DISPENSARY SERVICES QUALITY SCHEME 200910 SELF ASSESSMENT RELATED

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					                                         DISPENSARY SERVICES QUALITY SCHEME
                                                       2009/10

                            SELF ASSESSMENT RELATED TO KEY POINTS IN THE SCHEME

                                                 PRACTICE DECLARATION

Practice Stamp:




Self Assessment Completed by (Name and Designation): …………………………………………………………………………………………….

Date of Completion:             ………………………………………………………

On behalf of (to be signed by ALL partners):

Print name ……………………………… Signature ………………………………                  Print name ………………………… Signature ……………….......

Print name ……………………………… Signature ………………………………                  Print name ………………………… Signature ……………….......

Print name ……………………………… Signature ………………………………                  Print name ………………………… Signature ……………….......

Print name ……………………………… Signature ………………………………                  Print name ………………………… Signature ……………….......

Print name ……………………………… Signature ………………………………                  Print name ………………………… Signature ……………….......



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Notes for completion:



  It will help you if you refer to the Dispensary Services Quality Scheme Supplementary Guidance for Revisions to
  the GMS Contract 2006/07 and the National Health Service Act 1977 - The Statement of Financial Entitlements
  (Amendment) (No5) Directions 2006.

  Please indicate your assessment of your practice’s achievement of the specific requirements, set out in the
  specification in the supplementary guidance referred to above, as at the date of completion.

  If you tick “Not Achieved”, please attach a brief action plan.

  You MUST include free text descriptions/information where requested. Failure to do so will result in further
  enquiries and possible delays in payment.

  Please make sure that for each indicator that requests specific evidence that you supply this to demonstrate
  compliance.

  Completed self-assessment checklists for DSQS 09/10 should be returned by January 31st 2010 to the Medicine
  Management Office at ABTHC, South William Street, Workington CA14 2EW or via email to
  sally.styles@cumbriaPCT.nhs.uk



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You are asked to assess your practice against the key requirements by ticking the most appropriate option.

           Specification of Requirements                                  Description/Comments                        Achieved?    Evidence
                   (% Weighting)                                                                                        X/√       Submitted?

1.0 ACCOUNTABLE GP (2%) - Name of Partner or               Please provide the name of the accountable GP:
    Salaried GP who has accountability for the
    quality of dispensing services (NB – If this
    changes in-year the practice must notify the PCT, in
    writing, within 28 days of the change occurring)


2.0 NUMBER OF DISPENSING PATIENTS – on list                Please provide number:
on 1st January 2010


3.0 DISPENSING STAFF QUALIFICATIONS (25%)                  The practice must provide a list of all staff engaged in
                                                           dispensing-related activities including the following
3.1 Staff who dispense independently                       information for each member of staff:-
(unsupervised)
Minimum standard – staff to be competent to a                 (i)     Name and number of hours per week spent
minimum standard equivalent to the pharmacy services                  on dispensing-related activities
Scottish / National Vocational Qualification (S/NVQ)          (ii)    Whether they work independently
level 2                                                               (unsupervised) or with supervision
AND completed 1000hrs over the past 5 years in a GP           (iii)   If they work independently then list formal
dispensary or community pharmacy.                                     qualifications achieved (including dates
                                                                      achieved and awarding body) AND confirm
3.2 Staff who dispense with supervision                               they have completed 1000hours over the
‘Dispense’ includes assembling, labelling and bagging.                past 5 years in a GP dispensary or
‘Supervision’ includes a final check of the dispensed                 community pharmacy
product by a qualified person and access to a qualified       (iv)    If they work under supervision then indicate
person                                                                who supervises their role and whether they
                                                                      have a certificate of competence signed by
Minimum requirement – these staff must have a                         the Practice Manager and Accountable GP.
certificate of competency signed by the Practice
Manager (if any) and the Accountable GP in respect of
all the dispensing activities that they undertake.

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4.0 DISPENSING STAFF COMPETENCIES and CPD
and APPRAISAL (25%)                                 Minimum requirement –
                                                       • Staff who work with supervision in the dispensary
4.1 Competencies                                          MUST have the required experience and
                                                          competencies. A certificate of competency must
** Please use the PCT staff competencies resource         be signed by the practice manager and
pack.                                                     Accountable GP in respect of the roles they
                                                          undertake.

                                                       •   ALL staff working in the dispensary should
                                                           continue to demonstrate the competencies and
                                                           knowledge to perform the tasks and roles
                                                           assigned to them.

                                                    Minimum Requirement – Practice must carry out and
                                                    complete a written record of an appraisal of all
4.2 Appraisal and CPD
                                                    dispensing staff (i.e. undertaking any of the following
                                                    tasks – prescription receipt and collection; assembly of
                                                    prescribed items; ordering, receiving and storing
                                                    pharmaceutical stock). Each member of staff must also
                                                    have a personal development plan and they should
                                                    actively maintain a CPD portfolio.

                                                    Their competence in performing dispensary tasks should
                                                    also be assessed at least annually. (Competence
                                                    assessment forms part of the governance framework of
                                                    the dispensary).

                                                    For each member of your dispensary staff please submit
                                                    a copy of their certificate of competence AND one
                                                    example of an entry from each of the seven competency
                                                    sections (i.e. Customer Service, Health & Safety, Teams
                                                    & Teamwork etc.) in their individual competency
                                                    portfolio. For new members of staff who have only
                                                    recently started collecting evidence please submit one
                                                    example from each section covered to date.

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5.0 MINIMUM HOURS – DISPENSING STAFF (1%)             Please provide details of number of items dispensed per
                                                      month and dispensing hours each week:

                                                      ………… items dispensed per month


                                                      …………. Total Dispensing staff hours each week
                                                      (staff hours should relate to those hours that staff are
                                                      engaged in dispensing activities)


6.0 DUTY OF CONFIDENTIALITY (1%)                      Minimum requirement – all employee contracts for
                                                      dispensing staff should include a duty of patient
                                                      confidentiality as a specific requirement, with written
                                                      disciplinary policy and procedures set out for non
                                                      compliance


7.0 DISPENSARY SERVICES STANDARD                      Minimum requirement – the practice MUST have
OPERATING PROCEDURES (SOPs) (10%)                     written SOPs in place. These should be specific to the
                                                      practice and should set out in writing what should be
At a minimum the SOPs should cover:                   done, when, where and by whom. These SOPs must
    • Ordering                                        also be reviewed and updated at least once a year and
    • Receipt                                         whenever dispensing procedures are amended.
    • Supply and dispensing
    • Destruction and disposal                        Please submit a complete list of the SOPs currently in
    • Patient returns                                 place within the practice, together with the date they
                                                      were last reviewed. Plus a copy of your DRUM SOP.
There should also be separate SOPs for CDs covering
the above and the following procedures;
    • Storage and keys
    • Access to stock and keys
    • Record keeping
    • Who should be alerted if complications arise



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8.0 CLINICAL AUDIT (10%)                  Minimum requirement – the practice will be expected
                                          to complete the PCT DSQS Clinical Audit ‘Waste
                                          Medicines’ 2009-10 and submit a copy of their Action
                                          Plan and audit forms.




9.0 SERIOUS UNTOWARD INCIDENT REPORTING   Minimum requirement – Serious untoward incidents /
(5%)                                      Significant events in dispensing must be reported to the
                                          PCT, and used as a learning opportunity for all relevant
                                          staff. The practice should also have a system in place for
                                          managing and learning from near misses.

                                          Please describe your process for sharing and learning
                                          from near misses AND significant events in dispensing
                                          within the practice, distinguishing the difference between
                                          the two processes:




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10.0 PATIENT INFORMATION (1%)   Minimum requirement – the practice must provide
                                information to their patients on the dispensing services
                                provided by the practice, and how to obtain medicines
                                urgently.

                                Please describe how the practice achieves this e.g. via
                                practice leaflet, posters:




                                Minimum requirement – The practice must inform the
                                PCT of the hours of availability of dispensing services
                                provided. These times must also be displayed
                                prominently on the premises from which they carry out
                                dispensing and that they are legible from outside the
                                premises when they are shut.

                                Please provide details of hours of availability:




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11.0 DISPENSING REVIEW OF USE OF MEDICINES   Minimum requirement – 10% of dispensing patients
(DRUMs) (20%)                                prescribed medicines should have received a face-to-
                                             face review of compliance and concordance.

Suggested target groups:                     Number of patients eligible for DRUM review on 1/04/09
                                             (i.e. number of dispensing patients receiving 1 or more
      patients > 65yrs                       repeat medicines) ………
      patients on 4 or more medicines
      patients recently discharged           10% target number (i.e. number of DRUMs to be
                                             completed by 31/03/10) ………

                                             Number of DRUMs completed during the period 1/04/09
                                             to date ………

                                             Please submit your final number of DRUMs
                                             completed on 31/03/10 to
                                             sally.styles@cumbriaPCT.nhs.uk in order that final
                                             payment may be processed.


                                             Please provide names of staff undertaking DRUMs:




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