The National Standards for Safer, Better Healthcare (NSSBH) were announced by the Health Information and Quality Authority (HIQA) in June 2012. These standards are aimed at promoting a culture of safety and quality in all healthcare facilities and placing the patient at the centre of healthcare provision. It is anticipated that in future they will be linked to a licensing system for all healthcare providers, including GPs.
Irish GPs and the College support continuous quality improvement in general practice and have been active participants in the maintenance of standards through the professional competence scheme (PCS) and in meeting health and safety regulations. If the HIQA process can be shown to improve quality of service for patients while keeping the associated bureaucratic load under control, then it is something that GPs would support, ICGP medical director Margaret O’Riordan points out.
However, she says GPs have been expressing concerns about the prospect of being assessed on yet another set of quality and safety rules.
“Up front and central to the application of these standards must be a clear understanding of the resource and time implications for their implementation in a time of economic recession. General practice has endured a severe drop in income coupled with an increase in workload over the past few years. Therefore the last thing any GP wants to hear is the advent of more regulation and more paperwork to demonstrate compliance with these new standards.
“There will still be resources needed to put time aside in the practice to document compliance with the regulations, so these resources should be included in any new contract negotiations,” Dr O’Riordan stresses.
The application of the NSSBH will involve HIQA checking whether individual GP practices are meeting these standards. The date for commencement of the inspection regime in general practice is not known but it may commence from 2016 onwards and this is where many GPs are concerned about ‘audit overload’.
Taking account of the realities of general practice
GPs, already subject to the rigours of PCS requirements and health and safety rules, and hard pressed by increasing practice workload, are concerned that the new HIQA process will be non-pragmatic and over-prescriptive, and will not take sufficient account of the realities of general practice in Ireland.
Many GPs who are attached to nursing homes say they have had negative experiences of what they feel was the over-bureaucratic and unrealistic application of HIQA standards to these care facilities. However, the message from the College in relation to the planned HIQA inspection regime is that help is at hand.
Managing HIQA process
According to Margaret O’Riordan, there are three reasons why the new HIQA process can be managed in a realistic manner in general practice.
Firstly, she says, the College has been doing extensive preparatory work through a working group chaired by Dr John Delap to translate the standards as they would apply to general practice and in doing so, has developed specific tools to support GPs through the new process.
The working group was established in 2013 and included College members, the IMO, the HSE and patient representatives. Practice nurses and practice managers were also consulted. Within College, Dr O’Riordan, along with Dr Andree Rochfort and Jantze Cotter have been working to provide GPs with the resources they will need to work with the NSSBH regime, when it comes in.
The College is providing GPs with detailed ‘how-to’ resources in relation to the various standards and how they can apply them to practices (see Tables 1,2,3).
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A dedicated web page for members has been set up for this purpose: www.icgp.ie/NationalStandards (only accessible through log in with an ICGP member ID and pin)
Secondly, according to Dr O’Riordan, the vast majority of GPs will already be meeting most of the quality standards outlined by HIQA (see www.hiqa.ie), through the PCS system, health and safety rules, and employment legislation, and this is likely to be taken into account in the HIQA process.
A degree of overlap
“There would be a fair degree of overlap between what most GPs are already doing and documenting under existing regulatory systems, and the new HIQA process. So yes, there will be some extra work involved, but we would hope that it will not be too onerous, given that GPs will in many ways be documenting what they are already doing.
“So what we are saying to GPs is, you are doing most of this already. If you’re not, some of it you should be doing anyway through health and safety, employment legislation and the PCS. So for example, there is no reason why many of your documented practice meetings and yearly audits which qualify for internal points on your PCS will not meet the HIQA standards as well.”
Thirdly, from soundings made through meetings with HIQA, the College feels that a pragmatic approach is likely to be taken to the mechanics of the new HIQA standards regime. The ICGP working group would like to see self-assessment and self-audit by GPs as a practical approach, backed up by random checks, being its modus operandi, as has been the case with the Medical Council’s oversight of the PCS scheme.
HIQA, she says, is more than likely to adopt this approach as it would be both effective in terms of monitoring quality standards, and pragmatic too, when faced with the alternative prospect of having to separately inspect 1,600 GP practice centres nationally.
“While obviously, the HIQA regime will have workload implications for GPs, it’s unlikely that the majority of GPs will have too much to be concerned about. The College, and it is hoped HIQA, will be approaching this process as very much a quality improvement scheme and not a ‘pass-fail’ situation. The approach is expected to be supportive rather than punitive, as is the case with the PCS at the moment. This would mean that doctors will be facilitated and given a good opportunity to ensure that they are meeting any HIQA standards they may not be already be adhering to.”
No one size fits all
“An important thing to note is that there can be no ‘one size fits all’ when it comes to applying the standards”, Dr O’Riordan stresses.
“For example, the standards regime will require practices to have a patient safety statement. It won’t be just a question of taking the sample health and safety statement as supplied by the College and say ‘this is our practice statement’. You would have to take it and adapt it to your particular practice, depending on its location, building infrastructure etc. In many instances the necessary changes to the wording of the statement will be small yet indicative that the contents have been modified to meet individual practice needs.
“The important thing will be for GPs to adapt the NSSBH rules to their own practice situation. There is a good deal of flexibility here. As long as this has been done satisfactorily and in accordance with the principles behind the standards, GPs should have nothing to worry about.
“Another important thing to state is that HIQA will not be using the same criteria for GP practices they might apply to nursing homes or hospitals, which are totally different environments, in that they are where people are usually residing and/or being treated on a long-term basis. HIQA will be focusing on different things to some extent with GP practices. So for example, they are unlikely to be focusing on the furniture in your practice or that the curtains are a bit worn.
It’s about processes rather than physical surroundings
“In workshops we have been holding on the HIQA criteria, many GPs have had the impression that HIQA checks will be, among other things, about your chairs, carpets and curtains or whether your waiting room is of a minimum size, resulting in you having to replace your practice furniture, fixtures and fittings or do extensions.
“In fact”, Margaret says, ”it will be a lot more about processes, rather than physical surroundings; for example, listening to patient feedback, evidence that you are delivering a quality service. While obviously there will be a certain level expected in relation to such things as disabled access, lighting, and basic infrastructural standards (these would in any case be more than likely covered by existing Health and Safety requirements), these are unlikely to be the main focus of HIQA checks.
“We don’t know exactly when the NSSBH regime is going to be implemented; we have been told 2016, but this may not be written in stone. However, we could well be given short notice for the implementation of the inspection regime when the time comes, so it is best for us all to be prepared.
“We have been talking to HIQA throughout the process of drawing up guidelines for GPs, and a HIQA representative has attended some meetings of the working group. The feedback is that we are going in the right direction in terms of the advice we are giving to GPs and that HIQA is happy with the way we are interpreting the thrust of the standards regime.
“So what we are saying to GPs is, you are going to be doing most of this stuff already. If you’re not, some of it you should be doing anyway through health and safety, employment legislation and the PCS.
“It’s important to state too that the guidance we are giving to GPs on implementing the standards would have in mind a single-handed practitioner, whose practice resources would by their nature be more limited than those of a large primary care centre. So our message is, if a single-handed GP can do it, then a larger practice certainly can,” Dr O’Riordan stresses.
“Our role is in supporting College members in meeting these standards. All GPs are interested in quality and safety when it comes to patient care. In implementing the standards, our attitude is that if it is kept simple, and brought down to the level of the individual practising GP, rather than it being a ‘tick-box’ bureaucratic exercise, this system will work really well for all concerned: HIQA, GPs and patients, with the minimum of difficulty and stress.”
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