Clinical governance
Learning Outcomes Audit GMC RCGP
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Learning Outcomes
Primary Care Management
Primary care management
All GPs should be actively involved in clinical governance. General practice training programmes should provide an environment where specialty registrars (GP) acquire the knowledge and skills required in this essential area of practice. They should also demonstrate appropriate attitudes to clinical governance to their educational supervisors and GP trainers.
The GP should be able to:
Describe the elements of clinical governance:
  •   quality improvement (including clinical audit)
  •   leadership
  •   evidence-based practice
  •   dissemination of good practice, ideas and innovation
Clinical Risk Reduction
  •   detection of adverse events
  •   learning lessons from complaints
  •   addressing poor clinical performance
  •   professional development programmes
  •   high-quality data and record keeping
Describe the relationship between clinical governance, continuing professional development, appraisal and revalidation
Describe the key aspects of NHS quality improvement systems, at national and local levels
Describe the General Medical Council’s Good Medical Practice and the RCGP’s Good Medical Practice for General Practitioners
Describe the codes and standards that apply to GPs and primary care - professional, regulatory, NHS, legal and other [e.g. local] standards, clinical and professional conduct
Describe a definition of clinical guidelines, their development, knowing how to assess the quality of a clinical guideline, kite-marking, differences between a CG and a protocol, the method for development in the UK
Demonstrate a working knowledge of performance indicators, their uses and abuses
Describe the system of underperformance, methods of diagnosis and management, and local procedures
Describe when it is appropriate to raise concerns and how to access local complaints systems – to know what action to take when a colleague gives cause for concern, whether a fellow doctor in primary or secondary care or other healthcare professional, and the support available
Describe the accountability of a GP
Describe how the performance of a GP and a practice might be defined and assessed
Describe the requirements for a practice-level clinical governance lead and their key relationships internally and externally.
Person-centred Care
Person-centred care
Patients, their families and carers have an important role in the holistic judgement of the quality of health care; their views are therefore essential for the development of high- quality health care. Patients should be encouraged to be actively involved in planning their care and in the development of services at practice level and beyond. There are many well- defined techniques for gaining the views of patients and engaging them individually and in groups.
The GP should be able to:
  • Describe techniques for ascertaining the views of patients, e.g. quantitative methods including surveys or qualitative interview techniques including focus groups
  • Discuss the benefits of involving lay people in the improvement of health services and setting up patient fora and groups
  • Demonstrate that they share the decision-making process with patients in their consultations
  • Describe the benefits of allowing patients access to their records
  • Describe the benefits of engaging patients in the care of others, e.g. the Expert Patient Programme
  • Describe the NHS complaints systems and optimal methods for learning from complaints and dealing with patients.
Problem-solving
Specific problem-solving skills
The GP should be able to:
  • Conduct a clinical audit
  • Conduct a significant event audit
  • Demonstrate skills in giving colleagues feedback about critical incidents
  • Develop and organise practice information systems about performance
  • Locate information about standards, clinical guidelines, critical appraisal and databases
  • Appraise critically data about performance indicators (e.g. prescribing, referrals, chronic disease management) their determinants and variation
  • Describe the variation in GP and practice performance and the determinants of this
  • Undertake a change management project in introducing a clinical development or guideline
  • Conduct a PDSA cycle (plan–do–study–act).
Comprehensive Approach
A comprehensive approach
Clinical governance provides a framework for drawing together the different strands of quality improvement.
The GP should be able to:
  • Demonstrate an evidence-based approach to the care of patients (see 3.5, Evidence- Based Practice).
Community Orientation
Community orientation
GPs have a responsibility for the community in which they work that extends beyond the consultation with an individual patient. The work of family doctors is determined by the makeup of the community and therefore they must understand the potentials and limitations of the community in which they work, and its character in terms of socio- economic and health features.
The GP should be able to:
  • Demonstrate how to involve patients and carers in their care, in decision- making and in quality improvement processes
  • Describe why they should involve patients from a wide spread of backgrounds that reflect the population that they serve
  • Describe the problems resulting from inequalities in healthcare provision and how involvement of patients will assist in planning services to address the inequalities
  • Describe the importance of practice- and community-based information in the quality assurance of each doctor’s practice.
Holistic Approach
A holistic approach
The awareness of the positive benefits of involving patients in their care and in the systems of healthcare provision and quality improvement chime well with the work of Kemper who describes holism as fundamentally involving ‘caring for the whole person in the context of the person’s values, their family beliefs, their family system, and their culture in the larger community, and considering a range of therapies based on the evidence of their benefits and cost’.16
Or, as Pietroni puts it, holism involves a ‘willingness to use a wide range of interventions … an emphasis on a more participatory relationship between doctor and patient; and an awareness of the impact of the “health” of the practitioner on the patient’.17
The GP should be able to:
  • Describe the concept of holism and its implications for the patient’s care
  • Demonstrate an appreciation of patients’ experiences, beliefs, values and expectations, and the value of engaging patients in the management of their illness and conditions.
Context
Contextual aspects
By understanding the context of doctors themselves and the environment in which they work, including their working conditions, community, culture, financial and regulatory frameworks, the GP should be able to:
  • Describe the impact of the local community, including socio-economic factors, geography and culture, on the workplace and patient care
  • Describe the impact of overall workload on the care given to the individual patient, and the facilities (e.g. staff, equipment) available to deliver that care
  • Describe the financial and legal frameworks in which health care is given at practice level
  • Describe the impact of the doctor’s personal housing and working environment on the care that he or she provides.
Attitude
Attitudinal aspects
Based on the doctor’s professional capabilities, values, feelings and ethics, the GP should be able to:
  • Discuss awareness of his or her own capabilities and values
  • Identify ethical aspects of clinical practice (prevention, diagnostics, therapy, factors that influence lifestyles)
  • Discuss awareness of self: an understanding that his or her own attitudes and feelings are important determinants of how he or she practises
  • Discuss, justify and clarify personal ethics
  • Describe the interaction of work and the doctor’s own private life, and striving for a good balance between them.
Science
Scientific aspects
By adopting a critical and research-based approach to practice and maintaining this through continuing learning and quality improvement, the GP should be able to:
  • Describe the general principles, methods and concepts of scientific research, and the fundamentals of statistics (incidence, prevalence, predicted value, etc.) and quality assurance science
  • Discuss the scientific backgrounds of pathology; symptoms and diagnosis; therapy and prognosis; epidemiology; decision theory; theories about the forming of hypotheses and problem-solving; and preventative health care
  • Access, read and assess medical literature critically
  • Develop and maintain continuing learning and quality improvement.
Audit
Audit Process
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GMC
Good Medical Practice
Mapping of the RCGP Curriculum against the General Medical Council’s Good Medical Practice (2002)
Good Medical Practice Corresponding paragraphs in the Curriculum
Good clinical care
Clinical care
Domain 1: Primary care management
1.1To manage primary contact with patients, dealing with unselected problems
1.2To cover the full range of health conditions
1.3To coordinate care with other professionals in primary care and with other specialists
1.4To master effective and appropriate care provision and health service utilisation
1.5To make available to the patient the appropriate services within the healthcare system
Domain 2: Person-centred care
2.1To adopt a person-centred approach in dealing with patients and their problems, both in the context of patient’s circumstances
2.2To use the general practice consultation to bring about an effective doctor–patient relationship, always respecting the patient’s autonomy
2.3To communicate, to set priorities and to act in partnership
Domain 3: Specific problem-solving skills
3.1To relate specific decision-making processes to the prevalence and incidence of illness in the community
3.2To selectively gather and interpret information from history-taking, physical examination and investigations, and apply it to an appropriate management plan in collaboration with the patient
3.3To adopt appropriate working principles (e.g. incremental investigation, using time as a tool), and to tolerate uncertainty
3.4To intervene urgently when necessary
3.5To manage conditions that may present early and in an undifferentiated way
Domain 4: A comprehensive approach
4.1To simultaneously manage multiple complaints and pathologies, both acute and chronic health problems
4.2To promote health and wellbeing by applying health promotion and disease prevention strategies appropriately
Domain 5: Community orientation
5.1To reconcile the health needs of individual patients and the health needs of the community in which they live, balancing these with available resources.
Domain 6: A holistic approach
6.1To use bio-psycho-social models, taking into account cultural and existential dimensions
Good clinical care
Keeping records, writing reports and keeping your colleagues informed
Domain 1: Primary care management
1.3To coordinate care with other professionals in primary care, and with other specialists
Domain 2: Person-centred care
2.3To communicate, to set priorities and to act in partnership
Good clinical care
Access, availability and providing care out of hours
Domain 2: Person-centred care
2.4To provide long-term continuity of care as determined by the needs of the patient, referring to continuing and coordinated care management
Good clinical care
Treatment in emergencies
Domain 3: Specific problem-solving skills
3.4To intervene urgently when necessary
Good clinical care
Making effective use of resources
Domain 3: Specific problem-solving skills
3.3To adopt appropriate working principles (e.g. incremental investigation, using time as a tool), and to tolerate uncertainty
3.6To make effective and efficient use of diagnostic and therapeutic interventions
Domain 4: A comprehensive approach
4.3To manage and coordinate health promotion, prevention, cure, care, rehabilitation and palliation
Domain 5: Community orientation
5.1To reconcile the health needs of individual patients and the health needs of the community in which they live, balancing these with available resources
Maintaining good medical practice
Keeping up to date, and maintaining your performance
Essential feature 3: Scientific aspects
4 Being able to develop and maintain continuing learning and quality improvement
Relationships with patients
Providing information about your services
Domain 2: Person-centred care
2.3To communicate, to set priorities and to act in partnership
Relationships with patients
Maintaining trust
Domain 2: Person-centred care
2.1To adopt a person-centred approach in dealing with patients and their problems, both in the context of patient’s circumstances
2.2To use the general practice consultation to bring about an effective doctor–patient relationship, always respecting the patient’s autonomy
2.3To communicate, to set priorities and to act in partnership
Essential feature 2: Attitudinal aspects
1 Being aware of their own capabilities and values
2 Identifying ethical aspects of clinical practice (prevention, diagnostics, therapy, factors that influence lifestyles)
3 Justifying and clarifying personal ethics
Relationships with patients
Avoiding discrimination and prejudice against patients
Domain 6: A holistic approach
6.1To use bio-psycho-social models, taking into account cultural and existential dimensions
Relationships with patients
If things go wrong
Essential feature 1: Contextual aspects
1 Having an understanding of the impact of the local community, including socio- economic factors, geography and culture, on the workplace and patient care
2 Being aware of the impact of overall workload on the care given to the individual patient, and the facilities (e.g. staff, equipment) available to deliver that care
3 Having an understanding of the financial and legal frameworks in which health care is given at practice level
4 Having an understanding of the impact of the doctor’s personal housing and working environment on the care that s/he provides
Essential feature 2: Attitudinal aspects
1 Being aware of their own capabilities and values
2 Identifying ethical aspects of clinical practice (prevention, diagnostics, therapy, factors that influence lifestyles)
3 Having an awareness of self: an understanding that their own attitudes and feelings are important determinants of how they practice
4 Justifying and clarifying personal ethics
Working with colleagues
Working with colleagues and working in teams
Domain 1: Primary care management
1.3To coordinate care with other professionals in primary care, and with other specialists
1.5To make available to the patient the appropriate services within the healthcare system
Domain 4: A comprehensive approach
4.3To manage and coordinate health promotion, prevention, cure, care, rehabilitation and palliation
Working with colleagues
Referring patients
Domain 1: Primary care management
1.3To coordinate care with other professionals in primary care, and with other specialists
1.5To make available to the patient the appropriate services within the healthcare system
Working with colleagues
Accepting posts
Essential feature 2: Attitudinal aspects
1 Being aware of one’s own capabilities and values
4 Justifying and clarifying personal ethics
Teaching and training, appraising and assessing
Teaching and training, appraising and assessing
Not explicitly covered in this statement but covered in supplementary RCGP curriculum statements
Probity
Research Financial and commercial dealings Providing references
Essential feature 2: Attitudinal aspects
1 Being aware of one’s own capabilities and values
2 Identifying ethical aspects of clinical practice (prevention, diagnostics, therapy, factors that influence lifestyles)
4 Justifying and clarifying personal ethics
Health and the performance of
other doctors
Protecting patients when your own health or the health, conduct or conduct, or performance of other doctors puts patients at risk
Essential feature 2: Attitudinal aspects
1 Being aware of their own capabilities and values
3 Having an awareness of self: an understanding that their own attitudes and feelings are important determinants of how they practice
5 Being aware of the interaction of work and doctor’s own private life and striving for a good balance between them
Consent
RCGP
Good medical practice for GP's
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Revalidation
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