The CQC has developed a suite of clinical searches which are now routinely used when carrying out inspections of GP practices. They were designed to focus on areas of clinical importance, reflecting the profession’s agreed shared view of quality and to contribute to a consistent regulatory approach. The majority of the searches focus on safe prescribing, monitoring of higher risk drugs and identification of potential missed diagnoses. They identify cohorts of patients who may require further attention.
In order to be open and transparent about the regulatory processes, the CQC are working with Ardens as part of a 12-month pilot to create, review and deliver the searches on EMIS Web and SystmOne for GP practices. Cegedim Healthcare will be making the searches available for Vision GP practices. The searches and business rules are available free of charge for all GP practices.
The CQC searches have been specifically designed to identify potential significant risk and often have a degree of tolerance built into them, for example in relation to the intervals for monitoring medicines. They are not intended to be used (nor should they be) as a substitute for a practice’s own governance systems and processes for managing patient care, which should be designed to meet a gold standard in accordance with national guidance. For further information, please see GP Mythbuster 12: Accessing medical records during inspections
The Business Rules
The business rules and codes sets can be accessed online and are hosted on Ardens Manager. Please note that not all codes are available on the underlying clinical systems, so these may vary.
To join the open organisation group & access the searches on SystmOne:
1. Go to Setup > Users & Policies > Organisation Groups
2. Untick top left box ‘Only show groups this organisation has joined’
3. Go to Wiltshire > CQC Inspection Searches
4. Right click > Join Group then turn SystmOne off and back on again
5. Go to Reporting > Clinical Reporting > CQC Inspection Searches
Please note: Your organisation can only be a member of 25 groups. If you have exceeded this number, you will need to leave another first. For further information, please see this support article
The CQC and Ardens acknowledge the support provided by TPP during the initial conceptual discussions and for advice during the development and distribution of the searches.
EMIS Web Searches
To download the searches from the portal and import to EMIS Web:
1. Go to www.ardens.live/portal
2. Select “CQC Inspection Searches” followed by the download link
3. Save the folder of searches to your desktop
4. Go to EMIS > Population Reporting
5. Create a new folder called “CQC” and import the downloaded file here
Please note: First-time users will need to create a free account. Please do not share the downloaded searches with other GP practices as the Ardens Portal records which version of the searches you have downloaded for your GP practice so that we can contact you (if needed) when updates are released.
The CQC and Ardens acknowledge the support provided by EMIS during the initial conceptual discussions and for advice during the development of the searches.
The CQC and Ardens acknowledge the support provided by Cegedim Healthcare during for the building of the searches.
Frequently Asked Questions
What are these searches for?
These searches can be used by GP practices to identify patients who are potentially at risk from not having care delivered in line with national guidance. These searches should not be relied upon by GP practices as their only governance process. The CQC inspector and GP Specialist Advisor will run the searches, either remotely or on site during an inspection, and select searches from each category to review at least 5 patient records from.
The searches are for practices to transparently understand the specific areas that CQC routinely look at on inspections. CQC recognise, that with explicit written consent, GP Practices may wish to share their search results with their PCN, CCG medicines management team or other appropriate healthcare organisations to support their delivery of safe and effective patient care.
Who will have access to these searches?
The results from these searches will be available for staff from your practice to review. The CQC inspection team will analyse the results and review a random sample of patient records. They will record the high level search results but no patient identifiable information will be exported. The results will not be shared with any other third party, including Ardens.
How will the search results be used in my inspection and who will be able to see this?
During your inspection, your inspector will run these searches and use them for record reviews of particular patients and random patient sampling. They also will form the basis for conversations with the practice to further understand the results.
Why are CQC working with Ardens?
CQC use a suite of clinical searches that are routinely used to gather evidence in their GP inspections. CQC are not experts in EMIS Web and SystmOne and have therefore sought the support of Ardens to assist the delivery of these searches. This also ensures these searches are made easily available and transparent to practices.
Who are Ardens?
Ardens is a GP led organisation that offers clinical decision support tools to EMIS Web and SystmOne GP practices in England and are experts in configuring clinical systems, including searches.
Are the searches available to GP practices who do not use Ardens?
Yes. The searches are available free of charge to any GP practice who use EMIS Web, SystmOne or Vision.
Why were Ardens chosen?
After CQC spoke to a number of third party providers and following an approved selection process, Ardens were voted by an independent panel as the preferred CQC provider to support their clinical searches.
What is the relationship between CQC and Ardens?
The relationship is a partnership as part of a 12-month pilot. There is no charge from Ardens for their services.
What is Ardens role?
Ardens role is to assist in validating and deploying the routine CQC searches required as part of GP inspections to make the process easier for GP practices.
Are Ardens involved in deciding what is included in the suite of CQC searches?
Ardens are not involved in the final decision about the selection of searches, but provide advice and guidance on the best way to construct CQC recommended searches.
What is the intended benefit for GP Practices?
Ardens is asked regularly by GP practices for assistance with their CQC searches. By working with CQC to assist in the deployment of the searches, this is intended to make the inspection process as seamless and effortless as possible.
What do I do if I have any questions, feedback or think there is a problem with any of the searches?
For any of the above, including any suggestions of how you think the process can be improved or how we can help practices further, please just contact us
Clinical Frequently Asked Questions
DMARD and High Risk Drug Monitoring expectations regarding checking and recording monitoring is up to date
The CQC searches have been specifically designed to identify potential significant risk and often have a degree of tolerance built into them, for example in relation to the intervals for monitoring high risk medicines.
They are not intended to be used (nor should they be) as a substitute for a practice’s own governance systems and processes for managing patient care, which should be designed to meet a gold standard in accordance with national guidance.
When prescribing medicines which require regular monitoring, it is the responsibility of the clinician signing the prescription to ensure that all required monitoring is up to date and it is safe to issue the prescription.
Before issuing and signing a prescription (including for patients under shared care agreements) CQC expect the prescriber to:
- Confirm that monitoring is not overdue
- Review the monitoring to check that it is safe to continue prescribing the medicine. This includes all blood results or other required parameters or investigations (eg BP, pulse, height, weight, creatinine clearance, ECG, CXR etc)
- Ensure that the quantity of medicine issued does not exceed the date when monitoring is next due
- Record that they have checked monitoring is up to date prior to issuing the prescription if monitoring checks are not coded in the patient’s clinical record.
- Wherever possible prescribers should ensure that required monitoring results are coded in the patient’s clinical record. This can be done by Downloading results from the electronic hospital results system (eg ICE) or coding investigation results from correspondence
On inspection CQC will always review a random selection of patient records identified by a search especially if monitoring appears to be overdue, in order to confirm that the findings are accurate, and patients have not come to harm. CQC will check:
- Pathology results coded in the patient record
- Correspondence to look for monitoring results
- Consultation documentation to check for documented evidence that monitoring has been checked prior to issuing the prescription
If it is still not clear that monitoring has been undertaken within the recommended interval, CQC will ask the practice to show us the latest results from the electronic hospital records system, as the CQC GP Specialist Advisor will not be able to access these. Further information about the clinical record reviews and searches CQC perform can be found in Mythbuster 12. Mythbuster 84 contains information about managing high risk medicines in general practice
The purpose of the CQC searches is to identify potential risk and they are not intended to be an alternative to a practice’s own internal governance procedures which should be based on national guidance.
Some of the searches are ‘cohort’ searches which are never intended to show as zero, but are created to identify groups of patients meeting a particular criteria where a more detailed notes review will be undertaken.
When the search results are reviewed on inspection, the high level results are never taken at face value. Random reviews of a sample of patient records will be done to review management against certain criteria to ensure care and treatment (including monitoring) have been delivered in line with national guidance.
Many of the parameters for the CQC searches are set at intervals longer than those recommended by national guidance as CQC are wanting to identify outliers and potential risk, hence the reason for them not being used by practices for their own governance processes.
With regards to cohort searches (eg SGLT-2, hydrochlorothiazide, teratogenic searches etc), CQC are looking for documentation of discussions or communication with patients about the potential risks highlighted by MHRA alerts, that action has been taken as recommended by the alert and that care and treatment are being delivered in line with this.
CQC do not intend for patients to be removed from the search, as just adding a code to exclude a patient from the search does not mean that the actions recommended in the alert have been taken.
For other searches, once monitoring has been undertaken or medications adjusted to align with MHRA safety alerts or conditions coded where they may have been missed, patients will no longer appear in the search results.
Practices should have their own governance systems and processes in place. If they wish to create searches that exclude patients who they are assured have had the appropriate action taken for their own purposes of review, they are at liberty to do this. However, CQC will continue to review a sample of all patients prescribed these medicines to ensure that care is being delivered in accordance with national guidance.
Potential Missed Diagnosis of Diabetes – why does the search identify patients who had raised HbA1c readings in the past?
The CQC searches are risk-based searches and often have a degree of tolerance built into them. They are not intended to be used in isolation and are always combined with patient records reviews to determine if there is a potential or actual risk to the patient and what the level of risk might be if present.
CQC have deliberately selected to use two or more HbA1c readings of 48 or more to identify people who should have been diagnosed with diabetes, either currently or in the past. These patients should be having regular monitoring and have been appropriately coded in their clinical records.
A patient should be coded as having diabetes if they have had two consecutive HbA1c readings in the diabetic range (and there aren’t other factors that would mean the HbA1c should not have been used for diagnosis such as haemoglobinopathies, pregnancy, on steroids etc). The patient should also have been referred for appropriate screening (eye screening, foot checks etc), regular monitoring and reviews and to educational programmes for advice at the time of diagnosis.
If the Hba1c levels subsequently improve and the patient meets the criteria set out by The Primary Care Diabetes Society (PCDS) and Association of British Clinical Diabetologists (ABCD) position statement for diagnosing ‘diabetes in remission’, the code for diabetes should remain on their clinical records, but additional codes may then be added as appropriate, for example diabetes in remission and/or prediabetes. The PCDS and ABCD strongly recommended that “diabetes resolved” clinical codes should not be employed in clinical practice but that “diabetes in remission” codes should preferentially be adopted.
The criteria for diagnosis of ‘diabetes in remission’ are met when a person with confirmed type 2 diabetes has achieved all three of the following criteria:
- Weight loss;
- Fasting plasma glucose or HbA1c below the WHO diagnostic threshold (<7mmol/l or <48mmol/mol, respectively) on two occasions separated by at least 6 months;
- The attainment of these glycaemic parameters is following the complete cessation of all glucose-lowering therapies.”
Using the ‘diabetes in remission’ code will ensure that the patient continues to be invited for eye screening and is recalled for regular monitoring reviews to check the HbA1c reading are not rising diabetes returning.
If the HbA1c levels rise and enter the diabetic range again, further codes for diabetes diagnosis should be added to the patient’s clinical records, if a diabetes resolved or diabetes in remission code has previously been applied.
If a patient has been diagnosed and coded as having diabetes previously (including gestational diabetes and steroid induced diabetes), they will be excluded from the CQC search unless they have had two further raised HbA1c readings after the date of any diabetes resolved or remission code, or after 1 year of a gestational diabetes code being added.
The search also excludes those with haemoglobinopathies where the use of Hba1c is not advised.
The reporting functionalities of the clinical systems do not allow us to build a more refined search to identify when the two raised Hba1c levels are on consecutive dates. Therefore, the search occasionally identifies patients who have had intermittent, but not consecutive, raised HbA1cs in the diabetic range. The search also identifies people who have had the same data entered twice on the same day. It is for this reason the CQC GP Specialist Advisor will review a random sample of patient records identified by the search to determine if patient’s have had a missed diagnosis of diabetes.
What is the purpose of the ‘Medication Review’ searches?
All of the searches are designed to identify a report of a cohort of patients whose records are suitable for clinical review. In this case the searches identify patients who have a code on the records indicating a medication review has been undertaken in the past 3 months. There is one search looking at every patient and one search looking at patients over the age of 75 years.
A random selection of patients from the reports will be reviewed. The GP specialist advisor is looking to be assured that, for these patients, all of the necessary actions have been taken that would indicate a review of the medication had been completed.
- All monitoring necessary for the medicines/patient has been conducted/arranged/requested/enquired about
- Any potentially interacting medicines have been considered with a record of an appreciation of risks and actions to be taken if the patient remains on them,
- Any drug safety alert information relating to the patient’s medicines has been actioned. If patients remain on medicines where there has been clear guidance to avoid for that specific category of patient then a record is made of the decisions and conversations with patients that support the prescribing,
- Any potential concerns regarding concordance have been identified and actions taken where necessary (when viewed in the context of prescription issue etc),
If a code had been added without the above considerations being addressed, then CQC would consider there to be insufficient evidence of review.
It should be understood that the ‘target’ of the search is not the code it’s the outcome for the patient. The inspecting GP will take into account whether the required actions have already been undertaken for the patient in previous consultations or episodes of care and will understand that, perhaps in those cases, the ‘medication review’ code is being used to consolidate a variety of activities. This is why a clinical review of the notes is an essential part of the process.
CQC do not determine the exact timing of medication reviews, although this would usually be expected to be at least annually. The frequency should be based on individual patient needs and may need to be more often than once a year if, for example, if the patient is:
- frail and elderly
- prescribed multiple medicines
- prescribed medicines that require regular monitoring and review
- prescribed drugs of potential abuse or addiction
- has poor control of a long-term condition etc
CQC have seen situations where there appear to have been medication review codes added to many patients’ records, but the records show no evidence of the critical consideration of the patients’ medicines and areas of care have been missed.