2. Quality improvement activities QIA

NASGP AppraisalAidThe GMC requires that you “demonstrate that you regularly participate in activities that review and evaluate the quality of your work.”

Until recently, audit seemed to be seen as the gold standard appraisal quality improvement activity (QIA). Audit is a great tool for those with managerial responsibility to evaluate processes of care, spot weaknesses and implement organisational change. For those with no practice managerial role, such as locum GPs and some salaried GPs, full-cycle audit with retrospective data collection is not only a logistical challenge, it is also less meaningful as we are restricted in our ability to affect change across an organisation.

Happily, in its latest guidance, the RCGP has recognises the heterogeneity of GPs. Audit is still on the menu for those GPs for whom it is possible and relevant, but audit is no longer the supreme QIA for all GPs.

Alternative appraisal QIA quality improvement activities

So the door is open for sessional GPs to devise QIAs that are relevant to our diverse working lives.

The NASGP has pulled together ideas and resources based on the RCGP guidance and our own experience as sessional GPs undergoing appraisal, including Google Drive versions of the templates too.

It is by no means a definitive list. There are probably as many great ideas for QIAs as there are sessional GPs, and it would be of enormous value to us all (and our patients) if members of the NASGP community could share examples of QIAs that you have successfully submitted at appraisal. You’ll show you’re “working with colleagues”, and further improving quality by spreading best practice!


This template leads you through the process of carrying out a review of any chosen condition, with helpful tips of what to record along the way.

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Relatively simple to capture, generating great material for your appraisal and often acting as a springboard for other CPD and QIA activities, this template gives you a framework for recording one of your "typical" surgeries and adding comments from discussions with a suitable colleague.

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Another great meaningful activity for locums, if you struggle with what's meant by reflection, this template takes you through the steps of reflecting on a case of interest. You're probably already constantly "reflecting" as a natural part of being a GP - this just leads you through recording it in a format that will please your appraiser.

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Do your referral letters contain the necessary information in an accessible format that will allow for a smooth, timely referral experience for your patients?

This template consists of a 10 point scoring system of items that characterise a quality referral letter to allow you to grade the quality of your referral letters. It includes a framework to record a first round data collection and then a follow up second round data collection to review your progress. A great QIA to carry out on your own or as a GP learning group.

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Did you refer the patient to the right place at the right time?

As a locum it can be especially challenging to get feedback on our referrals. Nonetheless, this is a valuable area of learning in how to use local resources efficiently, and most importantly, doing our bit in helping our patients have the smoothest, safest journey possible.

Focus on a particular type of referral or take a slice of consecutive referrals. This template gives tips on how to keep a log of patients of interest, the issues to consider when accessing medical records after you've left the practice and a framework for reflecting on whether the referral went as planned.

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Meeting complex patients with multi-morbidities, and a medication list stretching across two screens, is not uncommon in general practice. Some of this polypharmacy will be what the Kings Fund in their 2013 report called appropriate in improving quality and duration of life.

Sadly, problematic polypharmacy is also out there, putting patients at risk of adverse drug reactions (ADRs), drug interactions (common causes of unplanned hospital admissions), as well as poor compliance and is a huge waste of resources.

As locums, coming across patients on long lists of medications can be a challenge, but as a fresh pair of eyes you might spot a risky drug combination or ADs that could be making a patient’s life miserable.

In their excellent March 2015 Polypharmacy Guidance, NHS Scotland developed a “7- steps approach to medication review”. We’ve referenced it in developing an easy reference template for those “Where do I start?” moments. You could take it a step further by recording and reflecting on a series of medication reviews as a QIA for your appraisal.

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We all know antibiotics are a finite resource; with primary care generating 80% of NHS antibiotic prescriptions, use this qualitative review of antibiotic prescribing to identify what factors drive your prescribing and if there are any changes you can make to help tackle antimicrobial resistance.


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Patients’ Unmet Needs

PUNs are Patients’ Unmet Needs. They are discovered in consultations simply by asking ourselves at the end, when the patient has gone, ‘How could I have done better?’ During consultations we are commonly aware of gaps in our ability, gaps in the in house systems or attitudinal problems. You need to focus on the patient’s needs to identify these. The doctor, not the patient, will decide whether the patient’s needs have been met.

Doctors' Educational Needs

And recognition of deficiencies leads to the discovery of Doctors' Educational Needs DENs. When you discover Patients’ Unmet Needs you have found your first PUN, leading you on to then construct your DEN.

We've put together this template to make it really easy to identify plenty of PUNs, leading you on to then create the DENs, all together in a very presentable AppraisalAid template to upload to your favourite appraisal toolkit like Clarity or Fourteen Fish.

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  • It is possible to audit areas of your personal practise. Or you could carry out an audit with colleagues from your locum group or chamber.
  • If you are based in, or have particular links with a practice, you may be able to get data retrospectively.
  • It is more likely that you will have to carry out a prospective data collection and it all starts to look very similar to a condition-based review. But we’re getting into semantics; call it what you will, this activity can lead to useful learning.

Referral letter outcome review for audit ideas for your referrals.

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Template for a run through of the audit process.

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Completed examples

This is where you come in. We'd love you to send in examples - stripped of any patient-identifiable information - that we can share here with the NASGP community.