NOE & QIA – intro

NATURALLY OCCURRING WHAT?  ISN’T THAT EARTHQUAKES AND STUFF?

No… that’s naturally occurring phenomena.

  • Naturally Occurring Evidence (NOE) NOE is a term for things which occur ‘naturally’ during the course of a GP’s professional working life which demonstrate your commitment to improving the care one gives to patients and enhancing their safety.  A subset of Naturally Occurring Evidence is Quality Improvement Activity.   
  • Quality Improvement Activity (QIA) The GMC definition of Quality Improvement Activity is any activity that is relevant to your work which includes an element of evaluation and action, and where possible, a demonstration of an outcome or change.  These activities should be robust and systematic.

IS NOE/QIA MANDATORY? (click to open me)

IS NOE/QIA MANDATORY?

No, neither is mandatory.   However, Yorkshire & the Humber Deanery take the stance that you should be strongly encouraged to do  some NOE/QIA type activities.   ARCP panel will take into account the presence or absence of NOE/QIA activities when formulating your ARCP outcome.

IF IT IS NOT MANDATORY WHY ARE WE STRONGLY ENCOURAGED TO DO IT?

IF IT IS NOT MANDATORY WHY ARE WE STRONGLY ENCOURAGED TO DO IT?

NOE/QIA provides easy evidence for key competencies like

  • 07  Primary Care administration and IMT 
    Which is “about the appropriate use of primary care administration systems effective record keeping and information technology for the benefit of patient care’. So getting data out and using this to improve care through audit is clearly part of this competency domain.
  • 08 Working with colleagues and in teams 
    For example, audit is not just about collecting the data and analysing this (which may well involve several other members of the team); it is also about looking for ways to persuade people to change their traditional approaches and improve care … or “working effectively with other professionals to ensure patient care…”
  • 09 Community Orientation
    Most NOE/QIA activities involve moving away from caring for the patient immediately in front of the GP and looking at “the management of the health and social care of the practice population…” This is a core part of the definition of Community Orientation.
  • 10 Maintaining performance, learning and teaching 
    There are several parts of the word pictures used to describe this competence which particularly address the audit/ project… “investigates personal performance”… and “evaluates the process of learning so as to make future learning cycles more effective.”

The more difficult competencies (like Community Orientation and Maintaining Performance, Learning & Teaching) are often difficult to provide evidence for elsewhere.   The more Naturally Occurring Evidence that you can record in your ePortfolio, the more evidence you will gather to demonstrate your proficiency in these competencies.

QIA is all about improving patient safety and improving the quality of the care that you provide.  All qualified GPs have to engage in QIA for their appraisal (currently, they have to provide atleast 3 types of QIA in 5 years PLUS 10 SEAs too!).  Therefore, following  on from this, we expect trainees to engage in QIA and the evidence for it needs to be readily available in their ePortfolio.  Can you see how it will help you with your appraisal when you qualify as a GP?  Can you see how it might be best to start getting familiar with it now?

NOE/QIA: SO, WHAT SORTS OF THINGS AM I EXPECTED TO DO & HOW MANY?

NOE/QIA: SO, WHAT SORTS OF THINGS AM I EXPECTED TO DO & HOW MANY?

Do whatever interests you!   But as a MINIMUM, we would suggest

  • 1 x Significant Event every 6 months.
  • 1 x Audit or Project throughout your training period.
  • 1 x Reflection On Your Post every  6 months.
  • 1 x Case Presentation or any Presentation every 6 months – either to the scheme, your hospital department or your training practice.

A LIST OF QIA/NOE ACTIVITIES

A LIST OF QIA/NOE ACTIVITIES

You don’t have to do everything on this list.  Pick a few that generate an interest.  This is an opportunity for you to play with them with some support from your trainer.  Grab the opportunity!

  • Audit
    The Audit Cycle measures the quality of care we provide to our patients.  Most trainees go for an audit of some sort of clinical area.  For instance, the control or warfarin, LFTs being checked post stating, or exercise instead of NSAIDs for tennis elbow.  But it needn’t be.  For instance, you could do an audit of ‘the doctor’s bag’ or the comprehensiveness of patient details on blood result forms etc.  Think laterally and be creative.  (By the way, other common examples of audit relate to minor surgery, cervical smears, monitoring of DMARDs, end of life care, cancer diagnosis, referrals and admissions, hypertension management, leg ulcer care, investigations and imaging).
  • Review of Clinical Outcomes
    This could include a review of QoF data, commissioning information, minor surgery data, morbidity/mortality data, review of outcomes of acute admissions, quality of record keeping, review of telephone triage outcomes.
  • Significant Event Analysis
    Significant events area certainty in all of our working lives.  Things will occasionally go wrong.  It’s important not to brush these off but to study them and learn from them.  These don’t need to be serious events – but even near misses that could have potentially had a really adverse outcome.  We need to put measures into place to stop their likelihood of recurrence.
  • Clinical Case Study/Notes Review/Case Discussion
    This is where you engage your peers/multidisciplinary team in a review of an interesting or challenging case – usually to understand a topic more generally.  You might focus on a clinical area – like an unusual presentation of chest pain (reminding us all about being ‘broad minded’) or it might focus on medication (e.g. patient who was tried on several migraine treatments – to help illustrate perhaps a structured management approach) or you might focus on something totally different (like care pathways or organisations).
  • Random Case Analysis
    Engaging in a dialogue with one of your peers – looking at one of your surgeries, and picking some patients at random – to explore what you have done well, what could have been better and determine future learning needs.  More resources on Random Case Analyses – click here.
  • Child & Adult Protection training
  • It is a GMC mandatory requirement for qualified GPs to engage in level 3 training every 3 years.   Trainees should engage too (at least to level 2)  - it will become an eventual requirement anyway – best engage now.
  • Referrals Analysis
    Some GPs over-refer, others under-refer.  Where do you lie on this scale?  You can even pick one area to look at – like musculoskeletal medicine referrals.
  • Investigations Analysis
    Some GPs over-investigate, others under-investigate.  Where do you lie on this scale?  Again, you can even pick one area to look at –xrays or CT scans for instance.
  • Prescribing Analysis
    It is good to review your own prescribing behaviour – for instance, how often you resort to antibiotics or NSAIDS … the list is endless.
  • Discussion paper
    For instance, reviewing the most cost-efficient method of managing a condition.
  • A literature review
    To formulate and evidence-based approach to managing a condition based on a review of the literature out there.
  • Questionnaire
    This needn’t be something worthy of publication (unless you want to).  It’s okay to keep things simple – for instance, a questionnaire to see what patients think of the GP locums the practice employs or something more clinical like patient choice in contraception.
  • Research Study
    If your practice is already involved in the GP based research – then think about getting involved.
  • New Service Development & Implementation
    This doesn’t have to be a new clinic.  For example, it could be a new screening programme (eg for vit D deficiency).
  • Complaints Review
    A write up of your complaints, a thorough analysis of them, and key learning points.
  • Reflection on your post/job
    To show what you have learnt, highlight remaining (and new) needs and thus help with your continuing personal & professional development plan.

Here are two great documents which give more advice about some of the above activities and provide templates and suggestions.

  1. Northern Deanery document for Sessional GPs
  2. Somerset LMC document for Locum GPs

WHAT IMPORTANT ADVICE CAN YOU GIVE ME TO HELP ME WITH MY QIA/NOE ACTIVITY?

WHAT IMPORTANT ADVICE CAN YOU GIVE ME TO HELP ME WITH MY QIA/NOE ACTIVITY?

Whatever activity you choose to do, it must…

  • Be relevant to your work
  • Show personal involvement (not the work of others)
  • Involves evaluation of current practice
  • Results in an outcome or some sort of change.

and try and pick something that

  • interests you rather than what the practice wants you to do.  Pick something that ‘lights your fire’.
  • has relevance and applicabiltiy.  In other words, something worthwhile doing because it will make a difference, rather than something  that is merely interesting.

SPECIFIC ADVICE

  • For Audits & Projects (like research, questionnaires, literature reviews, case discussions, discussion papers and so on), click here
  • For Significant Event Analysis: click here
  • For Referral Analysis: click here

ARE THERE ANY EXAMPLES OF ALL THESE DIFFERENT TYPES OF NOE/QIA THINGS?

ARE THERE ANY EXAMPLES OF ALL THESE DIFFERENT TYPES OF NOE/QIA THINGS?

WHAT COMPETENCIES DO THESE QIA/NOE ACTIVITIES COVER?

 WHAT COMPETENCIES DO THESE QIA/NOE ACTIVITIES COVER?

What you can link your QIA/NOE activity to depends on the nature of the event.

Most Audits and Projects provide easy evidence for the following competencies:

  • 07  Primary Care administration and IMT
    Which is “about the appropriate use of primary care administration systems effective record keeping and information technology for the benefit of patient care’. So getting data out and using this to improve care through audit is clearly part of this competency domain.
  • 08 Working with colleagues and in teams
    For example, audit is not just about collecting the data and analysing this (which may well involve several other members of the team); it is also about looking for ways to persuade people to change their traditional approaches and improve care … or “working effectively with other professionals to ensure patient care…”
  • 09 Community Orientation
    Most NOE/QIA activities involve moving away from caring for the patient immediately in front of the GP and looking at “the management of the health and social care of the practice population…” This is a core part of the definition of Community Orientation.
  • 10 Maintaining performance, learning and teaching
    There are several parts of the word pictures used to describe this competence which particularly address the audit/ project… “investigates personal performance”… and “evaluates the process of learning so as to make future learning cycles more effective.”

In addition, the audit should include an evidence-based rationale for why it was conducted and how the standards were set. Doing this automatically provides evidence for tricky sections of Competence domain 10 that deal with accessing the evidence, using critical appraisal skills and often, keeping abreast of contemporary medical issues.

Significant Events

  • 8 Working with colleagues and in teams
    SEAs provide an opportunity to work with your colleagues to make things better.  Talking together to improve systems for instance.  Working out together the multiple factors that led to the SEA.  Events that relate to teamworking.
  • 10 Maintaining performance, learning and teaching
    SEA is particularly good evidence for this domain, because it allows trainees to show reflection on performance and subsequent improvement, which is the heart of what this domain is about.
  • 12 Fitness to practice
    If the SEA includes discussion about the performance of those involved in the event, including the trainee
  • 11 Maintaining an ethical approach
    The SEA discussion provides an opportunity for the feelings of those involved to be aired. For example, the values, beliefs, prejudices and ethical approaches of those involved might be discussed and reflection on this (anonymised) can provide evidence for this domain.

Very often SEAs provide a good example of several competencies being demonstrated together and may highlight the way to development in others.  Because the SEAs chosen are often clinical it is likely that these will cover especially the first 6 competencies , and should provide the ES and the ARCP panel with a short cut to displays of effective reflective learning on several competencies.

REFLECTION ON THE POST

  • Please file your entry for this under Courses & Certificates.
  • The trainee should look at the important issue of self-care and work-life balance (Competency domain 12- Fitness to practice).
  • The core of the reflection on post will provide significant evidence around Competence domain 10 (Maintaining performance, learning and teaching) by encouraging the GPSTR to look at what has been learnt, and what remains to be learnt from the post that is finishing and starting to plan for learning in the next post. (thus encouraging appropriate PDP entries)
  • The reflection should look at the hospital posts and reflect on the learning that is relevant to GP… which will include a Community Orientation aspect (competency domain 9) by detailing how the resources encountered in the post can be accessed/used by GPs.

CASE STUDY/PRESENTATION

  • Please file your case study or presentation under Lecture/Seminar in your ePortfolio.
  • The case study/presentation mainly covers competency domain 10: Learning and teaching.  It is important to ensure that the GMC expectation that doctors are involved in teaching is included and completion of all the word pictures in this competency domain requires demonstration of teaching and learning from that teaching. (“identifies learning objectives and uses teaching methods appropriate to these” and “assists in making assessments of learners” ).  So the process of reflecting and writing up the case study/presentation is evidence for primarily competency domain 10… though the content of the presentation may also address other competencies.
  • Question from a recent Trainer: Does the presentation have to be at Half-Day Release to peers?  Can it be to members of our PHCT?  Can it even be a presentation to our medical students?   Answer: To answer this question, one has to think about the purpose of the presentation. The purpose behind the presentation is to help the trainee acquire some teaching and planning skills.   Therefore, a presentation to any of these groups (including medical students) is simply fine.  But the GP trainee should have given some thought to it rather than a quick and dirty presentation. In other words: a) identifying the audience’s learning needs b) setting some aims and objectives c) thinking about the method of delivery/presentation and if they’re super duper trainees d) evaluating the session.

COMPLAINTS AND SIGNIFICANT UNTOWARD INCIDENTS (SUIs)

  • Please detail these in the Form R.   You should also write a reflective piece about it in your learning log – in particular, what have you learnt.
  • Declaring the absence or demonstrating an appropriate response to complaints is a professional expectation (and so relates to domain 12 – Fitness to practice).
  • Complaints are significant events and as such also relate to domain 10 – Maintaining performance, learning and teaching.
  • Which other competencies are involved will depend on the nature of the complaint made.  Statistically complaints are likely to relate to Communication (domain 1), Practicing holistically (domain 2) and to domain 8 (Working with colleagues and in teams) but there may well be elements of Clinical management (5) and of course the Data gathering (3) element is often central to establishing what happened… were the notes adequately detailed?