The Primary Care Respiratory Society-UK Quality Award: development and piloting of quality standards for primary care respiratory medicine

Abstract

In an attempt to improve the standards of primary respiratory care in the UK, the Primary Care Respiratory Society-UK (PCRS-UK), in conjunction with other leading respiratory-interested health professional and patient groups, has devised a General Practice Quality Award for Respiratory Medicine. The Award is divided into three modules separated into a total of seven clinical standards (in parentheses): ‘Clinical’ (prevention, early and accurate diagnosis, acute care, chronic care); ‘Organisational’ (equipment); and ‘The Practice Team’ (practice learning needs, educational strategy). Assessment is by submission of a written portfolio of 37 pieces of evidence including audit, reflective learning, patient feedback, and significant event analyses. The Award was piloted in five respiratory-interested practices across the UK. The practices reported improvements in practice organisation, practice teamwork, improved process measures such as improvement in quality of spirometry, and improved patient access to patient services. All practices in the UK are being invited to apply for the Award in 2013. It is hoped that it will provide a framework and stimulus for provision of high-quality primary respiratory care, not only in the UK, but also some aspects of the Award may be applicable on a wider international scale.

Background

Against a global background of rising healthcare demands and constrained healthcare funding, it is imperative that the quality of healthcare provision is not diluted. In the UK the provision of high-quality medical care has become a pivotal part of government health policy via the Quality, Improvement, Productivity and Prevention (QIPP) agenda¹ and the National Health Service (NHS) Outcomes Framework 2010.² The Department of Health (DH) Outcomes Strategy for People with COPD and Asthma³ and its companion document⁴ outline the aspirations for high-quality care in chronic obstructive pulmonary disease (COPD) and asthma. There is, however, evidence of suboptimal care including substantial variation in standards in COPD care across England,⁵ variation in the quality of primary care spirometry,⁶ and deficiencies in the assessment of the acute asthma attack.⁷

With this background in mind, a meeting of respiratory-interested patient and health professional organisations led by the Primary Care Respiratory Society-UK (PCRS-UK) met in 2009 to discuss how to raise the quality of primary respiratory care. The decision was made to develop a Quality Award which would set out the standards that best define high-quality primary respiratory care and reward practices that met these standards (Box 1).

Box 1: Aim of the PCRS-UK Practice Quality Award

To set out the standards that best define high quality respiratory care in primary care, providing:

• Recognition of practices delivering a high standard of respiratory care

• A quality assurance mark for patients, commissioning groups and the wider NHS

• A developmental framework that can be used at practice, locality and national levels to promote, support and reward quality respiratory care in the primary care setting

Development process

The Award design was devised and the development of the Award overseen by a multidisciplinary steering group composed of members from respiratory-interested health professionals and patient organisations (see Appendix 1, available online at www.thepcrj.org).

The Quality Standards were initially developed by a multidisciplinary Module Development Group (see Appendix 2, available online at www.thepcrj.org). This group drew upon national respiratory guidelines to produce an initial set of standards and evidence requirements.^3,8–13 This initial set was modified by a larger group using the following criteria: whether the standards were truly evidence-based; were practical and deliverable; were generalisable across a UK primary care population; and whether they were evaluable. The number of items of evidence was further reduced after consultation with seven primary care practices varying in size, geography, and socio-economics across the spectrum of UK general practice using the same criteria.

Design and scope of the Award

The Award has been partly based on the generic Royal College of General Practitioners Quality Practice Award (QPA)¹⁴ which assesses quality of care across a wide range of disease areas managed in general practice. QPA involves submission of a written portfolio of evidence across several modules, concentrating mainly on practice organisation.

The PCRS-UK Award is divided into three modules: ‘Clinical’, ‘Organisation’, and ‘The Practice Team’. These are subdivided into seven standards as shown in Box 2.

The clinical standards are mainly centred on the disease areas of asthma and COPD, but examples of good practice in other areas of respiratory medicine can be submitted. The format of the standards has been modelled on that used by Health Improvement Scotland in their Asthma and COPD Services Clinical Standards.^12,13 Each standard has a headline statement (e.g. “People listed on the asthma and COPD registers are offered regular structured review of their condition”), followed by the rationale for the statement and finally the evidence required to meet that standard. The full quality standards are shown in Figure 1.

Figure 1

Quality standards

Practices are asked to submit 37 pieces of written evidence within a 6-month period to the PCRS-UK assessors comprising audits, protocols, significant event analyses, patient case histories, and examples of reflective learning. Assessment of the written portfolio is carried out by two trained independent assessors drawn from the stakeholder organisations. A practice is required to provide all the evidence that it meets these standards in order to gain the PCRS-UK Quality Award.

Box 2: Modules and Standards of the Quality Award

• Clinical

  • Prevention

  • Early and accurate diagnosis

  • Acute care

  • Chronic care

• Organisational

  • Equipment

• The Practice Team

  • Practice learning needs

  • Educational strategy

Piloting of the Award

The Award was initially piloted in 2011 in five respiratory-interested practices in England and Scotland to establish whether working for the Award was feasible and to iron out any practical problems.

All phase 1 pilot practices successfully gained the Award. The practices reported that working for the Award had led to numerous improvements in practice organisation, varying from updating outdated protocols to actively involving all members of the practice team rather than respiratory care being carried out by one or two individuals.

As a result of the audit, there were significant improvements in some practices in the quality of spirometry, increased influenza vaccination uptake, and improved review of patients after hospital admission for acute COPD and asthma. The improvements were largely confined to process outcomes such as improved quality of care rather than outcome measures such as reduction in hospital admissions and exacerbations which were not recorded in this pilot phase. However, examples of tangible benefits from patients included improved access to surgery appointments for school children with asthma and improved access to smoking cessation services.

We also analysed qualitative feedback from these practices. Although practices acknowledged the need for extra time to complete the Award, feedback has been positive with comments such as “It has given us the opportunity to take time to really look at our respiratory service in detail … and we're doing a good job” and “It was a motivating process and helped us engage the whole team”.

The experience and feedback of the five pilot practices demonstrated that the PCRS-UK Quality Award is an important developmental opportunity for the whole practice and does drive improvements in care, even in high performing practices.

Following this initial pilot phase, minor adjustments to the original evidence requirements (such as examples of patient feedback questionnaires, suggested surveys and audits, and a more detailed practice profile) were made to the Award, which is being tested further in pilot phase 2.

Discussion

Improvement in the quality of provision of healthcare has been a major priority in the UK and many healthcare systems throughout the world. The development and implementation of a Quality Award was seen by the stakeholder organisations as a method of incorporating the key elements of quality care improvement using Wagner's Chronic Care Model¹⁵ (improved organisation, improved health professional clinical care using education, and peer review) into a quality improvement method award that would be achievable in a wide range of primary care practices and raise standards of care.

Although quality awards have been used to improve healthcare for several years, the evidence base for their efficacy is not large. The European Foundation for Quality Management¹⁶ has devised a model of healthcare quality improvement and Quality Award which has been adopted by many healthcare organisations in the Netherlands and Germany. However, a systematic review of performance based on this model showed only weak evidence of improvements.¹⁷ Surprisingly, there has only been limited evaluation of the UK Royal College of General Practitioners QPA which mainly focused on general practice organisation.⁴ A postal questionnaire sent to practices that had completed the QPA stated that there was an improvement in practice teamwork.¹⁸ In view of this limited evidence, it is important that this Respiratory Practice Award is properly evaluated when it is rolled out beyond the pilot stage.

The development of the PCRS-UK Quality Award involved the successful co-operation of respiratory-interested multi-professional and patient groups. During the iterative process the initial number of pieces of evidence required was reduced to minimise practice workload, and an important section added to include patient experience and practice feedback.

The feedback from the pilot practices suggested that there was a significant amount of work involved in collating the evidence needed for the Award. However, the impact of this increased workload could be greatly reduced by sharing the evidence submission with other members of the primary healthcare team. In return, there were tangible gains with regard to improved teamwork, patient access, and raised process standards (see “Piloting of the Award” section). This should be tempered by the fact that the pilot 1 practices were already respiratory-interested organisations. In addition, questions remain about long-term sustainability of the Award — for example, will improvements be maintained if key personnel leave the practice and will short-term process improvements translate into longer-term outcome benefits such as reduced patient admissions or improved patient quality of life?

It is planned to make the fully functional PCRS-UK Quality Award available to all general practices in the UK in 2013. As the Award is rolled out to a wider range of practices, there is a need to train more assessors. This is being met by training both lay and health professional assessors. A major challenge will be to encourage practices to apply for the Award. One possibility is to encourage groups of practices (e.g. Clinical Commissioning Groups in England) to apply for the Award to meet the UK Government's QIPP agenda using national or local financial incentives. Another possibility is to make individual modules available either as a precursor to carrying out the whole Award or as a quality improvement tool in its own right. Although developed for the UK, the standards would fit with most developed healthcare systems that rely on primary care for the diagnosis, treatment, and management of long-term conditions. It is acknowledged that some of the individual pieces of evidence might need to be changed to reflect local practice, although significant event analyses, reflection on multidisciplinary working, and completed audits are universally applicable.

Conclusions

The PCRS-UK Quality Award has been developed in conjunction with major professional and patient respiratory organisations in the UK. It offers a possible tool to provide a developmental framework that can be used at the practice, locality, and national level to promote high-quality respiratory medicine in primary care.

Further details of the Award can be found on the PCRS-UK website (http://www.pcrs-uk.org/pcrs-uk-quality-award).