How do Practices know how they are doing?

What data do you collect to inform your decision-making as a practice? Different colours represent different practices.

We asked some practices in a Federation to tell us what measures / indicators they collect to inform their practice decision-making in terms of how they organise (their operational management), the quality of their work, and their financial robustness. This is what they told us.

What surprised us is how little overlap there was in terms of what each practice used regularly. The range of measurement used was wide, but there was little consistency across different practices.

 

The focus of operational measurement and use of data was overwhelmingly focussed on managing the present.

Quality and safety measurement was focused on the past – i.e. the measurement created a retrospective view rather than a prospective view.

We know that you get more of what you pay attention to.

So what you measure determines what you do. The metrics that shape your decision-making are important. They relate to the sort of practice you want to be, and the difference you want to make. 

This is what a group of practices told us about what they collect. It was copious, and it didn’t all add up into a comprehensive or coherent view of the practices work.

This exercise helps practices think about the data they need to be effective as a provider of care and as a business (after all, GP practices are private subcontractors to the NHS). Most of the measurement was about activity (generally managing and counting appointments), and so its no wonder this is the focus of how problems are seen, but also assumptions to where solutions lie. There was little about actual demand (need), or population health. In fact the metrics seemed to be dictated by contracts and incentive structures (namely QOF) – and not necessarily by patient need.

So where do you start as a practice? 

1. Be clear about your purpose. What is it you want to achieve as a practice in terms of your impact on health, the quality of your services, what sort of place your practice is to work in, and your financial viability?
2. Then set out some goals for your practice – what would the above answers look like if you were doing it all well? How would you know?
3. Now what metrics help you understand how you are doing now, and how robust you are for the future? Think about trends as well as static points. 
4. Finally how often do you need to review these metrics? Do you have a top 5 that you look at every week as it gives you a good ‘temperature test’? 

Here is a basic example from a practice

Raising the bar

The above creates a predominately operational view. To move to a view that helps with the improvement of core process, you would seek to create measures and information loops that help you understand variation in process capability, variation in clinical decision making and, most fundamentally, whether or not you are genuinely meeting demand (need).

This could be seen as needing a fair bit of investment to put in place. It certainly needs a little staff time each week to pull together – so essentially it costs money to create this data driven view. My view is most practices are not ‘corner shop’ businesses any more. Turnovers of in excess of £1million and 20+staff are not uncommon. The ‘work’ of general practice is complicated and patients are becoming more dependent. Given all of this, then can practice be run without a balanced measures set, i.e. run predominantly on subjective decision-making? I suspect not.

We are keen to hear examples from practices. If you would like to share your examples on this blog do get in touch.

Nick Downham Guest Blog

Setting up a Team to Develop Primary Care

This blog sets out what is required in a team that sets out to develop primary care. I start with a brief summary of our approach but the most important section of this blog is the style of and skills in any PC development team. There are lots of PC developments going on, but it takes a mix of skills to be a really effective development partner to practices.

The Approach

We have developed an approach to Primary Care Development in the LSBU Primary Care Quality Academy that has two stages. The Lab approach is described in more detail in the next blog.

Stage One : Readiness

A combination of data work to collaboratively review demand and a practice visit to discuss the practice ‘system’.

Which has the following specific data to understand the here and now of the practice culture, approach to access, and how its meeting/managing demand

This is followed by

Stage Two: Delivery

A mixture of a short course, communities of practice, further data work, and on-site bespoke development.

The Principles that Underpin How the Development Team Works

We have found that this is what it takes to do this work  in terms of principles:

• A neutral non-judgmental partner willing to walk alongside the practices as they develop; but also rigorous and challenging/ critical friendship.
• Start with what’s really going on in the practice using data and system maps to understand the patterns of behaviour
• Work with their real time current issues – we start where they want to start.
• Sort and filter all the advice available to general practice on quality and change.
• Work with the practice as a system not a series of parts that can be fixed mechanistically – we start anywhere and go everywhere
  • across appointment systems and how people move through the system;
  • clinical and management variation in signposting,
  • referral and clinical decisions;
  • skill mix – who does what work;
  • building the assets of the communities; working with the folk who are struggling

And this is what it takes to do this work in terms of our practice:

• A team that has expertise across all the emerging needs of the practice, with a portfolio of primary care specific methods – QI methods, Data, Citizen engagement and asset building; team development and peer decision-making; clinical variation; working as a system.
• Build the relationships that enable them to decompress – we listen (for hours) meaningfully to their experience, assumptions and opinions.
• Reframe the issues so that they relate directly to the practice’s business.
• Respect their learning and creating headspace and a learning environment.
• Secure pace and spread through Communities of Practice.
• Work with the top of the system to generate accountability for the issues that reside at the whole system level.
• Walk practices through their challenges, depersonalising and de-externalising them.

The Development Team needs these skills

Specific Skills:

1. Systems Thinking and Practice: the practice is a system and it operates within a system. You need a team member who understands power in systems, how systems adapt and how best to intervene in systems. At minimum clear about Tame and Wicked issues and can help any team clarify these (Grint), Adaptive Leadership (Heifetz) and Power in systems (Oshry).
2. Adult learning, including collaborative learning e.g. experience in Communities of Practice (Wenger) and rigour in these methods.
3. Quality Improvement – Detailed knowledge of and experience in applying: Deming’s System of Profound Knowledge, Flow, Failure Demand, Mapping the system (providing a system map), Quality and Safety. See following section.
4. Coproduction – experience of the full process of coproduction from co-discover, to co-design to co-deliver to co-evaluate. Co-design is not coproduction, and your team member(s) need to know the difference between Voice, Choice and Coproduction 
5. Collaborative Communities – we work with Altogether Better as our partners in supporting Collaborative Communities. We haven’t found anyone who is as good as they are.
6. Group Dynamics, Peer Leadership and Governance Facilitation – There are times when the owners primarily GP partners need in depth specific work on their group dynamics, how they manage power, how they take responsibility, how they make collective decisions. This is different from the day to day work we do with the practice as a whole to work as a team. This requires skills and training in basic group dynamics.
7. Data for Quality – a team able to focus on the key facts that will disturb the system, ways of presenting data that provoke thinking and learning, and an ability not to get sucked into perpetual analysis. Analysis is attractive because if means you don’t have to act. The data team need to know at what point to expect the PC team to act. The data team has to be able to facilitate the PC team to get to the heart of the issue and then provide or support the practice to provide the data that helps answer their questions. Dashboards are not helpful. Specific data relating to specific questions that get to the heart of the practices understanding of need and flow are critical. Being able to present their clearly to complete data novices is essential. Finally they need to be able to help the practices identify and generate metrics to help them understand the impact of their changes and to be able to evaluate the usefulness of the PCQA.
8. Great admin! Even better great admin that knows how to relate to professionals and can form good relationships with the practices and the practice admin.
9. Project management – to keep track on progress and impact.
10. Evaluation –skills in evaluating the whole using qualitative and quantitative data (and time to do it!)

Nick Downham, Tony Hufflet and Becky Malby