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‘From good to great’ – the quality feat

17 October 2011

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Jack Nagle
PhD BE(Hons) MBA

Chief Executive Officer,
Alpha Primary Care

Jack has worked for more than 20 years in industry in various senior roles, most recently as Operations and Engineering Director for Boston Scientific until he set up Alpha in 2003. He has a keen interest in all healthcare matters and a particular interest in total quality management and how it can lead to quantum improvements in healthcare delivery systems

Few practice managers can hope to escape from the word ‘quality’ these days. The government has reaffirmed the need to place quality of care at the heart of the NHS. The white paper, Equity and Excellence, makes clear that quality cannot be delivered by top-down targets but by focusing on outcomes, giving real power to patients and devolving accountability to the frontline.(1) NHS Chief Executive Sir David Nicholson put quality firmly at the top of the healthcare agenda by issuing a ‘QIPP (Quality, Innovation, Productivity and Prevention) challenge’ to chief executives throughout the NHS in 2010.

A frequently used definition of quality is: “Delighting the customer by fully meeting their needs and expectations.” These may include service, appearance, availability, delivery and reliability. So if general practice is to deliver a quality service it must understand the true needs and expectations of its patients.

Total Quality Management (TQM) is a philosophy that enables the management of people and business processes to ensure complete customer satisfaction. It has been used widely in industry to deliver huge benefits in customer service, efficiency and cost reductions. Its implementation within a healthcare environment can deliver quantum levels in improvement to healthcare service delivery.

So what does quality mean in the context of practice management and what are the implications of quality being promoted so forcefully at a governmental and national level? Essentially, and with reference to the philosophy of TQM, it means:

  • Focus on the patient.
  • Focus on preventing problems rather than having to fix them.
  • Relentlessly eliminating waste and inefficiencies.
  • Involving all staff.
  • Benchmarking and sharing best practice.
  • Monitoring and reviewing performance.

So why is quality now so important? Is it really going to impact on anything general practice does, on the role of the practice manager and the performance of the practice? The simple answer is ‘yes’, on all counts. This becomes more evident when looking at the background and the intent of the QIPP initiative.

QIPP is seen as an essential initiative in driving quality within the NHS and in securing cost savings over the coming years. The NHS needs to achieve more than £20bn in efficiency savings because of growing demand. With factors such as an ageing population putting the NHS under increasing pressure, it is not possible for the health service to go on as before.

Now, more than ever before, the NHS has to achieve value for money and the best possible quality. The QIPP initiative is all about ensuring that each pound spent is used to bring maximum benefit and quality of care to patients. The QIPP challenge demands action at regional and national level to drive up quality while making the best use of scarce resources.

The Department of Health has set up several workstreams to help manage the delivery of QIPP. One of these reviews central budgets and international comparisons, while further workstreams look at system changes needed to support delivery, including:

  • Primary care productivity.
  • Appropriate care, decommissioning and demand management.
  • New models of care, self-care and prevention.
  • Secondary care productivity.

Proposals for new ways of working or service redesign should demonstrate how they meet the QIPP challenge if they are to be successful. The philosophy underpins the NHS Plan for 2010-15 and the latest operating framework.(2,3)

Benchmarking is an effective way of comparing general practice performances and in helping practice managers identify areas for improvement, leading to gains in quality and productivity.(4)

Figure 1 shows an example of practice improvements resulting from the introduction of quality improvement initiatives.


The Quality and Outcomes Framework (QOF) indicators in England have undergone revisions since they were first introduced and further changes were made for the start of the fiscal year 2011/12. While voluntary, QOF revenue has become an important component of practice income, accounting for approximately 15% of total practice income annually. Each QOF point is worth approx £130 for 2011/2012.

The 20011/12 QOF measures achievement against 142 indicators; practices scores points on the basis of achievement against each indicator (up to a maximum of 1,000 points):

  • Clinical care: 87 indicators across 20 clinical areas (eg, coronary heart disease, heart failure, hypertension).
  • Organisational: 45 indicators across six organisational areas – records and information, information for patients, education and training, practice management, medicines management, quality and productivity.
  • Patient experience: one indicator that relates to length of consultations.
  • Additional services: nine indicators across four service areas – cervical screening, child health surveillance, maternity service and contraceptive services.

The 11 indicators around medicines management, hospital referrals and emergency admissions are the first explicitly QIPP-related incentives to be written into the QOF.

To deliver on all the practice’s goals and targets, managers will need to have in place an effective quality management system, one that is right for their practice needs and size.

The Care Quality Commission (CQC) is the new independent health and social care regulator for England (see Resource). The CQC makes sure that essential common quality standards are being met where care is provided and works towards the improvement of care services. It promotes the rights and interests of people who use services and has a wide range of enforcement powers to take action on their behalf if services are found to be unacceptably poor.

The CQC’s functions are: assuring safety and quality, performance assessment of commissioners and providers, monitoring the operation of the Mental Health Act and ensuring that regulation and inspection activity across health and adult social care is co-ordinated and managed.

The CQC’s vision is of high-quality health and social care that supports people to live healthy and independent lives; helps people and their carers make informed choices about care; and responds to individual needs. ‘High-quality care’ means care that:

  • Is safe.
  • Leads to the right outcomes, including clinical outcomes (for example, do patients get the right treatment and are they well cared for?).
  • Is a good experience for the people who use it, their carers and their families.
  • Helps prevent illness and promotes healthy, independent living.
  • Is available to those who need it when they need it.
  • Provides good value for money.

In 2010, the CQC introduced a new registration system. Subject to legislation, all health and adult social care providers of regulated activities will be required by law to be registered with the CQC, under the Care Standards Act 2000. The act gives the CQC a wider range of enforcement powers, along with flexibility in how and when to use them. This will allow the regulator greater powers to achieve compliance with registration requirements.

From April 2013, all GP practices must be registered with the CQC. If the practice is part of a co-operative or federation – for example, providing out-of-hours or enhanced services – the co-operative or federation will need to be registered if it is a separate legal entity, as well as each practice. To maintain their registration, practices will need to demonstrate an ongoing compliance to 16 core registration regulations relating to essential standards of quality and safety:

  • 1. Care and welfare of people who use services.
  • 2. Assessing and monitoring the quality of service provision.
  • 3. Safeguarding from abuse people who use services.
  • 4. Cleanliness and infection control.
  • 5. Management of medicines.
  • 6. Meeting nutritional needs.
  • 7. Safety and suitability of premises.
  • 8. Safety, availability and suitability of equipment.
  • 9. Respecting and involving people who use services.
  • 10. Consent to care and treatment.
  • 11. Complaints.
  • 12. Records.
  • 13. Requirements relating to workers.
  • 14. Staffing.
  • 15. Supporting workers.
  • 16. Co-operating with other providers.

Preparing your practice for registration
While full guidelines are still being prepared by the CQC, it is clear that each practice will need to demonstrate conformance to the 16 core registration regulations. This will be achieved by having in place all the necessary protocols defining each process and the associated standards of each, by training all staff in these procedures and by demonstrating the effectiveness and ongoing compliance to these standards.

A ‘Quality Plan’ and ‘Quality Management System’ provide the framework within which a practice can:

  • Map all its core processes.
  • Develop an inter-relationship map between each core process (to show how standards will be met).
  • Develop protocols for each mapped process.
  • Train staff in all protocols.
  • Establish an audit system to verify the effectiveness and ongoing compliance to the standards.

Developing a quality culture
All leaders and managers must be well informed, set clear goals and achievable targets and promote a culture of continuous improvement. Practice managers need to be able to respond to constant change, daily pressures and a changing regulatory environment. The benefits of TQM include greater competitive advantage and potentially massive financial savings around the “cost of quality”.(5)

Introducing quality standards is necessary to comply with CQC registration. However, it would be a missed opportunity to see this as an imposition of regulatory standards and a bureaucratic exercise that will burden the practice team.

Implementing and developing a quality culture can yield significant improvements in practice performance. Culture is deeply rooted in organisations and manifests itself as the organisation’s regular way of doing things and its values, policies and unwritten rules for getting on in the workplace.
True leaders of quality must lead by example and work on the practice culture to introduce real change and promote the new philosophy with enthusiasm, conviction and, most importantly, through appropriate behaviours.

Management is one of the most exhilarating and risky activities in the world. TQM can give practice managers real advantage in facing the many challenges the future will bring. They have an exciting opportunity to deliver quantum improvements within the healthcare and general practice environment. The opportunity is here, now.

1. Department of Health. Equity and excellence: liberating the NHS. London: DH; 2010. Available from:…
2. Department of Health. NHS 2010-2015: from good to great. Preventative, people-centred, productive. London: DH; 2009. Available from:…
3. Department of Health. The Operating Framework for the NHS in England 2011/12. London: DH; 2010. Available from:…
4. Nagle JP, Heffernan T, Naughton A. Patients are not cars. Forum 2006;41-3.
5. Bank J. The Essence of Total Quality Management. Harlow: Pearson; 1999.

Care Quality Commission