PMS Key Performance Indicators YEAR:

Transcription

1 PMS Key Performance Indicators YER: ear 1 pril 2016 to 31 March Practices are required to confirm their choice of KPIs, from this list, for practice provision in 2016/17. NOTE: The practice choice of KPIs forms part of the PMS agreement between Practice code: e.g. / B / te: Practice end of year report is the default. The Indicator B 1 Infant feeding % of infant feeding status (ie breastfed or artificial feeding) recorded as % of total HS 6-8 week checks. hecks must be included on template. 2 Smoking in pregnancy 3 Smoking and mental health % pregnant women recorded as smoker, smoking discussed, referred to stop smoking services % patients with newly diagnosed mental health problemsincluding depression recorded as a smoker, smoking discussed, referred to stop smoking services, and followed up on next visit 98% 90% 90-70% 60% 50% 40% The practice has made checks on infant feeding.please refer to screenshot attached named KPI 1-Infant Feeding ll pregnant women have been coded with a smoking status as being a smoke,smoking discussed or referred to stop smoking services..hence we meet the % for KPI.Screenshot attached KPI 2- Smoking in pregnancy 60% 50% 40% 4 Health checks % of eligible population offered health check 20% 10% 5% 5 lcohol % of adult population screened for alcohol use using UDIT-, and where over 15 referred to specialist service if appropriate 6 Mental health % patients on register for long term conditionsother than those indicated in QOF screened for depression 7 Obesity: adults % of adults with BMI recorded over 30 referred to weight management services and followed up on next visit 8 Obesity: children % of children with BMI in the 91st centile referred to weight management services In order for practices to receive payment 1 nominated clinician should: 1. attend public health commissioned childhood obesity 3 hours brief intervention training 2. attend the 1 day childhood obesity training to give apprpriate advice and information to families. The nominated clinician should then feedback to the rest of the practice team via an education session B The practice has offered health checks to the eligible patient population and hence we have partially met the KPI.Please see document labelled KPI 4-Health hecks 20% 15% 10% 70% 60% <60% 60% 50% 40% 60% 50% 40% Provide the % of children with a BMI in the 91st centile referred to weight management services only

2 PMS Key Performance Indicators YER: e.g. / B / te: Practice end of year report is the default. The Indicator B 9 Phlebotomy Practice offers the choice of phlebotomy facilities to any patient that can have blood taken in a community setting mid 0% The practice provides phlebotomy services to registered patients which is a local commissioning service in community based setting, we offer patients from other practices to use the service provided for Enfield. KPI 9- Phlebotomy document attached. 10 Over 65s medication review Percentage of over 65s on 4 or more meds receiving 6 monthly medication review 90% 80% 70%. 11 Practice opening hours Practice is open at least 52.5 hours per week, and able to take calls over lunch time. 12 linical availability linical appointments available total at least 16.5 hours per 1000 patients per week. mid 0% mid 0% The practice operation times were 52.5 hours per week and able to take calls over lunch We have met this criteria of clinical avalible hours.please see attached KPI Patient Participation Group Patients have influenced service redesign through the practice PPG, been involved in discussions with the practice about the development and selection of KPIs for Practice to publish its KPIs in surgery waiting room and on practice website and to engage the PPG in monitoring its KPI mid 0% PPG report is uploaded in practice website and also published in the practice waiting area.please see two attached documents for KP Learning disabilities Percentage of patients on the learning disabilities register who are given a consultation with a clinician for an annual health needs assessment (template to be developed) 15 Hepatitis B and screening 16 Hepatitis B vaccination Percentage of adult injecting or former injecting drug users offered screening for blood borne virus (hep B &, HIV) Percentage of adult injecting or former injecting drug usersoffered vaccination for hepatitis B 50% 40% 30% The practice has given a consultation to patients in the LD register and hence we met the KPI.Please see screenshot attached named KPI 14- Learning Disabilities. 90% 80% 70%. 90% 80% 70%. 17 Looked after children 18 Looked after children Establish a register and ensure an annual health check offered nnual health check delivered (template to be developed) mid 0% 50% 40% 30%. 19 BP monitoring Practice to offer 24hr Blood Pressure monitoring to all who need it 20 Nursing home Weekly ward round and monthly meeting with geriatrician with report provided to demonstrate 21 Special patient notes Special patient notes for 111/out of hours as percentage of palliative care register no mid 0% Screenshot attached for KPI19 -The practice has met this KPI by offering 24hr Blood pressure no mid 0% 80% 70% 60%.

3 PMS Key Performance Indicators YER: e.g. / B / te: Practice end of year report is the default. The Indicator B minute appointment times 23 MMR invitations for teenagers who were not fully immunised in childhood Practice offers 15 minute appointment times for routine booked appointments (NOTE: KPI 22 and 27 cannot both be selected) Regular quarterly search of practice population to identify year olds who have not been fully immunised (consider copying parents in as appropriate) Letters sent informing them of vaccination status enclosing leaflets about MMR and recommending vaccination. ppointment slots made available with clinician for vaccination and also for advice for patient and family as required. DNs to be followed up with second letter after one month, 2nd round DN phone contact or letter one month later mid 0% Screenshot attached.we provide 15mins prebooked appointment for all regular patients.please see document KPI % 70% 50% chievement based on offer and on actual eligible population, reported through practice end of year report 24 trial fibrillation screening Initial F screen through initial pulse rhythm check followed up by EG (either in house or through referral) 25 Diabetes testing Screen patients in at risk groups for diabetes on an annual basis with a fasting blood glucose test with one or more of the following criteria: Patients with obesity Patients with IHD Patients with V Patients with hypertension Patients with a 10yr VD risk >20% 26 omplex cases and families Practice to offer Multi-disciplinary Intervention for omplex Families and hallenging Patients for patients and/or families that present with complex physical and social issues. Meetings to be held every other month, 6 times pa, involving linicians and other Practice and Primary are staff. Must include a GP trained in supervision of MDTs, and evidence must be provided of these skills. Local authority must be linked in as appropriate for complex families The practice has provided F screening to the required patients and hence KPI is met.please refer to screenshot attached KPI-24 chievement based on offer and on actual eligible population, reported through practice end of year report chievement based on offer and on actual eligible population, reported through practice end of year report mid 0% udit to be submitted for each family/case, including evidence of care plans and a named individual who is trained in supervision of MDTs.

4 PMS Key Performance Indicators YER: e.g. / B / te: Practice end of year report is the default. The Indicator B 27 Extended ppointments for non-english Speakers Extended ppointments for non-english Speakers (based on 2000 extended appointments / year). ll patients booked must be contacted the day before to remind them of their appointment. >2000 appts appts <500 appts n audit must be submitted of activity including offered appointments, attended and DNs. Plan of action to minimise DNs must also be submitted. 28 Diabetes care 1 - Year of are (NOTE: KPI 22 and 27 cannot both be selected) Practice to offer "Gold Standard" Diabetic Year of are treatment to all patients with Type 2 Diabetes. With this method of management, all type 2 diabetics should expect to receive the 15 Diabetes UK expectations of care (as appropriate) invited and 65% of invitees attend invited and 50% of invitees attend invited the practice offers diabetic year of care treatment to all patients with type 2 diabetes.see document attached KPI 28. Have also attached the GP contract diabetes template. audit must be submitted including details of all invitations sent and appointments attended and DNd. 29 Diabetes care 2 - pregnancy ll diabetics of child bearing age to be offered annual education about pregnancy if appropriate (similar to epilepsy and QoF) 75% mid 0% The practice offers diabetic care 2 education to diabetic women in child bearing age.see document attached KPI 29. n audit must be submitted giving details of activity 30 Diabetes care 3 - diabetes control in primary care Type 2 diabetics on insulin to be seen inhouse for their diabetic control unless other complications (such as KD3b or above) mean hospital management is indicated 75% 50% 0% n audit must be submitted giving details of activity 31 Diabetes care 4 - type 1 diabetics 32 Diabetes care 5 - insulin initiation Type 1 diabetics who do not wish to got to hospital 90% mid 0% are offered an appointment at least twice yearly for a diabetic review Initiate insulin for appropriate patients as per NIE guidance The practice offers diabetic care to patients with Type 1 Diabetes.See document attached KPI 31. n audit must be submitted giving details of activity mid 0% n audit must be submitted giving details of activity

5 PMS Key Performance Indicators YER: e.g. / B / te: Practice end of year report is the default. The Indicator B 33 Diabetes care 6 - GLP initiation 34 Patient Educational Sessions Initiate GLP1 for appropriate patients as per NIE guidance Practice to offer 6 meetings pa on a specific topic facilitated by members of the practice and others, on topics such as obesity, smoking, diabetes-ramadan, mental health, OPD. Practices should work in networks where possible, opening the sessions to neighbouring practices. Patient feedback forms on the sessions must be collected to determine their views on the session and what they would do differently as a result. mid 0% n audit must be submitted giving details of activity mid 0% n audit must be submitted of sessions carried out, numbers of attendees per meeting, and brief analysis of patients' responses in feedback. 35 nnual health checks for patients aged 75 years and over 36 Identification of mental health patients requiring psychotropic depot injections Practice should undertake: - Search to identify patients 75 years and over - invite patients in for check heck to consist of: - Medication review by pharmacist - Testing for major long term conditions - hearing - vision - mobility Identify patients on mental health register who require psychotropic depot injections. Keep track of compliance. Use a risk analysis by the psychiatrist to define the list. This will also take account of patient's choice. Includes carrying out an audit of how many patients on the register with details of treatment. Keep up to date phone numbers and key workers' details to follow up non attendance offer and 50% delivered offer n audit must be submitted summarising offers and appointments completed 0% mid 0% n audit must be submitted including the register number and compliance information 37 hild protection identification and monitoring in primary care Identify patients on the child protection register at every opportunity when interact with primary care and to discuss with attached HV on a regular basis. Includes carrying out an audit of how many patients have warning when electronic notes are accessed for a child or a member of the family that has a child on a child protection register. Meetings with health visitors for childen on register idenificatio n of children only 0% Freezywater has identified patients on the child protection register and had Regular meeting with health Visitor. Meetings are held in the surgery.the audit report and Minutes of meetings are attached in document named KPI hence meeting the criteria for this KPI. n audit must be submitted including the register and monitoring carried out. heck: The requirement is to confirm a total of 100 points that the practice will deliver in KPIs. Practices may choose to over provide however they may not underprovide. This means the total in olumn K line 41 should read 100 or above. Practices should aim to have an accumulative value of around 100. ny practice that completes all indicators i.e. has a total of 259 points will have their submission returned on the basis that they would appear not to have

6 PMS Key Performance Indicators YER: e.g. / B / te: Practice end of year report is the default. The Indicator B made practice specific choices above? entered your practice code at the top of your KPI list heck: Have you made choices totalling 100 or heck: Have you