And all from the back of an envelope!
Dentalghar speaks to Raj Rattan about his involvement in the development of Clinical Governance Progress Management and how it can save practices valuable time
Clinical Governance (CG) has been gaining momentum in practice thinking in the UK over the last 18 months or so. With it being a requirement of the NHS (National Health Service) contract, and the upcoming strategies that the Care Quality Commission will be putting in place, the time really is now for practices and PCTs (Primary Care Trusts) to ensure their CG procedures are in order.
One of the PCTs who have been more forward thinking about how they ensure compliance with CG is Bromley, located in the south east of England. Two years ago the PCT decided that what they needed was a programme whereby they could measure practices' performance in the different areas of CG and identifying the gaps.
This is where Raj came in. Raj Rattan is a practitioner based in West Wickham in Kent and a dental advisor at Bromley PCT. He was asked by the PCT to come up with a local Clinical Governance programme; the idea being that the PCT could then have some way of objectively measuring where practices were in terms of CG, what the ideal benchmark was, identifying the gap and helping practices bridge that gap. This was an ambitious project to undertake as Bromley's ‘patch' contains approximately 60 practices.
Raj recalled: "Once the PCT had asked me to come up with a local Clinical Governance programme, I devised a concept that was essentially based on the seven domains which the healthcare commission of the time had identified in the Standards for Better Oral Health document. Following on from that came a list of criteria and a scoring system, which allowed people to self-assess as well as allowing the PCT to analyse what was going on. It was all built in Excel; the outcome was that it would generate a series of graphs which would show practices where they were in each of the domains and how much each practice still needed to do."
It was the by chance that Raj had finalised his ideas and was scheduled to present them to the PCT as Bromley's lead on CG, Harry Goldingay, had spoken to Smile-on, a provider of online and distance learning programmes, about a new online CG programme. Raj said: "I gave my presentation on the Excel-based programme I had been working on and Harry commented to me ‘this is really interesting as what you've shown us I think would fit nicely with a call I had this afternoon from Smile-on with their programme'. This then lead to a meeting between the PCT and the company and I was asked to present my Excel ‘product'.
Raj was already acquainted with the people at Smile-on, having produced educational material for them in the past. "It was a huge help that I knew the team at Smile-on as I had worked on a few projects with them before. I passed my spreadsheet on to the team, and it was converted from a static spreadsheet to an online real-time programme that allowed the same sort of scoring."
CGPM was then developed as a partnership between Raj and the team at Bromley PCT (Harry Goldingay, Jill Webb, Emma Wallis and Carol Adeloy) and the development team at Smile-on. The aim was to make the programme easy to use for both practices and the PCT, and make the requirements for each domain clear so that practices were informed about what they needed to comply with.
Raj commented:
"There were two things I think that made our programme different at that time. One is that we scored practices against well-defined criteria but we also weighted the criteria. For example, if a practice hadn't scored against item x, then we could say that we weren't as bothered as item x was a minor protocol (i.e. the placing of a Health & Safety poster) that the practice could easily sort themselves. It's important, but not as important as say not taking a medical history for a patient. So by having the criteria and weighting them we were able to get a score. Following feedback we then did some joint work on what is now called CGPM (Clinical Governance Progress Management). The static product in the Clinical Governance CD was already in existence, so my work with the PCT on my spreadsheet was the bridge between what Smile-on had and what Bromley PCT wanted to do.
"What we now have is CGPM, which allows dentists to log on and self assess their CG procedures; PCTs can dial in and monitor progress, dentists can upload their evidence which the PCT can read, which is fantastic.
"Then what happens, and again I think this is quite unique, is the practice uploads all the relevant evidence to the online system, the PCT looks at it and then when the PCT comes round to do your CG practice visit they've already seen your evidence. So, a dental advisor will do the visit and say ‘I see you've already uploaded your infection control policy and I think it's really interesting, can you show us in the surgery how that works?'.
Raj added: "From the touch of a few buttons the PCT can get a picture not only what is happening in an individual practice in Bromley, they can also aggregate. Where we are now is every practice in Bromley has completed the online assessment, and have all have been visited - that's approximately 60 practices.
"Of course change is always hard and something on this scale has not come easily. Bromley PCT has had to work out a strategy to help make it easy for practices. Raj commented that there had been some resistance to CGPM, but that it was a common occurrence when change of this scale happened. "What was very interesting was there were a number of people who originally said ‘this is more paperwork - this is more admin'.
"The interesting thing was after having completed the process these same people were saying ‘you know what, now that I've done it I'm really glad I did as I am now more comfortable that I have now got all of these things in place.' It allows practices to comply with the contract and meets the PCT's agenda."
Before the programme was rolled out it was piloted on four pilot sites in the Bromley area. This allowed the development team to assess the usability of the system and gather feedback from real users who made themselves available as ‘guinea pigs' to see if it worked. After these pilots, changes were made to refine procedures and make the system more user-friendly for both practices and the PCT.
In an effort to make it easier for practices, the PCT organised a series of workshops with groups of 12-15 attending; booking a local college to enable everybody to access a computer workstation so they could log on to the system and try it out. Raj said: "We had originally run a series of workshop discussing the Clinical Governance CD.
When CGPM went live, we ran another series of workshops. Before we introduced CGPM we went to a lot of trouble to engage with dentists throughout the programme; we also consulted with the LDC (Local Dental Committee). The PCT told the practices ‘this is what we want to do'. There was resistance, there's bound to be, but the majority said ‘ok if this is what we need to do, let's find the nicest way in which to get it done and have a supportive way to do it'.
"The workshops ran over a period of six months at the end of last year. Because they were run in small groups, what we did was get the first cohort up to speed then they were the first group to be visited, then the second were the second to be visited and so on. So the whole programme was done in a very structured and supportive way because there was no point in doing the visit unless they had been to the workshop. And also at all times they had email access to people such as Harry and I to get help.
"This has meant the practice visits can now take no more than an hour and if practices have all of their paperwork organised, probably less than that. The shorter visits can take around 45 minutes, the longer ones can take up to 2.5 hours."
It has been a two-year journey to for Raj, Bromley PCT and Smile-on to get to where they are today, and Raj it deservedly proud of what has been achieved. "This has been terrific for me personally - I love working on new projects and I always felt where the hard bit of governance was actually doing the gap analysis; also measuring the improvement of practices. How I feel about it as an individual is probably the same as a photographer feels taking a picture then finds it hanging on someone's wall. I think actually seeing it, live and functional, having started to sketch it out literally on the back of an envelope - it's fantastic.
"A personal huge thanks to the PCT who gave me the freedom to develop my idea and allowed me the time to develop it properly. This has been a great example of teamwork between practitioners, a PCT and an IT provider. Also most of it was done remotely which saved time - we had no more than five face-to-face meetings.
"Finally, I'd like to acknowledge the pilot practices - their input was invaluable in the development of CGPM. I'd also like to acknowledge the LDC for their support during the rollout and a big thank you to all the practices in Bromley for their engagement."