A Journey Of Excellence In General Practice

A Journey of Excellence in General Practice Paresh Dawda South Street Surgery, Bishop’s Stortford

Abstract Background

•In 2006 South Street Surgery, a large 20000 patient training practice, embarked upon a journey of excellence and the practice was one of the first in the country to be awarded the European Foundation of Quality Management’s (EFQM) Committed to Excellence Award. •The aim was to become a “transformational organisation” in which quality improvement is part of everyone’s job and for improvement to happen in a structured measured manner so that it was sustainable.

Method

•An organisational audit using a multifaceted approach with the EFQM’s Excellence Model as a framework was conducted. Existing metrics e.g. patient surveys, data from QOF, complaints and financial performance were analysed. A staff survey was conducted and the partners and management team completed a self assessment tool. An external facilitator undertook one to one interviews with partners, managers and small group interviews with staff. •Feedback workshops with the partners were held and an organisational development plan was developed and implemented. This was communicated to all staff using a variety of methods. As improvement projects have taken place using quality improvement tools such as lean or six sigma members of staff have been increasingly involved in improvement events.

Results

•We have become a more patient centred and process based organisation. The project is ongoing but a number of benefits have already been identified including improvement to patient telephone access, a reduction in patient complaints, an improvement in follow up staff questionnaires, and the establishment of a patient forum to engage patients more.

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South Street Surgery A large General Practice with a registered list size of 20,000 patients. It operates over split sites and is a multidisciplinary teaching practice.

Ten partners including one nurse partner, approximately 50 employed staff in addition to an attached Primary Health Care Team. It provides a number of essential, additional and enhanced services under the nGMS contract framework.

The practice’s mission is to be ‘Delivering Excellence in Healthcare’ and it's vision is ‘To be recognised as an excellent healthcare organisation’.

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Introduction The Start • The practice embarked on this journey in 2006. Initially the objectives were not very clear. To define the objectives more precisely the author therefore discussed the ideas and expectations with partners individually. The emerging themes were very varied and non-specific. For example, comments included phrases such as “to bring about change more effectively”, “overhaul everything and start from scratch”, and “to change the culture of the practice”. However, culture is very complex. Organisational Audit • It was agreed that the aim of this project would be to perform an organisational audit using a multifaceted approach and use the results of that audit to produce an organisational development plan. Excellence Model • This needed a tool that is valid, reproducible and applicable to healthcare. It was agreed to use the European Foundation Quality Management (EFQM) Excellence Model (EFQM, 1992) as the instrument. Benefits Anticipated

• Patients: An improved culture of the practice will mean that it is more driven by patient needs and the “Voice of the Customer.” This will ultimately lead to improved patient focused care that will ultimately benefit the patients of the practice. • Practice: An increase in efficiency of the practice will enable it to make better use of resources and at the same time increase staff satisfaction and morale • NHS: Locality & PCT & Sharing good practice

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The Excellence Model The Excellence Model • Encompasses 9 criteria • There are 5“enabler” criteria • There are 4 “results” criteria • They have different weighting • Innovation and Learning is a critical success factor

Enablers • We focused on this area • We used a multifaceted approach • Partners and management completed Business Excellence Survey • Staff completed a staff survey • An external facilitator interviewed all staff and partners

Results • We used existing results to inform the right hand side of the model • Financial results • QOF • Patient Complaints • Patient Surveys

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Outcome Leadership

•Clarification of values, mission and vision, to help communicate business goals to staff and patients. •Develop a business management structure with training for partners in leadership and management.

Policy and Strategy

•Explicit short and long term objectives as part of a cohesive strategy. •Move to process based management to help with decision making and implementation.

Partnership and Resources

•Develop a financial strategy with management accounting system. •Need to improve partnership working with existing players in primary care e.g. PCT, locality groups, new entrants and voluntary sector.

People

•Improve learning from bottom up by encouraging feedback, empowerment and innovation. •Skills assessment and objective setting for all staff, including non-clinical staff.

Processes

•Improve customer focus by seeking and listening to feedback and acting accordingly. •Move to a structure of process based management with a development strategy.

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Organisational Structure The key change was to create a two dimensional organisational structure combining the traditional organisational chart with the new process based architecture.

Organisational Chart

Process Based Architecture

Partners

Business Excellence Director Business Support Administrator

Salaried Doctors

Nurse

HCA

Practice Services Manager

Practice Administration Manager

Receptionists

Medical Secretaries

Rota Supervisor

Finance Administration

Private Income Administration

Summarisers

Coders

Results Administration

General Administration

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How it works The Business Excellence Committee monitors the other process and provides the leadership.

• Each Process has a lead which is a Partner or Manager

Process Lead

Process Team

Process Work

• The process leads put together a process team • e.g. The ‘Recording and Monitoring Process’ is a team consisting of Lead Partner, Practice Administration Manager and representation from the summarisers and coders

• There is a programme of regular meetings for each of the process teams • Process issues are discussed in those teams and ideas for improvement are put forward • Decision making previously made at partnership meeting has been devolved to process teams

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Quality Improvement Projects • There are a large number of projects identified for improvement • BEC prioritises the projects based strategy agreed by partners Systemic Approach • Quality improvement in undertaken using proven methods such as The Improvement Method, Lean or Six Sigma • Staff are all involved in improvement • Patient focus is key to each and every improvement

45

Vision and mission/ strategy

40

Technology

35

Recording & Monitoring

30

People

25

Patient Relationships

20 15

Patient Care

New premises

10 Health & Safety

Dashboard

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• We have an internal dashboard that monitors our progress against our strategy and our own KPI • We are developing a data warehouse and implementing Business Process Intelligence systems

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Finance External Relationships Developing products and services

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Achievements Patient Focus • Patient Participation Group • Improved communication with patients via website and regular newsletters • Patient Involvement : A number of methods of seeking patient views are used including a survey website through which we can obtain patient views using surveys

Scorecard • We use a number of metrics to monitor our service and quality of care • We have seen improvements in patient telephone access, complaints, staff satisfaction • We are using tools such as the “Primary Care Trigger Tool”, as well as significant event auditing, staff reporting and clinical audit to improve patient safety and care

Recognition • We are one of the practices in the country to achieve the European Foundation of Quality Management’s Committed to Excellence Award and are progressing towards the next level known as Recognised for Excellence • We are members of the British Quality Foundation and have also achieved Investors in People • We have had a number of write ups about our work and have members of the practice have presented at National Conferences such as Lean and Six Sigma in Healthcare. 10