As part of the GMS contract for 2019/20 a new 'Quality Improvement' domain has been introduced which includes 'Prescribing safety'.
QI001. The contractor can demonstrate continuous quality improvement activity focused upon prescribing safety as specified in the QOF guidance.
QI002. The contractor has participated in network activity to regularly share and discuss learning from quality improvement activity as specified in the QOF guidance. This would usually include participating in a minimum of two peer review meetings.
Practices will need to:
- Evaluate the current quality of their prescribing safety and identify areas for improvement – this would usually include a baseline assessment of current prescribing (QI001)
- Identify quality improvement activities and set improvement goals to improve performance in the three identified areas – see below (QI001)
- Implement the improvement plan (QI001)
- Participate in a minimum of 2 network peer review meetings (QI002)
- Complete the quality improvement monitoring template in relation to this module (QI001 + QI002)
How to do a prescribing audit
A prescribing audit is considered to have five steps:
- Choose a relevant topic (such as NSAID prescribing)
- Derive some standards from good quality guidelines (e.g. NICE)
- Measure your prescribing practice (through searches in the clinical system) and compare how you do against your chosen standards
- Plan any actions needed to make improvements or sustain good practice and implement them, setting clear goals to achieve
- Repeat the measurement of your prescribing practice against the standards to assess the impact of the changes you have made. Continue repeated cycles of these steps as you judge necessary
Practices are required to complete the quality improvement monitoring template in relation to prescribing safety and self-declare that they have completed the activity described in their quality improvement plan. Practices will also need to self-declare that they have attended a minimum of two peer review meetings. The quality improvement monitoring template is available to download here.
Three identified areas
All practices should undertake an audit of the current quality of their prescribing in relation to NSAIDs, Valproate and Lithium. Where practices do not have any patients being prescribed lithium they may select an alternative medication to focus on Eg the appropriate monitoring of amiodarone or methotrexate. Even if a practice does not have any girls of any age or women of childbearing potential who are currently prescribed valproate, they should ensure their practice has a robust system in place to identify and refer for annual specialist review any new at-risk patients being prescribed valproate and should ensure continuous measurement of this measure.
Ardens has a number of reports to assist in reviewing female patients of childbearing potential on Valproate. These reports can be accessed in 'Clinical Reporting > Ardens > Prescribing | Alerts > Womens Health'. Along side the reports, Ardens has a Valproate monitoring template and patient status alert to highlight patients requiring review. Further information about the Ardens 'Valproate' resources can be found here.
Clear actions have been set for general practices to identify and recall existing patients, provide them with a copy of the Patient Guide, to check they have had a specialist review in the last year and to have systems in place to identify and appropriately manage new patients who are prescribed valproate and are of child bearing potential.
The pregnancy prevention programme requires GPs to:
- Ensure continuous use of highly effective contraception in all women of childbearing potential (consider the need for pregnancy testing if not a highly effective method).
- Check that all patients have an up to date, signed, Annual Risk Acknowledgment Form each time a repeat prescription is issued.
- Ensure the patient is referred back to the specialist for review, annually. • Refer back to the specialist urgently (within days) in case of unplanned pregnancy; or
- where a patient wants to plan a pregnancy.
The practices can use Ardens reports to identify at risk patients and ensure timely recall for clinical review in line with the MHRA alert. Such continuous measurement can be used to demonstrate compliance with the MHRA alert. The QOF quality improvement programme offers general practice a further opportunity to ensure these actions have been completed and that ongoing systems to protect patients from harm have been put in place.
Ardens has a number of resources available to review patients prescribed Lithium. There are reports to identify patients who have outstanding monitoring which can be accessed in 'Clinical Reporting > Ardens > Prescribing | Alerts > Mental health'. Along side the reports, Ardens has a Lithium monitoring template and patient status alert to highlight patients requiring review. Further information about the Ardens 'Lithium' resources can be found here.
Using Ardens searches practice will be able to identify individual patients prescribed lithium who are not being managed in line with NICE guidance. Practices are encouraged to review their process for following up a person who has not responded to invitations for monitoring or fails to order or collect prescriptions to ensure concordance with treatment plans and avoid clinical deterioration and crisis. Practices can use the quality improvement approach to ensure their processes for lithium monitoring are robust and comply with NICE guidance and take action to identify and reduce any risks to individual patients. Ardens has a robust drug motioning process which includes Lithium, find out more here.
Ardens has a number of resources available to review patients prescribed NSAIDs. There are reports to identify patients prescribed NSAIDs with a potential contraindication, or without appropriate gastroprotection which can be accessed in 'Clinical Reporting > Ardens > Prescribing | Alerts > NSAIDs and Paracetamol'. Along side the reports, Ardens has a NSAID monitoring template and patient status alert to highlight patients requiring review. Further information about the Ardens 'NSAID' resources can be found here.
Examples of the audit standards which practices could adopt are:
- No patients with a current clinical contraindication are currently being prescribed an NSAID medication.
- 100% of patients with an NSAID medication on regularly receiving a repeat prescription have had a documented clinical safety risk review in the last 12 months.
- 100% of patients identified as high risk and requiring ongoing treatment have been prescribed a selective NSAID.
- 100% of patients identified as moderate risk and requiring ongoing treatment have been prescribed an appropriate NSAID with proton pump inhibitor unless contraindicated.