliance with medications?•

What is the treatment for suspected poor compliance or multi-drug resistance?•

Are you familiar with drug treatment regimes?•

What are the processes used to notify infectious diseases?•

How are infectious cases of tuberculosis isolated?•


The clinical management of diabetic patients should include appropriate observa-

tions that are recorded annually15.

Have you recorded:

weight•

smoking history•

fundoscopy (two yearly)•

foot examination•

cardiac risk•

BP•

lipids•

renal function•

HbA1c•

Falls are common amongst the elderly. By systematically taking into account the

following areas when seeing a patient after a fall, it may be possible to break the

falls/immobility cycle16 .

Did you identify and treat the cause of the fall?•

Is medication a reason for the fall?•

What are the environmental issues?•

Did you identify preventive aspects e.g. spectacles, walking aids?•

Will increased physical exercise make a difference?•

Outcome (patient quality)

A change in patient’s current or future health status (including; physical, psychological,

social health and behavioural), that can be attributed to previous care.

Communicating with patients – how good are your communication skills17?

Patient feedback is the best way to understand patient perceptions of your

communication skills.

Do patients think that you listen well?•

Do you avoid medical jargon?•


Do patients understand your explanations?•

Do your patients feel reassured?•

Are patients able to express their fears or concerns?•

Patient feedback is also a way of determining satisfaction with the level of service your

practice provides. How do patients perceive the service provided in your practice17 ?

How comfortable is the waiting room?•

Are staff trained to handle telephone queries in a discreet manner?•

Do patients have to wait long before they see a doctor?•

What are patient perceptions of the reception staff?•

Do patients know the cost of your service?•

Improving patient outcomes may depend on the way you interact or interpret patient

cues. Some patients have multifactors that are the cause of their ongoing problems.

Their situation or illness may be attributable to factors beyond their control, and

yours. However, there are ways of identifying and developing different strategies

for care to improve outcomes – even if they are not clinical outcomes18.

Can you identify criteria for patients in the practice who have challenging health •

issues or circumstances beyond their control?

Who and how many of these patients can you identify?•

Do these patients have common characteristics?•

Can you develop new strategies for managing patients e.g. developing better •

communication skills, improving your knowledge of health conditions?

Will referral to another service be more beneficial to an outcome?•

Can you link patients to community organisations that provide extra support?•

GP Audits

Self Care

To provide good patient care a GP should consider their own state of wellness, or

otherwise. Burnout is a common cause of many GPs losing control of a situation and

affects their personal and professional lives19.


How do you rate your lifestyle? – Some studies found that GPs who felt in control of

their lives had developed coping strategies that worked19.

Can you identify imbalance in your life?•

Where are you in control?•

Where do you feel a loss of control?•

Do you participate in activities outside the practice?•

How much energy is spent on work activity by comparison with your own time?•

Self-prescribing19 – a study in the UK in 1993 found that 83% of GPs have

self prescribed their own medications. It is a practice that is easy to adopt

and can have harmful effects.

Are you aware of the dangers of self-prescribing?•

Can you describe your limits for self-prescribing?•

Do you discuss self-prescribing in a peer group situation?•

Do you have your own GP?•


Glossary

Aquickguidetoqualityjargon–thesedefinitionshavebeendraftedbytheRNZCGP

for use in quality related documents.

Acceptability

The profession as a whole regards the indicator and assessment method as acceptable20.

Accessibility

Services should be reasonably accessible when clinically needed. Necessary services

should be accessible to people regardless of age, sex, ethnicity, disability or health

status21.

Achievability

A set of minimum entry indicator standards must be achievable by general practice20.

Benchmark

Reference standards against which to compare results. These may be your own results

or another comparable population or national standard.

Clinical Audit

The measurement of an aspect of clinical care carried out by the practice team.

Continuous Quality Improvement

A culture that seeks never ending improvement of the whole system as part of normal

daily activity:

CQI Cycle: Topic ➙ Plan ➙ Data ➙ Check ➙ Action ➙ Review

Criteria

A discrete, definable, measurable and relevant component of a standard2.

Efficiency

Primary care services should be based on evidence of clinical effectiveness and resources

used efficiently21.


Data Collection

The availability and accessibility of the required data elements; the cost and effort required

to extract or collect data22.

Fairness

Services should not vary widely in range or quality in different parts of the country21.

Feasibility

The process of practice assessment must be feasible in terms of its implementation and

the time and effort required20.

Guidelines

Systematically developed statements, which assist doctors and patients in making deci-

sions about appropriate treatment for specific conditions.

IPA

Independent Practitioners Associations.

Indicators

Measurable elements of performance selected (by evidence or by consensus) for as-

sessment of quality (and change in quality) of care provided.

Key performance indicator

Criteria against which achievement of goals is measured.

Minimum standard

The standard required to satisfy an authority, e.g. Medical Council, Accreditation.

Outcome

A change in patient’s current or future health status (including; physical, psychological,

social health and behavioural), that can be attributed to previous care.

Process

Concerned with the technical aspects of medical care, activities of a health system or

practitioner in the provision of care23.

Protocol

A detailed account of the planned process for a specific situation or condition.


Quality

The measurement and judgement of the technical and interpersonal aspects of care

(“excellence”, “fitness for purpose”, “minimal defects”). Is a commitment to a process

of continuous improvement.

Quality assessment

Systematic collection and analysis of data about a service, including content, process

(delivery) and outcomes.

Quality assurance

Planned activities based on performance review with the aim of continually improving

standards of care3.

Relevance

The applicability and/or pertinence of the indicator to its users and customers22.

Reliability

Behaves similarly under different circumstances20.

Responsiveness

Services that reflect the needs and preferences of the individuals using them and the

health demographic and social needs of the area they serve21.

Standard

Essentially a mark of success in achieving the criterion and specifies the acceptable

level of care3.

Strategic Plan

An organisation-wide plan establishing overall objectives.

Structure

The buildings, personnel, equipment and protocols that facilitate the process of care23.

TQM – Total Quality Management

An overall organisational culture and strategy for engendering and sustaining CQI.

Validity

The indicators adequately measured what they purport to measure – good practice?22.


Appendix 1

Below are some examples of classifying and prioritising evidence.

Richard Baker5 suggests:

Mustdo–essentialcomponentsofcare–provenevidence(randomisedcontrol•

trials) that doing this will make a difference.

Shoulddo–someevidencethatthiswillmakeadifference–basedonqualitative•

and quantitative studies.

Coulddo–expertopinion,patientfeedback,notmuchevidencetoprovethatit•

will make a difference, but is identified by the practice, and/or patients as being

important.

Another classification suggested by the Canadian Task Force24

EVIDENCE LEVEL DESCRIPTION

A

based on well-designed randomised controlled trials,

meta-analysesorsystematicreviews–e.g.Cochrane

database, National Health Guidelines.

Bbased on well designed cohort or case control studies

–e.g.Medline.

C

basedonuncontrolledstudiesorconsensus–e.g.ex-

pert opinion such as QA specialists, media, government,

Colleges, patient feedback.

Ideally, evidence for indicators should be derived from level A or B evidence,

however, if that is not available then consensus evidence is reasonable.


If developing evidenced-based audits the RNZCGP guideline development tool may

be useful25.

EVIDENCE DESCRIPTION COMMENTS

I Randomised control trials RCTs can control for selection bias

–e.g.CochraneDatabase,National

Health Committee Guidelines.

II Non randomised control-

led studies

Selection bias may result from

unrecognised or recognised

differences between study and

comparison groups. Only by

randomisation can selection bias

be controlled.

III Non randomised cohort

studies. Other studies

with non experimental

design

Comparison between current

patients receiving intervention

and former patients with no

intervent ion. Select ion bias

caused by non randomisation

and biases from inappropriate

comparison – e.g. population-

based, case control studies or

needs assessment.

IV Case studies Information about a group of

patients. Series may provide useful

information about clinical course,

but can only hint at efficacy.

V Expert opinion It is not evidence, but is included

to ensure that when it is consid-

ered we place more evidence

than opinion in determining

appropriateness.


Appendix 2

Maintenance of Professional Standards (MOPS) Programme

MOPS credits

Credits

GPs can claim the following Continuous Quality Improvement (CQI) Activity credits

towards the Maintenance of Professional Standards programme (MOPS) once each

cycle has been completed.

Note: A cycle is defined as completing data, check, act and monitor stages. When

applying for credits each cycle can be treated as a separate exercise so it possible

to complete the first cycle in one triennium and the second in the next. However, it is

strongly recommended that you complete the whole cycle.

Claiming credits

In order to claim credits towards MOPS for completing these activities you are required

to write a summary of each activity completed.

Endorsement of CQI activities for the MOPS programme

If you have designed your own Continuous Quality Improvement Activity, you must

apply to the College for endorsement. For further information, you may contact the

Maintenance of Professional Standards Unit at the RNZCGP (04) 496 5999. When

applying for MOPS credits for an individually designed audit you must use the Re-

cording Sheet provided.

CQI Activity (completing the second audit)

Credits for a complete second audit may be claimed under the Continuous Quality

Improvement Activites section of the MOPS programme.

It is important that the whole process of check, action, monitoring progress in the first

audit has been undertaken as well as the second audit.


References

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the working well in Tamar programme. Southampton, UK: RCGP; 1996.

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of Leicester, 1996.

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10 Donabedian A. Explorations in quality assessment and monitoring Vol 1, the

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Health Administration Press, University of Michigan; 1980.

11 Øvretveit J. Health service quality, an introduction to quality methods for health

services. Oxford, UK: Blackwell Scientific Publications; 1992.


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aiming for excellence in general practice. Wellington, NZ: RNZCGP; January 2000.

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Welllington, NZ: RNZCGP; 1998.

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NZ: Public Health Group, MOH; 1996.

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lington, NZ: RNZCGP; 1993.

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17 Client Focussed Evaluation Programme. Doctor’s interpersonal skills questionnaire

and better practice patient questionnaire. Australia: CFEP, Griffiths University; 1995.

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19 The Royal New Zealand College of General Practitioners. Self care for GPs. Wel-


20 Royal Australian College of General Practitioners. Entry standards for general

practice accreditation. Australia: RACGP; 1996.

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24 Lawrence M, et al. Canadian task force on indicators of general practice. Canadian

MedicalAssociationJournal1979;121:193–254.

25 The Royal New Zealand College of General Practitioners. Guideline package.


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