Quality and Outcomes Framework

Asthma

Keep a register of patients

Diagnosed after 1st April 2006 need PEFR or Spirometry

Aged 14 - 19 and smoking status recorded

Annual review and patients must answer  if night symptoms, day symptoms and exercise related problems

Atrial Fibrillation

Keep a register of patients

Patient needs CHA2DS2-VASc in the last 12 months

Patients with  CHA2DS2-VASc  > 2 need anticoagulant

Cancer Care

Keep a register of patients

Cancer care review within 6 months of diagnosis

Chronic Kidney Disease

Keep a register of patients (over the age of 18 with CKD 3-5

COPD

Keep a register of patients

Spirometry with reversibility between 3 months before diagnosis and 1 year after diagnosis

FEV1 recorded

COPD annual review

• MRC dyspnoea score

• Exacerbating history

• Lung function

• Inhaler technique check

MRC score > 3 need O2 saturation recording

Influenza vaccination between 1st August - 31st March

Coronary Heart Disease

Keep a register of patients

BP reading < 150/90

Influenza vaccination between 1st August - 31st March

Patient needs to be taking either Aspirin / Clopidogrel or anticoagulant

Cytology

25 - 64 years of age and has had a cervical smear

Protocol in place for the management of screening (including training, recall and exception reporting)

Protocol for audit of screening and audit of inadequate samples every 2 years

Dementia

Register of patients

Face to face review of care plan

New patients have FBC UE, LFT, TFT, Gluc, B12, Folate, Calcium 12 month before or 6 months after diagnosis

Depression

Patients aged 18 or over with a new diagnosis have a review by a GP within 10 and 56 days of diagnosis

Diabetes

Keep a register of patients (over the age of 17)

Last IFCC < 59

Last IFCC <64

Last IFCC <75

Foot examination and risk classification

Last BP < 150/90

Last BP <140/80

ACEi or ARB if microalbuminuria or proteinuria

Last cholesterol < 5

Influenza vaccination between 1st August - 31st March

Referred to structured education programme within 9 months of entering register

Epilepsy

Register of patients

Hypertension

Register of patients

BP reading < 150/90

Heart Faliure

Register of patients

Needs ECHO confirmed diagnosis or coronary angio

ACEi or ARB

B Blocker (Must be bisoprolol, carvedilol or nebivolol)

Learning Disability

Register of patients

Mental Health

Register of patients with

• Schizophrenia, psychoses, bipolar disorder or prescribed lithium

Needs personal health plan

Alcohol consumption

BP check

Smear (if eligible female)

Lithium check in therapeutic range

Creatinine and TSH check if on lithium

Obesity

Register of patients aged over 18 with BMI > 30

Osteoporosis

Keep a register of patients -

• Age 50-74 with fragility fracture and DEXA confirmed osteoporosis

• Age >75 with fragility fracture

Patients in 1) receiving treatment

Patients in 2) receiving treatment

Palliative Care

Keep a register of patients

Review patients on the palliative care register at least every 3 months

Peripheral Vascular Disease

Keep a register of patients

Patient needs to be taking either Aspirin / Clopidogrel or OTC aspirin

BP reading < 150/90

Public Health

Aged > 45 with BP recorded in the last 5 years

Aged 30-75 with CVD risk >20% on statin

Rheumatoid Arthritis

Keep a register of patients (over the age of 16)

Annual face to face review

Sexual Health

Register of women prescribed contraception

Patients given emergency contraception are given information on LARC within 1 month of the prescription

Smoking

Smoking status for anyone with

• CHD / DM / CVA / BP / COPD / Asthma / Psychosis / PVD / CKD

Offer support and treatment

Smoking cessation advice

Support with literature and appropriate therapy

Sroke / Transient Ischemic Attack

Keep a register of patients

Diagnosed after 1st April 2014 and referral for investigations between 3/12 before and 1/12 after episode

BP reading < 150/90

TIA or non bleed CVA on antiplatelet or anticoagulant

Influenza vaccination between 1st August - 31st March