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This is any activity you undertake which you can show improves the quality of patient care. Most GPs will undertake several of the following:

Audit
This is the gold standard QIA which most GPs will undertake at least once during each 5 year revalidation cycle. It can be done on an individual basis or as part of a practice team activity. It is important that you are personally involved in the audit activity. If you are involved as part of a team you need to include a list of people involved including their designation and explain what your role has been. A full audit cycle involves two stages. The first stage outlines and reflects on the level of compliance achieved against the audit standard. The second stage (usually 1-3 years after the first stage) measures and reflects on whether compliance has improved with changes made after the first audit.

Audit resources:
How to do a Clinical Audit Successfully
Clinical Audit Report Template for GPs
Cancer Audit Template (RCGP): This template has been created by the RCGP for national data collection about cancer diagnosis and referral rates. You will see it is a tool enabling collection and review of data. If you use the tool to prospectively record all new cancer diagnoses it will provide data which can be compared on a yearly basis. This may then show changes in speed of referral, cancer diagnosis and outcomes.

Significant Event Audit (SEA)
If using the MAG appraisal form these SEAs are entered in section 8.

The GMC definition of a significant event means a serious untoward event that could or did lead to patient harm. For many GPs there will be no such events in an appraisal year.
However for the purposes of appraisal a broader definition of events is used. This includes

  • negative events or errors  which led to changes in procedures or patient care but did not result in patient harm
  • positive events which reinforced good practice.

Current SEA guidelines:
It is recommended that at least 2 such SEAs are discussed and the outcomes summarised using one of the following forms which are submitted at appraisal. If a GP has not had 2 SEAs then 2 Case Reviews (see below) or 1 SEA and 1 Case Review can be submitted.

Most practitioners will come across several SEAs every appraisal year. They should aim to discuss them in a forum including all members of the team, including relevant clinicians and administrative and reception staff when appropriate. This is much easier to conduct within primary care teams. Single-handed general practitioners and locums may therefore experience difficulties in conducting SEAs. They should try to discuss them in the practice in which the event occurred. If that is not possible, they may join a group of similar general practitioners who can, together, confidentially discuss each others’ SEAs. They can be summarised using the SEA reporting forms below:

An SEA record should contain the following items :

  • Title of the event
  • Date of the event
  • Date the event was discussed and the roles of those present
  • Description of the event involving the general practitioner
  • What went well?
  • What could have been done better?
  • Reflections on the event in terms of:
  • Knowledge, Skills and Performance
  • Safety and quality
  • Communication, partnership and teamwork
  • Maintaining trust
  • What changes have been agreed:
  • For me personally
  • For the team
  • Changes carried out and their effect
  • Review date


Serious Untoward Incident (SUI)
If using the MAG appraisal form such SUIs are entered in section 9.

A Serious Untoward Incident (SUI) is an incident that occurred during NHS funded healthcare (including in the community), which resulted in one or more of the following:

  • Unexpected or avoidable death or severe harm of one or more patients, staff or members of the public;
  • A never event - all never events are defined as serious incidents although not all never events necessarily result in severe harm or death. (see Never Events Framework1 and Never Events Lists2);
  • A scenario that prevents, or threatens to prevent, an organisation’s ability to continue to deliver healthcare services, including data loss, property damage or incidents in population programmes like screening and immunisation where harm potentially may extend to a large population;
  • Allegations, or incidents, of physical abuse and sexual assault or abuse;
  • Loss of confidence in the service, adverse media coverage or public concern about healthcare or an organisation;
  • Any incident involving the actual or potential loss of personal information that could lead to identity fraud or have other significant impact on individuals3 (this definition applies irrespective of the media involved and includes both loss of electronic media and paper records)

Serious incidents requiring investigation in healthcare are rare4, but when they do occur, everyone must make sure there are systematic measures in place to respond. These measures must protect patients and ensure that robust investigations are carried out, which result in organisations learning from serious incidents to minimise the risk of the incident happening again.

Primary Care Examples 5

  • Death on Premises
  • Grade 3 or 4 Pressure Ulcers originating in Primary Care (See Appendix 10 for additional information)
  • Health Care Acquired Infections originating from Primary Care
  • Suicide in a patient not known to other secondary care support services
  • Maladministration of Insulin
  • Falls from unrestricted window
  • Failure to monitor or respond to oxygen saturation
  • Wrong Site Surgery (extraction of incorrect tooth)
  • Sharps injury of a high risk patient
  • Misidentification of a patient
  • Screening Error, e.g. vaccination incident or omission of patient from smear list
  • Practice governance failure
  • Probity leading to loss of practice funds
  • Major Health & Safety Incident

1https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/142016/Never_events_policy_framework.pdf 
2
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/142013/Never_events_201213.pdf 
3
http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/links/suichecklist.pdf 
4 100 incidents were reported to D & N Area Team in the past year and 80% of incidents were pressure ulcer related
5 Please note that this is not an exhaustive list, any incident causing serious harm or death should be reported as a serious incident
 

To assist you with the reporting and investigation of serious incidents the above and following documents are attached for your information, please be aware that you may choose to continue to use your own organisational templates however the Area Team may request further information where additional assurances are required:

SUI reporting form

Please be aware that the Area Team requires to be informed of all Primary Care Independent Contractors Serious Incidents/Never Events/High Level Incidents (as per attached guidance policy and Serious Incident Framework March 2013). This framework is currently being updated therefore further guidance and tools may be shared later this year.

If you have any queries regarding the above please do not hesitate to contact the Area Team 
england.derbyandnotts-sisubmissions@nhs.net.

Case review
If a GP has not had 2 SEAs then 2 Case Reviews (see below) or 1 SEA and 1 Case Review can be submitted. Examples include:

  1. a documented account of one or more interesting or challenging cases which affirmed good practice or led to changes in practice. The doctor should have discussed the case review with a peer, another specialist or within a multi-disciplinary team.
  2. a group of cases where the management was changed in keeping with new advice or guidelines and the outcome reviewed with peers.
  3. a review of several patients with a similar presentation discussed with peers which led to improved diagnosis and / or management.

Case review structured reflective template for GPs

Referral review
A doctor can keep a log of a certain type of referrals, for example emergencies, 2 week waits, suspected skin cancers, for a defined time period. The outcomes of these referrals can be logged in a spreadsheet. This can be used to produce a review of outcomes including appropriateness of referral.

Prescribing review
A review of a group of patients' medication to assess if this is in keeping with current prescribing advice.

Starting a group of patients on new medication following new guidelines or advice and reviewing the outcomes after an appropriate time period.

All these forms of QIA should ideally be discussed within an MDT meeting to allow group input and learning. However if undertaken by for example a locum doctor where this may not be possible discussion at appraisal is acceptable.

 
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