Quality and outcomes framework guidance:
Summary of indicators - organisational domain
2008/9
Records and Information
Records 3 - 1 point
The practice has a system for transferring and acting on information about patients seen by other doctors out of hours
Records 8 - 1 point
There is a designated place for the recording of drug allergies and adverse reactions in the notes and these are clearly recorded
Records 9 - 4 points
For repeat medicines, an indication for the drug can be identified in the records (for drugs added to the repeat prescription with effect from 1 April 2004). Minimum Standard 80%
Records 11 - 10 points
The blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 65% of patients
Records 13 - 2 points
There is a system to alert the out-of-hours service or duty doctor to patients dying at home
Records 15 - 25 points
The practice has up-to-date clinical summaries in at least 60% of patient records
Records 17 - 5 points
The blood pressure of patients aged 45 and over is recorded in the preceding 5 years for at least 80% of patients
Records 18 - 8 points
The practice has up-to-date clinical summaries in at least 80% of patient records
Records 19 - 7 points
80% of newly registered patients have had their notes summarised within 8 weeks of receipt by the practice
Records 20 - 12 points
The practice has up-to-date clinical summaries in at least 70% of patient records
Records 21 - 1 point
Ethnic origin is recorded for 100% of new registrations
Records 22 - 11 points
The percentage of patients aged over 15 years whose notes record smoking status in the past 27 months, except those who have never smoked where smoking status need be recorded only once (payment stages 40 – 90%)
Information 4 - 1 point
If a patient is removed from a practice’s list, the practice provides an explanation of the reasons in writing to the patient and information on how to find a new practice, unless it is perceived that such an action would result in a violent response by the patient
Information 5 - 2 points
The practice supports smokers in stopping smoking by a strategy which includes providing literature and offering appropriate therapy
Education and Training
Education 1 - 4 points
There is a record of all practice-employed clinical staff having attended training/updating in basic life support skills in the preceding 18 months
Education 5 - 3 points
There is a record of all practice-employed staff having attended training/updating in basic life support skills in the preceding 36 months
Education 6 - 3 points
The practice conducts an annual review of patient complaints and suggestions to ascertain general learning points which are shared with the team
Education 7 - 4 points
The practice has undertaken a minimum of twelve significant event reviews in the past 3 years which could include:
- Any death occurring in the practice premises
- New cancer diagnoses
- Deaths where terminal care has taken place at home
- Any suicides
- Admissions under the Mental Health Act
- Child protection cases
- Medication errors
A significant event occurring when a patient may have been subjected to harm, had the circumstance/ outcome been different
Education 8 - 5 points
All practice-employed nurses have personal learning plans which have been reviewed at annual appraisal
Education 9 - 3 points
All practice-employed non-clinical team members have an annual appraisal
Education 10 - 6 points
The practice has undertaken a minimum of three significant event reviews within the last year
Practice Management
Management 1 - 1 point
Individual healthcare professionals have access to information on local procedures relating to Child Protection
Management 2 - 1 point
There are clearly defined arrangements for backing up computer data, back-up verification, safe storage of back-up tapes and authorisation for loading programmes where a computer is used
Management 3 - 0.5 points
The Hepatitis B status of all doctors and relevant practice-employed staff is recorded and immunisation recommended if required in accordance with national guidance
Management 5 - 3 points
The practice offers a range of appointment times to patients, which as a minimum should include morning and afternoon appointments five mornings and four afternoons per week, except where agreed with the PCO
Management 7 - 3 points
The practice has systems in place to ensure regular and appropriate inspection, calibration, maintenance and replacement of equipment including:
- A defined responsible person
- Clear recording
- Systematic pre-planned schedules
- Reporting of faults
Management 9 - 3 points
The practice has a protocol for the identification of carers and a mechanism for the referral of carers for social services assessment
Management 10 - 2 points
There is a written procedures manual that includes staff employment policies including equal opportunities, bullying and harassment and sickness absence (including illegal drugs, alcohol and stress), to which staff have access
Medicines Management
Medicines 2 - 2 points
The practice possesses the equipment and in-date emergency drugs to treat anaphylaxis
Medicines 3 - 2 points
There is a system for checking the expiry dates of emergency drugs on at least an annual basis
Medicines 4 - 3 points
The number of hours from requesting a prescription to availability for collection by the patient is 72 hours or less (excluding weekends and bank/local holidays)
Medicines 6 - 4 points
The practice meets the PCO prescribing adviser at least annually and agrees up to three actions related to prescribing
Medicines 8 - 6 points
The number of hours from requesting a prescription to availability for collection by the patient is 48 hours or less (excluding weekends and bank/local holidays)
Medicines 10 - 4 points
The practice meets the PCO prescribing adviser at least annually, has agreed up to three actions related to prescribing and subsequently provided evidence of change
Medicines 11 - 7 points
A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed four or more repeat medicines. Standard 80%
Medicines 12- 8 points
A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines. Standard 80%