Facilitator Handbook 2005 - PRIMIS

PRIMIS 

Facilitator Handbook 

August 2005

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Contents 

Introduction 1 

The PRIMIS National Team 2 

Your Local PRIMIS Scheme 7 

The PRIMIS Training Agenda 13 

Training Needs Assessment and Scheme Management 17 

What is Primary Care? 21 

Quality Data, Quality Outcomes 25 

Clinical Coding 29 

The MIQUEST Process 33 

Data Analysis, Interpretation and Feedback 37 

Facilitation Skills 39 

Annual Review 43 

CHART 47 

Action Planning and Supporting Change 51 

Information Governance 55 

Path to Paperless 59 

Data Quality and Patient Safety 63 

Supporting Quality Outcomes 67 

Supporting Quality Services 71 

Supporting Quality Review 75 

Primary Care Data Uses and Abuses 79 

Glossary 83

Introduction 

PRIMIS Facilitator Handbook 

Introduction 

The aim of the Primary Care Information Services (PRIMIS) Facilitator Handbook is to support 

the information facilitator’s individual learning portfolio by introducing each of the training topics 

offered as part of the PRIMIS training programme. The Handbook does not replace the need to 

attend the training, but serves to prepare the facilitator for the training and give references for 

additional reading which facilitators can choose to pursue, either in preparation for the training 

day or for further information following the training. Detailed information on the setting up and 

running of a local PRIMIS scheme is contained within the PRIMIS Guidelines. 

In addition to the Facilitator Handbook and PRIMIS Guidelines there are also workbooks to 

support the majority of the PRIMIS training modules. These workbooks, made available to 

those attending the training, include background information and practical exercises and 

scenarios, and are designed to build up a full resource for future use. A manual for the 

MIQUEST data extraction software is made available separately to those attending the 

MIQUEST Process training module. 

This Handbook is divided into sections that mirror the training modules offered by PRIMIS, as 

shown below: 

PRIMIS Training Modules 

• Training Needs Analysis and Scheme Management 

• What Is Primary Care? 

• Quality Data, Quality Outcomes 

• Clinical Coding 

• The MIQUEST Process 

• Data Analysis, Interpretation and Feedback 

• Facilitation Skills 

• Annual Review 

• CHART 

• Action Planning and Supporting Change 

• Information Governance 

• Path to Paperless 

• Data Quality and Patient Safety 

• Supporting Quality Outcomes 

• Supporting Quality Services 

• Supporting Quality Review 

• Primary Care Data Uses and Abuses 

PRIMIS 1


Introduction 

The PRIMIS National Team 

Introduction 

PRIMIS is a free training and support service to help GPs provide quality patient care by 

making the best use of their clinical computer systems and improving data quality and 

information management. Launched in April 2000, PRIMIS is currently managed by NHS 

Connecting for Health and is based in the Division of Primary Care at the University of 

Nottingham. 

PRIMIS works with local information facilitators, employed by Primary Care Organisations 

(PCOs) or local Health Informatics Services across England, to provide GPs and practice staff 

with: 

• training in information management skills 

• analysis of data quality and key clinical topics 

• feedback and interpretation of analyses 

• support in developing and delivering action plans to improve data quality. 

The benefits to practices and PCOs of participating in a local PRIMIS scheme are outlined 

below. 

Benefits of participating in a local PRIMIS scheme 

• Training for local information facilitators whose role is to help GPs and 

other members of primary health care teams assess and improve data 

quality and information management, ultimately improving patient care 

and ensuring patient safety 

• Tools and techniques to assist PCOs in comparative analysis, which will 

provide benchmarks as a basis for tackling inequality in access 

• Improved chronic disease registers. This facilitates the proactive 

management, comprehensive treatment and monitoring of "at risk" 

patients 

• Assistance for practices in meeting clinical governance agendas and 

national service framework requirements 

• Support in building and maintaining quality primary care electronic 

patient records to support the information requirements of primary care 

medical contracts 

• Support and advice for practices participating in the quality and 

outcomes framework of the new GMS contract 

• Better use of clinical information systems to ensure patient safety 

• Support for large national information-dependent projects, such as 

Electronic Transmission of Prescriptions (ETP), Choose and Book and 

GP to GP transfer of data, and data migration to the NHS Care Records 

Service, ensuring that data uploaded follows uniform quality standards 

2 PRIMIS

Introduction 


Data quality has now been recognised as a crucial element of the ongoing development of 

primary care, as part of the wider NHS community. As quality payments in the new GMS 

contract are calculated on recorded clinical data, data quality is no longer just the domain of 

‘techy GPs’. Virtually all practices now have clinical computer systems, but the level and 

effectiveness of their use is variable. PRIMIS helps practices to improve their information 

management skills and their use of technology to support improved patient care. 

The PRIMIS Team 

PRIMIS consists of the following teams: 

Directors 

The four Directors are responsible for aligning the service with national policy, the overall 

organisation and delivery of the service, ensuring appropriate clinical input to the service, and 

overseeing the technical resources used by the PRIMIS Team. 

Clinical Advisers 

The team of Clinical Advisers provides support to the Learning Consultants and facilitators on 

a cluster basis, as well as contributing to the development of queries and software through the 

Clinical Advisory Group, under the chairmanship of the Clinical Director. 

Training and Support Team 

Training and support for facilitators are provided by a team of Learning Consultants based 

across the five clusters in England: 

North East 

North West 

and West 

Midlands 

Eastern 

Cluster Map 

London 

Southern 

This team is responsible for the delivery of the training set out later in this Handbook, as well 

as ongoing support for schemes through such means as scheme reviews and Facilitators’ 

Forums. 



Introduction 

Information Team 

Based in Nottingham, the Information Team is responsible for: 

• provision of a data analysis service using carefully developed MIQUEST queries 

• the analysis and reporting of anonymised practice data submitted through the data 

analysis service 

• the provision of a comparative analysis service (CAS) to enable schemes to 

compare their data on selected clinical topics with aggregated data from other 

participating PRIMIS schemes 

• the provision of helpdesk support for facilitators 

• the development and support of CHART (Care and Health Analysis in Real Time) 

software to support practices with their own data analysis. 

Communications Team 

The Communications Team is responsible for all internal and external communications about 

the service. 

Technical Support Team 

The Technical Support Team is responsible for the provision of IT support to the PRIMIS Team. 

They are also responsible for facilitators’ access to the PRIMIS website. 

Technical Consultants 

The Technical Consultants are responsible for advice and support on MIQUEST software, and 

also for the development and ongoing maintenance and support of a number of software 

applications, including Rush, CHART and CHARTOnline. They work closely with the 

Information and Technical Support Teams. 


Introduction 



University of Nottingham 

14th Floor Tower Building 

University Park 

Nottingham 

NG7 2RD 

www.primis.nhs.uk 

General enquiries 

enquiries@primis.nottingham.ac.uk 

Tel: 0115 846 6420 

Fax: 0115 846 6432 

Information Team enquiries 

information.team@primis.nottingham.ac.uk 

Tel: 0115 846 6320 

Fax: 0115 846 6432 

Helpdesk enquiries 

helpdesk@primis.nottingham.ac.uk 

Tel: 0115 846 6320 

Training enquiries 

Useful PRIMIS contacts 

Individual Learning Consultants will give facilitators their mobile number and email address 

Website access enquiries 

enquiries@primis.nottingham.ac.uk 

Tel: 0115 846 6427 



Introduction 


Your Local PRIMIS Scheme 



A local project or scheme wishing to improve the use of primary care clinical systems may be 

organised in various ways and at different organisational levels, such as a PCO or local Health 

Informatics Service. 

Before PRIMIS is able to begin training or data quality analysis work with a PCO, a project 

plan must have been approved and a facilitator or team of facilitators employed. 

The role of the facilitator 

Depending on how much work has been already achieved by the scheme, facilitators may 

need to be proactive in setting up or finalising the project plan. Alternatively, facilitators may be 

recruited to an established scheme. Either way, training and support are provided by PRIMIS. 

For new schemes, following initial 

training by PRIMIS, facilitators will 

begin to work directly with practices. 

For each one, this involves getting to 

know the practice team, evaluating 

training and development needs, and 

examining current use of the clinical 

system. Data quality may be assessed 

by running sets of MIQUEST queries 

and feeding back the analysed results 

with suitable interpretation. Action 

plans can then be formulated and 

agreed, which may include identifying 

training needs, changes in the way the 

system is used and indicators of 

progress. 

Once the initial quality improvement 

work has been started, the local 

scheme can consider incorporating 

other PRIMIS activities, such as 

joining the comparative analysis 

service or using the CHART software. 

By this stage, schemes tend to move 

away from a standard pattern in order 

to support local needs. The variety of 

work carried out by PRIMIS facilitators 

across England can be seen on the 

Schemes Showcase pages of the 

PRIMIS website. 

Keys to Successful 

Planning for Data Quality 

Primary care organisations that have 

successfully implemented PRIMIS projects 

have capitalised on the following key factors: 

• Clear vision and objectives 

• Activity plan with targets 

• Adequate resources 

• Management commitment and support 

• Clinical ownership 

• Recruiting the right people 

• Realistic expectations 

• Control and risk management 

• Linking in with other activities and 

initiatives 

• Clearly defined reporting structures 

• Commitment to monitor progress 

The role of the facilitator is discussed in detail during the Scheme Management training 

module. Also, more information is available in the Introducing PRIMIS booklet available from 

PRIMIS. 




Other key factors identified as important for project success by PRIMIS schemes: 

• Good communication 

• Clear and realistic project milestones 

• Willingness to change 

• Training 

• Understanding the importance of data quality 

• Adopting an educational approach, not performance management 

The first year 

The plan shown in the box below outlines a suggested initial timetable for a new facilitator 

starting with a new PRIMIS scheme. In addition to the core training modules listed, facilitators 

may access other PRIMIS training as required (see page 1). 

Extract from a typical facilitator’s plan for the first year of a new PRIMIS project 

Facilitator induction with PCO 

PRIMIS Training - Training Needs Analysis 

and Scheme Management, Quality Data, 

Quality Outcomes, Clinical Coding 

Develop Baseline 

Recruit/first visit to Practices 

Report to PCO - baseline findings 

Review/develop recording processes 

PRIMIS Training - The MIQUEST Process 

Data extraction - PDQ and RPDQ queries 

PRIMIS Training - Data Analysis, Interpretation 

and Feedback, Facilitation Skills 

Feedback to practices 

Develop/deliver training for practices 

Apr May Jun Jul Aug Sep Oct Nov 




Information Governance issues and the PRIMIS process 

Information about patients held by a general practice is confidential. Under certain 

circumstances, data can be released to a PCO or other external enquirer. Scheme managers 

and practices need to be clear about their respective responsibilities. 

There are several issues to be addressed, as follows: 

Confidentiality of patients 

Data by which any patient could be identified must not be extracted from a practice system by 

or for the use of an external enquirer. This clearly rules out such items as the names of 

patients or their addresses. It also rules out combinations of data items – such as age, sex and 

postcode – which, if considered together, could identify a patient. 

The MIQUEST Protocols 

The MIQUEST protocols contain full data security and confidentiality safeguards as outlined in 

the box below. 

Data security and confidentiality safeguards built into the MIQUEST protocols 

Before a query is run, the practice has: 

• the opportunity to scrutinise the query 

• to authorise the query before it can be 

run 

• the safeguard that an external 

enquirer may not access any strong 

patient identifiers, such as name, 

address, full date of birth, full 

postcode, etc. 

After a query has run, the practice has: 

• the opportunity to scrutinise the 

response 

• to authorise the response before it is 

released to an enquirer 

The PRIMIS Guidelines contains extensive recommendations about steps that must be taken 

to protect the confidentiality of individual patients and of practices. Where anonymised 

information is sufficient for a purpose, information that would enable the patient’s identity to be 

traced must be omitted. 




There are purposes, other than for delivering personal care and treatment, for which it is 

legitimate to use personal information about patients, provided that patients in general are 

made aware that personal information may be used to prepare statistics to support such 

purposes. These purposes include: 

• assuring and improving the quality of care and treatment (e.g. through clinical audit) 

• monitoring and improving public health 

• managing and planning services 

• statistical analysis and medical or health services research to support any of the 

above. 

Although the data extracted will not in itself identify individual patients, it will still be necessary 

to avoid ill-considered aggregation of data which may threaten the confidentiality of the 

individual. This is especially important with rare conditions involving small numbers of patients, 

or conditions associated with recognisable characteristics, or where patients with combinations 

of conditions are being selected. Both participating GPs and the data quality improvement 

scheme must be alert to these potential problems and seek to prevent them. 

Aggregating selective information about a small number of patients may not always safeguard 

confidentiality adequately. Those with control of the information must make a judgement, taking 

into account clinical and other relevant considerations, as to the point at which there is no 

perceptible risk of patient identities being discovered from the aggregated material, either by 

itself or in combination with other information available to, or potentially accessible by, 

recipients of the information. 

Confidentiality is an essential component of the clinical consultation in the provision of health 

care. The clinical professions have stringent requirements with regard to confidentiality in their 

codes of ethics. The NHS Confidentiality Code of Practice is a guide to required practice, for 

those who work within or under contract to NHS organisations concerning confidentiality and 

patients’ consent to using their health records. 

A copy of the NHS Confidentiality Code of Practice or further information about the ways in 

which patient information is used in the NHS, and the need to ensure confidentiality, can be 

obtained from: 

www.dh.gov.uk/PolicyAndGuidance/InformationPolicy/PatientConfidentialityAndCaldicottGuardians/fs/en 

Agreements between the data quality improvement scheme and each practice 

The responsibilities of the practices and the managers of the data quality improvement scheme 

need to be clarified by a formal agreement. A skeleton agreement is provided in the PRIMIS 

Guidelines. Such agreements are necessary for a variety of reasons, including the need to 

fulfil the requirements of confidentiality. 

Data must not be extracted which go beyond the terms of the agreement between the 

practices and the scheme managers, nor must data be used for purposes outside the formal 

agreement. Any new uses may need special agreements and due consideration of the 

confidentiality aspects. In the scenario where a practice contributes to a national data quality 

improvement scheme, such as the PRIMIS Comparative Analysis Service, but is also part of a 




local scheme (PCO, MAAG, research network, etc.), the practice would have several data 

collection agreements. 

Scheme managers are advised to review and, where necessary, update agreement terms on a 

regular basis. 

Confidentiality of practices 

Practices must be anonymised in feedback or other reports that present analyses of data in a 

comparative fashion. This implies that each practice must have a code number or name 

assigned to it, and that the key to the code is itself kept securely. Different data quality 

improvement schemes may require different anonymised codes. If all practices in a scheme 

agree, then practice identities may be disclosed. However, preservation of anonymity should 

be the starting point. 

Even when using an anonymised code to identify practices, schemes must still take extra care 

when presenting analyses showing a small number of practices that share certain 

characteristics. For example, if a scheme produced a graph highlighting results for a subset of 

practices in a small geographical area that contained only two or three practices, it might be 

possible to infer the identity of those practices. 

Security of IT systems 

The possibility of unauthorised access to data held in the scheme’s computer systems must be 

considered. Although any data extract may, in itself, conform to the requirements of patient 

confidentiality, linking or otherwise cross-referencing it to other data sets may make it possible 

to identify patients. 

Anti-virus software 

If the scheme is receiving any data directly from practices using MIQUEST, then – as with the 

receipt of any external disks – arrangements will need to be made to ensure thorough and 

comprehensive use of anti-virus software. The scheme will require virus-scanning software that 

is regularly updated. It will also need internal security policies and procedures to be reviewed 

and revised appropriately. This issue also needs to be discussed with practices. 

Practices will need to review their own internal security arrangements and ensure that good 

quality and updated anti-virus software is in place to scan disks received from their local 

facilitator. Internal procedures may have to be reviewed and revised to ensure that these 

issues are dealt with comprehensively. See the latest version of the PRIMIS Guidelines for 

further details. 

Personal integrity 

During the course of their work, the staff of data quality improvement schemes will encounter 

confidential information, perhaps in the form of documents or letters in practice offices. 

Absolute personal integrity is essential. The subject is complex and reference should be made 

to the section on confidentiality in the PRIMIS Guidelines. 

Data Protection Act 1998 

Practices involved in the scheme must be appropriately registered for the Data Protection Act 

and ensure that registration is kept in order. See 

www.hmso.gov.uk/acts/acts1998/19980029.htm#aofs for more information. 




Records management 

As part of a data quality improvement scheme, the facilitator and/or scheme manager may well 

be creating and storing a number of documents, such as practice-based reports and action 

plans, data quality audits, minutes of meetings, progress reports, guidance, newsletters and so 

on. 

It is recommended that records management systems are in place that meet the needs of the 

scheme and the requirements of the organisation’s records management policy. The Freedom 

of Information Act 2000 gives a general right of access to information held by public bodies, 

including GP practices and PCTs, and has also established a code of practice on records 

management. Further information regarding the Freedom of Information Act 2000 and the NHS 

can be found at www.foi.nhs.uk/ 

The following issues should be considered: 

• records should be easily located and retrieved 

• information should be recorded legibly and jargon-free 

• data should be stored with suitable anonymisation and security. 

Facilitators and/or scheme managers are advised to follow their organisation’s records 

management policy when creating, storing and disposing of information. 


The PRIMIS Training Agenda 



PRIMIS training is based on the adult learning approach developed by influential American 

adult educator, Malcolm Knowles, who put forward the theory of andragogy – where students 

are guided by tutors, rather than taught. This approach takes account of prior knowledge and 

experience and involves learners in planning their own training programmes. 

PRIMIS training is tailored to the needs of individual facilitators, determined by a Training 

Needs Assessment (TNA) carried out by the PRIMIS Learning Consultant at the beginning of 

the training. The complete learning process is a cyclical one as shown below, and 

incorporates: 

• acquiring new skills 

• applying those skills 

• reviewing the effects of those skills. 

Concrete 

Experience 

Putting it into practice 

Reflective 

Observation 

Objectively analyse the 

outcome 

Active 

Experimentation 

Experimenting to find 

solutions 

David A. Kolb 

Abstract 

Conceptualisation 

Reviewing your conceptual 

understanding 




Reflecting on what has been learned and how it can be applied is a very important part of the 

learning process. By using a learning diary, the learner can take control of this learning cycle 

and use it to their best advantage. Learners are recommended to record: 

• the learning that has taken place 

• the learner’s feelings, reactions and judgements about the learning or training 

• the learner’s assessment of the relevance of that learning 

• the learner’s application of what has been learned 

The PRIMIS Training Modules 

PRIMIS offers a complete programme of training, education and support for information 

facilitators working in primary care. PRIMIS training equips facilitators with the knowledge and 

expertise needed to help GP practices improve and maintain data quality and information 

management skills. 

Training topics are taught by different methods, including individual scheme training sessions 

and group workshops, depending on the nature of the subject and the facilitator’s needs. The 

training programme is made up of a number of days, allocated according to the needs of the 

individual facilitator, from the following modules. Each module is explained in some detail in 

later chapters within this Handbook. 

Training Needs Assessment and Scheme Management 

PRIMIS helps facilitators assess their existing skills and knowledge, taking the 

learner’s prior knowledge and experience into account and involving them in 

planning their own training. PRIMIS provides guidance on scheme management, 

obtaining resources and equipment and networking within organisations, as well as 

recruiting and carrying out baseline assessments with practices and covering 

issues of security and confidentiality. 

What is Primary Care? 

In this module, facilitators are introduced to the complexities of primary care, 

including practice structure, funding and the new GMS contract. 

What is PRIMIS? 

This module provides facilitators with an understanding of what PRIMIS is and why 

it is needed. The PRIMIS training, data quality analysis and comparative analysis 

services are described in detail. Facilitators gain an understanding of their role in 

improving data quality and the critical factors that can impact on the success of a 

PRIMIS scheme. 

Quality Data, Quality Outcomes 

This module provides facilitators with an understanding of the importance of data 

quality. Actual practice scenarios are used to demonstrate situations that might 

confront practices in achieving good data quality. 




Clinical Coding 

In this module, facilitators are given a basic understanding of the history, principles 

and structure of clinical codes, together with an understanding of the benefits of 

using clinical codes for recording in primary care. 

The MIQUEST Process 

This two-day module provides facilitators with an understanding of the functions of 

the MIQUEST Query Manager and Response Manager, including configuring sets 

of queries, importing response files and aggregating and anonymising response 

files. 

Data Analysis, Interpretation and Feedback 

This module provides PRIMIS facilitators with the skills to understand analysed 

data, identify questions raised by the data, and feed back to practices in a 

supportive way. It also guides facilitators in how to help practices design action 

plans to improve data quality. 

CHART 

Facilitators are trained to use CHART (Care and Health Analysis in Real Time), a 

clinical information feedback tool developed by PRIMIS. CHART enables practices 

to analyse and view their data using a number of different query libraries, including 

one for the new GMS contract. 

The following modules are more generic than the above scheme-based modules. For many of 

the topics, it would benefit the facilitator to have undertaken the above modules to provide a 

rounded understanding of information management in primary care before undertaking these 

training sessions, although this is not a necessity. 

Facilitation Skills 

This module is run on a group basis and gives tools and techniques for identifying 

different behaviours and learning styles, managing different situations, and 

preparing for and managing meetings. It also provides guidance on other 

facilitation skills, like listening and negotiating. 

Annual Review 

A regular review with PRIMIS enables both the facilitator and their organisation to 

continually evaluate their aims and objectives, and to be responsive and proactive 

in making suitable changes. 

Action Planning and Supporting Change 

Facilitators are given an understanding of change management theory and 

techniques, enabling them to support the development, implementation and review 

of practice-based action plans. 




Information Governance 

With increasing emphasis on confidentiality and security in health care, this module 

is based on the policy and legal context of Caldicott, the Data Protection Act, 

BS7799 and the Freedom of Information Act. Facilitators gain an understanding of 

risk management and information governance, and how these interact with the 

PRIMIS process and agreements. 

Path to Paperless 

This module provides facilitators with guidance on the legal considerations and 

protocols required to be able to support their practices through the transition from 

paper to electronic patient records. 

Data Quality and Patient Safety 

Facilitators learn about the role of the National Patient Safety Agency and the 

safety features inherent in GP clinical computer systems, as well as the impact of 

data quality on patient safety. 

Supporting Quality Outcomes 

This module helps facilitators to guide practices in implementing the quality and 

outcomes framework of the new GMS contract. The training provides an 

understanding of the structure, process and outcomes for each of the clinical 

indicators and the ten disease areas in the clinical domain. 

Supporting Quality Services 

This training session looks at changes to the provision of primary health care 

services in the new GMS contract. It focuses on particular issues around Directed 

Enhanced Services and National Enhanced Services so that facilitators can help 

practices with data recording. 

Supporting Quality Review 

Facilitators are given an overview of the recording and review arrangements for the 

new GMS contract and an awareness of the data needed to support the reporting 

and verification process. 

Primary Care Data Uses and Abuses 

This module helps facilitators and others in their PCO to understand how to use 

aggregated primary care data to support their work, as well as becoming aware of 

some of the pitfalls to avoid. 





Background 

There are many factors that determine how successful a project is in meeting its objectives. 

Setting up a project to improve information management skills and data quality in primary care 

is no easy task. Many of the existing PRIMIS schemes have taken different approaches to their 

scheme management. For example, in Cambridgeshire the emphasis was put on: 

• having a clear vision of what was 

expected from the initiative 

• recruiting the right people 

• management support 

• clinical ownership 

Management support, recruiting the right people, 

having clear objectives and a detailed activity 

plan are common themes across many schemes. 

"The whole emphasis has been on 

actually setting up the process and 

making sure that there is ownership of the 

problems within the practice. We need to 

put in place a process that keeps it going 

when we walk away as facilitators." 

Cambridgeshire PRIMIS 

The aim of this training module is to provide guidance on project management, obtaining 

resources and equipment, networking within organisations, and recruiting and carrying out 

baseline assessments with practices, including issues of security and confidentiality. 

Facilitators are also provided with an awareness of the MIQUEST process, an understanding 

of issues surrounding data confidentiality, and an understanding of how to construct an action 

plan. The training includes the development of an individual action plan for the first few months 

of the facilitator’s work, based on their own training needs. Also covered are the skills and 

techniques required for the facilitator to assess the information training needs of the practices 

that they will be supporting. 

The Training 

The training takes place over a half or full day, and is run on an individual scheme basis. The 

training session starts with the facilitator completing a Training Needs Assessment (TNA) to 

enable the Learning Consultant to tailor the PRIMIS training package to their individual needs. 

The exact format of the training will then depend on the previous experience of the facilitator 

and the current status of the project, but is likely to include discussion around some or all of 

the following topics: 

• reasons for setting up a data quality improvement scheme 

• how a data quality improvement scheme is organised 

• managing the scheme and maintaining enthusiasm 

• the role of the local project board and who should be involved 

• information governance issues 

• the role of the facilitator 

• recruiting practices 




• an overview of general practice computer systems 

• how to carry out a baseline assessment 

By the end of the session, the facilitator will have developed their own short term activity plan. 

Learning Objectives 

The training will provide information facilitators with: 

• an understanding of what a TNA is and why one is needed 

• a training plan based on their own needs 

• an understanding of how the results of a TNA can be used to develop an action plan 

to help a practice team improve their ability to record high-quality patient data by 

identifying gaps in training and understanding of roles 

• an understanding of the different stages in the management of a scheme and how to 

plan each stage 

• an understanding of how to conduct a baseline assessment of practices’ computer 

usage and recruit practices to participate in the scheme 

• an awareness of the MIQUEST process and an understanding of the issues of 

confidentiality 

• an understanding of how to compile an action plan and the completion of a shortterm 

action plan for their individual scheme 

• an understanding of their role and the critical factors that can impact on the success 

of a scheme 

Further Reading 

PRIMIS Guidelines 


Roth J. Needs and Needs Assessment Process. Evaluation Practice. 1990; 11:141-3. 

Department of Health: Patient Confidentiality and Access to Health Records 

www.dh.gov.uk/PolicyAndGuidance/InformationPolicy/PatientConfidentialityAndCaldicottGuardians/fs/en 

Data Protection Act 

www.hmso.gov.uk/acts/acts1998/19980029.htm#aofs 




Training Plan - Links to other PRIMIS training 

Facilitators attending the Scheme Management training module would also find the 

following training modules of interest: 


What is PRIMIS? 









What Is Primary Care? 



Background 

What does it all mean? In a period when primary 

care has seen some of the largest structural 

changes in decades, with new contracts for GPs 

and new organisations cropping up virtually 

weekly, how does someone new to primary care 

find their way around? 

One thing that has been consistent throughout 

all the changes is the need for good quality data. 

Facilitators working in information management 

within primary care are now more in demand 

than ever. 

The Training 

• LDP 

This training module is intended for those 

facilitators who are new to the NHS or have 

never worked within a primary care organisation before. It may also prove to be a useful 

source of information for those who require a refresher on what is happening in and around 

primary care. The main aim is to introduce the facilitator to topics and sources of information 

what they will need to be familiar with in order to fulfil their role successfully. 

This training is delivered via an electronic program which the facilitator can obtain from his or 

her Learning Consultant. The facilitator can then individually run the program and determine 

their own pace and route through the module and can re-run the program again at any time in 

the future. Use is made of web hyperlinks in the program to take the reader to the home web 

page of various organisations for further in-depth reading as required. This can be followed up 

by a half or full day session as required. 

The main sections of the training course are: 


What is it and how is it defined? What is a General Medical Practitioner? Using links to various 

NHS organisations’ websites, answers to the above questions and more are provided. 

Relationship between primary care and other NHS agencies 

An organisational diagram is used to chart the NHS from the Department of Health through to 

Strategic Health Authorities and then down to the providers of local services, such as acute 

and community care trusts. Each organisation’s responsibilities are documented. 

Relationship between different organisations in primary care 

What Does it All Mean? 

• PCO 

• SHA 

• DoH 

• NPfIT 

• NHS Connecting for Health 

• Clusters 

• nGMS 

• QOF 

The responsibilities and links between Primary Care Organisations, Out of Hours, doctors’ 

surgeries, dentists, opticians and pharmacists are outlined. NHS walk-in centres and NHS 

Direct are also covered in the analysis. A pen picture of PRIMIS itself is also included. 




Structure of General Practice 

The organisation of general practice is dissected in detail, with the emphasis on the new 

working arrangements since the arrival of the new GMS contract in April 2004. The services 

offered by general practice now under nGMS are outlined along with the funding available. A 

background to the workings of the quality and outcomes framework (QOF) and the differences 

between GMS and PMS (Personal Medical Services) practices are detailed. 

Primary Health Care Team (PHCT) 

A comprehensive insight is provided into the roles operating within the PHCT, from different 

types of GPs, including GPs with Special Interests (GPwSI) to other clinical roles such as the 

Practice Nurse and the Health Care Assistant. The managerial and clinical roles within a 

practice are also discussed, with numerous web links to professional bodies representing each 

profession. 

Computerisation and General Practice 

The history of the background and use of computers in general practice since 1970 is traced. 

Important landmarks such as the background of Requirements for Accreditation (RFA), the 

NHS Plan, the 1990 GP Contract and the Wanless Report are included. More recently, NHS 

Connecting for Health and its stated aims are documented. 

Abbreviations used in Primary Care 

A simple listing is collected together in one place of a number of organisations operating in the 

NHS and their acronyms. Where available, a web link to each organisation’s home web page 

is made available for further reading. 



• understanding of what primary care is 

• awareness of the relationships between primary care and other NHS agencies 

• understanding of the relationships between the different organisations in primary 

care 

• understanding of the structure of, and relationships within, general practice 

• awareness of events that have brought primary care to its present position 

• understanding of internal and external forces that can have an impact on data 

quality in primary care 

• understanding of how PRIMIS can support primary care in improving data quality 







Department of Health 

http://www.dh.gov.uk 

National Association of Primary Care 

www.primarycare.co.uk 

National Primary Care Development Team 

www.npdt.org 

Primary Health Care Specialist Group of the British Computer Society 

www.phcsg.org.uk 

National PCT Database 

www.primary-care-db.org.uk 


Facilitators completing the What is Primary Care? training module would also find the 


• Scheme Management 

















Background 

The effective use of information 

management and technology is at the 

heart of the strategy to modernise the 

NHS, with quality information seen as 

the key to improving patient care and 

public health. 

"The most valuable repository about the current 

health of the population may well be GP records." 

Information for Health, NHS Executive, 1998 

The new GMS contract puts an emphasis on data quality for measuring achievement. 

“In order to measure achievement, practices will have to enter and retrieve high quality 

information from their practice clinical systems. To qualify for payment, quality framework 

data will be recordable, repeatable, reliable, consistent and auditable. IM&T systems are 

required in order to deliver such requirements. Education and training of practice staff will 

be supported through funded national programmes.” 

New GMS Contract 2003 - Investing in General Practice 

However, the primary care clinical system is more than just a data repository, being used as an 

integral part of the GP’s decision-making process during the consultation. Data quality is 

therefore essential at many levels. 

In 2000, electronic records were granted medico-legal status. Although provision is made for 

non-computerised practices, the expectation is that complete and accurate data will be 

recorded on a GP clinical system. There are certain areas of the patient’s medical history 

under the new GMS contract where there is consensus on how data should be entered. 

However, this is not always the case, especially in general practice where patients often 

present with problems which are not necessarily clear-cut and easy to record, are seen by 

different professionals and in different places. It is, therefore, essential to understand the 

processes involved in capturing data from the various sources within and outside of the 

practice in an accurate format. 

Data which are not accurate, complete, relevant, up-to-date and accessible may be dangerous 

to patients. For example, if a repeat prescription is not recorded accurately, severe harm to the 

patient could ensue; if an allergy is not entered, the record is not complete – such 

inadequacies could lead to medico-legal problems for the clinician and the practice. 

The Quality Data, Quality Outcomes training module provides new PRIMIS facilitators with 

knowledge and understanding of the importance of data quality and the recording of data for 

the quality and outcomes indicators of the new GMS contract. It will raise an awareness of the 

issues around the flow of data in and around a general practice and the difficulties in recording 

data and validating the quality of the data when they are entered and when they are later 

retrieved. 

The information facilitator will be able to encourage practices to use their GP clinical systems 

for recording data for quality outcomes, and apply change management theory to general 

practice. 




The Training 

The training takes place over a full day and is run on an individual scheme basis covering the 

following topics: 

• why data quality is important 

• how data quality is defined 

• the baseline essential elements of a patient record and how they are created 

• the importance of capturing data from home visits and other locations outside of 

the GP surgery 

• mapping data flows from secondary care into a practice to eventual entry onto the 

clinical system 

• the differences and similarities between the NSFs, National Institute for Clinical 

Excellence (NICE) guidelines and Quality and Outcomes Framework (QOF) 

indicators and the essential data recording requirements for each 

• practical knowledge of clinical coding structures 

• problems faced by many practices with consistency in methods of data capture and 

entry between all practice staff 

• methods of entering and capturing data onto a clinical system 

• how to raise the issue of data quality and help practices to address any problems 

and share best practice. 



• an awareness of what is meant by the patient’s story and their contact with the 

healthcare professionals in a GP practice, including what data recording is required 

at each step 

• an awareness of the importance of data quality and its relevance to recording 

issues pertaining to the patient’s story 

• an understanding of the necessity to identify all relevant information coming into 

the practice 

• an awareness of what is required to collect all the relevant information in the 

correct format 

• an awareness of the range of options for storing the data 

• an understanding of the knowledge required to retrieve the data in an accurate 

format 

• knowledge and understanding of data quality theory and its application to the 

patient’s story 

• an understanding of future issues that may affect primary care data. 






www.primis.nhs.uk/pages/download_template.asp?r=Guidelines_Sept01.pdf 

Good Practice Guidelines for General Practice Electronic Patient Records. 2000. GMC GPs 

Committee and the RCGP on behalf of the NHS Executive. London: GMC. 

www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/Publicati 

onsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4008657&chk=rr8fQT 

Maintaining Good Medical Practice 2. London: GMC; 1998. 

Medical Records. London: Medical Protection Society; 1999. 

Morris D. Acquiring computer literacy. British Medical Journal. 1998; 317:2. 

Roscoe T. Paper vs electronic medical records (special paper). Wisdom website; 2000 

http://wisdomnet.co.uk/paper.html 

Report on the Review of Patient-identifiable Information. The Caldicott Committee. London: 

Department of Health; 1997. 

Play IT Safe – a practical guide to IT Security for everyone working in General Practice 

www.connectingforhealth.nhs.uk/publications/comms_tkjune05/NHSnumberarticleforsyndicatio 

n.pdf/view?searchterm=Play%20IT%20safe 

Pringle M. Using a computer in the consultation. In: Sheldon M, Stoddart N, eds. Trends in 

General Practice computing. London: Royal College of General Practitioners; 1985. 

Waring N. To what extent are practices “paperless” and what are the constraints to them 

becoming more so? British Journal of General Practice. 2000; 50: 46-7. 

Watkins C et al. General practitioners’ use of computers during the consultation. British Journal 

General Practice. 1999; 49:481-3. 


Facilitators attending the Quality Data Quality Outcomes training module would 

also find the following training modules of interest: 















Background 

General practice systems use ‘clinical coding’ to store data. To record data, the user enters a 

medical term or concept. The computer system then presents a set of ‘terms’ or ‘rubrics’, 

together with ‘codes’. Assisted by the rubric, a choice is made and the data item is thereby 

recorded. An important part of setting recording guidelines is to ensure that appropriate codes 

are assigned for the items in the data set and that these codes are used for entering data in 

the patient’s record at the appropriate stage in the cycle of care. 

In the early 1980s, Dr James Read developed a coding system for general practice for the 

purpose of maintaining a computerised patient record. It allowed for increased efficiency and 

improved preventative procedures. This coding system became known as the ‘Read Code’ and 

remains as the accepted standard for British general practice. The coding system copyright 

was purchased by the Secretary of State for Health in 1990 and the Read Code became 

Crown Copyright. It has been subsequently developed in later versions to include terminology 

content appropriate for a wider range of health care specialities and professional groups. All 

versions of the Read Code are maintained and developed by NHS Connecting for Health. 

There are three versions of the Read Code currently in use as shown in the box below: 

The current three versions of Read Code in general practice 

• GP 4 byte set (referred to as Version 0) 

• GP 5 byte set (referred to as Version 2) 

• Clinical Terms Version 3 (referred to as CTV3) 

The GP 4 byte set was developed for use in GP systems and the codes are four characters 

long, allowing four levels of detail. The GP 5 byte set extended the codes to five characters - 

and thus a fifth level of detail - and included cross reference to the International Classification 

of Diseases tenth revision ICD-10. Clinical Terms version 3 (CTV3) incorporates 

comprehensive codes for the acute sector, as well as general practice, allowing for storage, 

retrieval, cross-mapping and analysis of patient information. The mostly widely used set within 

GP clinical systems at present is the GP 5 byte set. 

The important point to be aware of is the ‘hierarchical’ nature of Read codes, as demonstrated 

in the example shown below. As the diagnosis becomes more specific, so the appropriate 

Read code carries more significant characters to reflect the greater level of detail. The coding 

scheme is a structured collection of ‘terms’ with each clinical entity, known as a concept, being 

represented by a preferred term. Each concept has a unique alphanumeric code, known as the 

Read code. 




Example of the hierarchical nature of Read codes 

Level Term Read 4-byte Read Version 2 

1 Circulatory system disease G… G.... 

2 Ischaemic heart disease G4.. G3... 

3 Acute myocardial infarction G41. G30.. 

4 Anterior myocardial infarction G301. 

5 Acute anteroseptal infarction G3011 

The NHS Executive and the College of American Pathologists (CAP) have developed a new 

collaborative work, SNOMED Clinical Terms. This coding system combines CAP’s SNOMED 

RT with the Clinical Terms Version 3 (Read Codes) and is called SNOMED CT. This single 

unified terminology will underpin the development of the integrated electronic patient record 

and is a pivotal part of the National Programme for Information Technology National Care 

Record Service. PRIMIS is currently developing a training module on SNOMED CT. 

The Training 

The training takes place over a half day and is run on an individual scheme basis. 

It covers the advantages and disadvantages of coding, the different coding schemes in use 

across health care and a detailed overview of Read codes, including the structure, the 

hierarchy and the Read code chapters. The training also provides practical techniques and 

exercises for searching for Read codes within a browser. 

Further information on the background and subject matter included in this training is available 

in the form of a workbook. This is provided to facilitators during the training. 



• an understanding of the history, principles and structure of the Read codes in the 

various versions 

• skills in finding and selecting appropriate codes for specified conditions/ 

investigations/procedures, etc., using a variety of Read Code browsers (including 

GP systems, CLUE and NHS Connecting for Health) 

• an understanding of the limitations of Read codes when grouped for analysis 

• skills to enable them to teach practice team members how to find and select the 

appropriate Read code using the Read code browser available to them 







NHS Connecting for Health 

www.connectingforhealth.nhs.uk 


Facilitators attending the Clinical Coding training module would also find the following 

training modules of interest: 



• CHART 










Background 

MIQUEST stands for: Morbidity Information Query and Export Syntax and is a software tool to 

extract and aggregate comparable data from disparate GP systems. It is a method for 

extracting data in a computer-readable form that uses a common query language for health 

known as Health Query Language (HQL) and can therefore be used with a variety of different 

GP clinical computer systems, using the system’s own MIQUEST interpreter. Both MIQUEST 

and the system interpreters incorporate various security and confidentiality safeguards which 

enforce security constraints to prevent unauthorised extraction of patient-identifiable data. 

MIQUEST has been endorsed by the NHS as the recommended method of expressing queries 

and extracting data from different types of practice systems and it has therefore been adopted 

as the standard method for PRIMIS. 

MIQUEST in itself is not a data quality improvement method, but is one of the many tools that 

an information facilitator will use when working with a practice to improve their data quality. 

MIQUEST Enquirer software is Crown Copyright, for use only by authorised personnel within 

the NHS. Technical maintenance and development support for MIQUEST Enquirer is provided 

by NHS Connecting for Health, but the suppliers of each GP computer system are responsible 

for support and maintenance of their system’s own MIQUEST interpreter. 

MIQUEST is available on the majority of GP clinical computer systems that are in use today. 

This is because it is part of the General Medical Practice Computer Systems – Requirements 

for Accreditation (RFA99) scheme. Where MIQUEST is available for a particular GP clinical 

system, it should be used as the preferred method of extraction of data from that system for 

PRIMIS purposes. 

MIQUEST Enquirer software includes a Query Manager to facilitate the distribution of queries 

and a Response Manager to organise and aggregate the responses received from participants 

in a local or national data collection scheme. An HQL Editor is also available to facilitate the 

writing of queries. However, it should be noted that the construction of a MIQUEST query set 

and the coding required for it can be complex and often time consuming, requiring both clinical 

and technical input. 

The responses from a MIQUEST-generated query are created as Comma Separated Value 

(CSV) files. Analytical tools such as PRIMIS Rush and CHART use these files to create easyto-view 

graphs, summary sheets and spreadsheets, enabling trained information facilitators to 

interpret and make sense of the data extracted. 

The Training 

The training takes place over two full days and is run on an individual scheme basis. 

Prior to training, information facilitators will be required to install the MIQUEST software on 

their PC or laptop. This is available from Connecting for Health on a CD-ROM. Contact the 

Connecting for Health helpdesk on 01392 251289, or email helpdesk@nhsia.nhs.uk or visit 

www.nhsia.nhs.uk/nhais/pages/products/vaprod/miquest/ to fill out an online request form. 




The first day concentrates on the benefits and process of using MIQUEST as part of a data 

quality improvement scheme. It will provide an understanding of Query structure and the use 

of the MIQUEST Query Manager. An overview is given on how the data extraction process 

works, as shown in the box below, once the preliminary steps of agreeing objectives and 

setting up the scheme have been implemented. 

Five steps of PRIMIS data extraction process 

• Confidentiality Agreement 

• Query Manager 

• MIQUEST Interpreter (Clinical System) 

• Response Manager 

• Analysis Package (PRIMIS Rush) 

The training shows the information facilitator how to download Data Quality query sets, how to 

populate the Query Manager with their allocated practice details and how to prepare the 

practice query disk using the Query Manager. 

The second day’s training focuses on the MIQUEST Interpreters. It includes on-site visits to 

local GP practices in order to run a set of training MIQUEST queries. This is then followed by 

training on the use of the Response Manager to aggregate and anonymise the data extracted. 

Finally information facilitators are shown how to submit their data extraction to PRIMIS for 

analysis. 


in the PRIMIS MIQUEST Manual. This is provided to facilitators during the training. 


The first day’s training (MIQUEST Overview and Query Manager) will provide information 

facilitators with an understanding of: 

• the functions of MIQUEST Query Manager 

• how to set up scheme details (Remote and Local), practices, agreements, etc. 

• how to add new practices, new agreements, etc. 

• how to configure sets of queries for their scheme/PCO/practices 




The second day’s training (MIQUEST System Interpreters and Response Manager) will 

provide information facilitators with an understanding of: 

• the functions of MIQUEST interpreters on clinical systems 

• how to import and run queries from different enquirers with appropriate security 

safeguards 

• how to export response files to disk or to transmit on a network when this option is 

available 

• how to work with volunteer practices and the PRIMIS Learning Consultant to teach 

practice staff the appropriate use of their MIQUEST interpreter 

• functions of MIQUEST Response Manager and how to aggregate anonymised data 

for analysis. 



www.primis.nhs.ukpages/download_template.asp?r=Guidelines_Sept01.pdf 

PRIMIS MIQUEST Manual 


Facilitators attending the MIQUEST training module would also find the following training 

modules of interest: 





• Project Review 


• CHART 








Background 

The use of MIQUEST in the PRIMIS process is twofold. Firstly, it provides a mechanism for the 

easy extraction of data recorded on a practice’s clinical system, enabling the practice to 

examine and improve data recording techniques. This method can be supplemented by using 

various analysis software tools such as CHART, the use of which is covered in a later module. 

Secondly, it enables practices to compare their data recording to that of other practices or 

against their own recording over time. In order to enable the effective use of MIQUEST, 

PRIMIS has developed several query sets. Each set has a different focus and is designed to 

meet a variety of needs. 

A key query set, and the one used most 

frequently, is the PRIMIS Data Quality set. 

This set has been designed to enable 

facilitators and participating practices to 

begin to identify areas where the data 

recorded on the clinical system is not of 

good quality: that is, it does not have the 

five characteristics of good quality listed in 

the box to the right. 

Five characteristics of good quality data 

• Completeness • Accessibility 

• Accuracy • Timeliness 

• Relevance 

The PRIMIS Data Quality query set is one of the most valuable sets in supporting information 

facilitators in their role. Facilitators run this set with all new practices joining the scheme, and 

repeat the run at regular intervals. Once a practice has identified the strengths and 

weaknesses of their data capture methods, they are then in a position to make improvements. 

The queries are intended to provide a basis for discussion and debate from which an action 

plan can be derived. By repeating data extractions at regular intervals, the practice will be able 

to demonstrate improvements over time and see the effectiveness of actions taken. 

The Training 

The training takes place over a half or full day and is run on an individual scheme basis. Data 

extracted from practices and submitted to PRIMIS by a scheme are analysed and reported 

back to the facilitator in an Excel format known as Rush. This format enables the facilitator to 

view the data in a variety of ways. Throughout the training, the facilitator is taken through their 

own practices’ data and shown how to use the analyses listed in the box below to identify 

where there are potential data quality issues. 

Analyses used in the PRIMIS Data Quality 

query set to highlight potential quality issues 

• Baseline prevalence • Risk factor recording 

• Apparent prevalence • Screening data recording 

• Comparison with proxy indicators • Data validity checks 




The training also covers techniques for feeding data back to practices and other appropriate 

bodies, such as the PCT or employing organisation, and the steps to be taken in developing 

an action plan for tackling changes that need to be made. An important part of the training is 

the management of confidentiality issues. 

On completion of the training, facilitators will be able to submit further data to the PRIMIS 

Information Team and receive the analysed data back via the PRIMIS secure website. 



• an understanding of how to download feedback and configure Rush 

• an understanding of Rush graph construction including the difference between 

morbidity, mortality, prevalence and incidence 

• an understanding of data quality issues that contribute to feedback results 

• an understanding of limitations and use of aggregated feedback data 

• an awareness of confidentiality issues relating to aggregated data 

• an awareness of additional methods, including clinical systems’ own search 

engines, to complement feedback. 





Before attending the Data Analysis, Interpretation and Feedback module, facilitators 

should already have attended the following PRIMIS training modules: 




Facilitators attending this training module would also find the following training modules 

of interest: 










Background 

“Managers are under increasing pressure to implement major structural reform in the NHS 

as well as achieving demanding national performance targets. At the same time they are 

expected to deliver changes in the culture of NHS organisations - changes which some 

regard as fundamental if real improvements are to be sustained. 

“The political imperative to deliver rapid objective change can lead managers to adopt an 

increasingly authoritarian style. Such an approach may be effective in producing short term 

measurable change, but it is likely to bring managers into direct conflict with doctors who 

value their professional autonomy and resist current attempts to ‘manage’ their 

performance. Management styles that make doctors unhappy may adversely affect both the 

quality of care and patients’ satisfaction. 

“Tension exists between the performance management role of managers and their 

responsibilities to produce changes in the culture of the NHS. This tension is becoming 

increasingly important for managers who work in primary care trusts - relatively new 

organisations that are expected to lead the reform of the NHS.” 

Marshall et al. Managing change in the culture of general practice: qualitative case studies 

in primary care trusts. British Medical Journal. 2003; 327:599-602. 

Facilitated change is key to helping organisations meet the demands of the current NHS. The 

input of a facilitator can have a very positive effect in smoothing the transition from one way of 

working to another. The facilitator works, either formally or informally, with the practice team to 

create a climate of trust and confidence where barriers to change can be acknowledged, 

discussed and addressed. 

It is recognised that when most changes go 

wrong, it is because too little time is spent 

exploring the background and the context for 

change, and helping people recognise the 

imperative for change. An effective change 

programme tends to adopt certain key 

characteristics as outlined in the box on the right. 

The facilitator is there to ensure a productive 

group process, whether this is brainstorming new 

ideas or improving existing processes. The role 

of the facilitator is to help and support the group 

to work as a constructive and cohesive unit and 

to enable them to take ownership of the process 

and undertake the task to achieve the objectives. 

Characteristics of a successful 

change programme 

• A clear understanding of the context 

and external factors driving change 

• Recognition of the implications for 

the organisation resulting in the 

recognition that the status quo will 

not do 

• A well devised change plan which 

highlights the application of change 

and how it will be delivered 

• An opportunity to be engaged in the 

implementation 




The Training 

The training takes place over a half or full day and is run as a group session. The aim of the 

training is to equip participants with the skills to effectively facilitate teams, particularly general 

practice teams. The training comprises interactive exercises using tools and techniques in 

facilitation based on the following topics: 

• definition of facilitation and the attributes that make an effective facilitator 

• understanding the core competencies needed in the process of facilitation 

• listening skills 

• communication styles 

• managing and making meetings effective 

• dealing with difficult behaviours 

• agreeing priorities 

• the importance of review 

• tools and techniques used in facilitation 





• a knowledge of the definition of a facilitator 

• an awareness of a selection of communication styles and skills 

• an understanding of how to deal with differing behavioural styles and how to facilitate 

meetings 

• an understanding of team working and negotiation skills 


Bray T. Training Sessions for Effective Meeting. Aldershot: Gower Publishing; 1995. 

Dobson A. Managing Meetings. Plymouth: How to Books; 1999. 

Duffy M, Griffin E. Facilitating Groups in Primary Care. Abingdon: Radcliffe Medical Press; 

2000. 

Hart L. The Faultless Facilitator. London: Kogan Page; 1992. 

Hunter D, Bailey A, Taylor B. The Facilitation of Groups. Aldershot: Gower Publishing; 1996. 




Johnson D, Johnson F. Joining Together: group theory and group skills. New Jersey: Prentice- 

Hall; 1991. 

Sharman D. The Perfect Meeting. London: Century Business Books; 1992. 

Primary Care Facilitation: what is it and what is the evidence of its effectiveness? Oxford: The 

National Primary Care Facilitation Programme; 1998. 

Middleton J. The Team Guide to Communication. Abingdon: Radcliffe Medical Press; 2000. 

Elwyn G, Greenhalgh T, Macfarlane F, Groups: a guide to small group work in healthcare, 

management, education and research. Abingdon: Radcliffe Medical Press; 2001. 

King J. Effective Facilitation. British Medical Journal 2002; 324:S36. 


Facilitators attending the Facilitation Skills training module would also find the following 

training modules of interest: 








Annual Review 


Annual Review 

Background 

Since April 2000 PRIMIS has been working, through local PCOs, to help GPs to make the best 

use of their clinical computer systems, both in meeting their organisational needs and in 

supporting good quality patient care as part of an ongoing programme of development. 

However, as with any work programme, regular progress reviews are essential. 

“The underlying objective for a project review is to improve the overall outcome. To achieve 

this, the review must be forward looking, constantly seeking to identify how current lessons 

can be exploited for future advantage. For a review to add real value, it must go beyond 

the superficial and drill down to the underlying capabilities. By doing this it can identify 

fundamental improvements that are the key to consistently improved performance in the 

future.” 

www.amtec.co.uk/private-sector-consulting/foundation/project_review/project_rev_overview.xhtml 

Many project and change management theories extol the virtue of ongoing review to ensure 

that projects remain on course, identify and address any issues as they arise, and constantly 

strive towards achieving the original aims and objectives of the project. A local PRIMIS project 

or scheme is no exception. 

The PRIMIS approach to training and working with an information facilitator is adaptive and the 

principles of the scheme review follow the broader principles of PRINCE 2 (PRojects IN 

Controlled Environments) methodology, a structured method for effective project management 

used extensively by UK Government organisations. 

The Training 

The training takes place over a half or full day and is run on an individual scheme basis, 

involving the information facilitator and preferably their line manager. It is usually held at the 

end of the first year of the project. Subsequent reviews may be conducted by correspondence. 

The training will be introduced with a presentation and discussion on what an annual review 

should include, what steps are involved and an explanation as to why it is an essential 

process. The various methods of conducting an annual review are also discussed. 

The aim of this training is twofold: to carry out a review of the local scheme and to equip the 

information facilitator with the skills to facilitate their practices to carry out reviews. 

The review itself will involve a guided discussion around key stages and events as outlined in 

the box on the following page. The experiences and the reflections from the facilitator will be 

documented. 



Annual Review 

Typical key stages and events for discussion at a project review 

• The specific objectives for the scheme 

• Progress against objectives 

• Reasons for non-achievement 

• Encountered problems and how they were resolved 

• Changes in direction 

• Unexpected benefits 

• Collaboration with other projects 

• Overall satisfaction 

• Funding, and further requirements 

• Action plan for the way forward 

The information facilitator may also be encouraged to conduct a self-evaluation SWOT 

(strengths, weaknesses, opportunities and threats) exercise to help highlight any areas of 

achievement or strengths that could be utilised further. The SWOT analysis will also help 

identify any areas that may be causing concern for the facilitator. The SWOT analysis process 

may be held in confidence between the facilitator and the Learning Consultant. 


The training should provide the information facilitator with an understanding of: 

• what an annual review should include 

• why an scheme review is needed 

• what steps are required when conducting an annual review 

• what methods can be used in an annual review 

The training will also help the information facilitator identify: 

• how the results of an annual review can be used to develop an action plan to improve 

their ability to project manage their PRIMIS programme 

• any gaps in training and missed milestones and the reasons for these 

• where the project has succeeded and any lessons that could be shared. 


Annual Review 


Further reading 



PRINCE 2 

www.prince2.com/whatisp2.html 


Before attending the Scheme Review training module, facilitators should have attended the 

following PRIMIS training modules and have completed a whole cycle of data flow mapping, 

data extraction and feedback: 






Facilitators attending this training module would also find the following training modules of 

interest: 






Annual Review 


CHART 


CHART 

Background 

CHART stands for Care and Health Analysis in Real Time. It is a software program based on 

Excel that enables the quick and easy viewing of data from clinical queries. The software, 

which has been developed by PRIMIS as an upgraded alternative to Rush for Practices, is 

designed to be used within practices allowing the practice staff or PRIMIS facilitator to produce 

health query language (HQL) queries, taken from a library, which are then run on their clinical 

system. The query responses are imported back into CHART. Results are displayed either as 

easy-to-read graphs, summary sheets or a spreadsheet. CHART gives a practice the option to 

run local, patient-identifiable queries or, if preferred, anonymised queries should they wish to 

share data confidentially. 

CHART can be used in conjunction with any RFA accredited clinical system with a functioning 

MIQUEST interpreter. As the responses are converted into Excel format, the software retains 

much of the original Excel functionality, including the ability to sort or filter the extracted data 

and drill down through graphical displays to quickly identify groups of patients by type of 

recording. Responses take the form of a spreadsheet with one line for each patient included in 

the cohort. Each column represents an indicator included in the query, giving a whole patient 

picture for that specific clinical area. Viewing the clinical data in this way enables gaps in the 

patients’ data relating to the specific query topic to be highlighted and, by using multi-factor 

filtering, complex data and/or clinical quality issues can be picked up: for example, identifying 

patients with a recorded diabetes diagnosis who have a raised HbA1c and a BMI greater than 

25. By archiving results and comparing them with later extractions, any changes or 

improvements can be identified. 



CHART 

The CHART queries 

Each clinical topic is arranged into groups of queries known as query libraries. The libraries 

currently available are shown in the box below. Each query library can be downloaded 

separately and used as and when needed. Date ranges within queries are controlled by the 

user and are automatically updated through the use of a reference date. New query libraries 

can be installed directly into existing CHART software. 

The CHART query sets have been 

developed by the PRIMIS Team, with 

significant clinical input from the 

PRIMIS Clinical Advisory Group. They 

have then undergone a process of beta 

testing before release. 

At the time of writing, the PRIMIS Team 

is currently working on a data quality 

library which will allow practices to 

identify gaps and errors in their patient 

records. 

CHART query libraries available (April 2005) 

• the nGMS query library - focusing on the 

new contract 

• the Flu query library - looking at influenza 

vaccinations 

• the original Rush query library - focusing on 

the Quality and Outcomes Framework 

Using CHART as a Data Quality Improvement Tool 

One of the big advantages of CHART is that it remains in the practice and is relatively simple 

for practice staff to use, following training provided by the facilitator. This gives practice staff 

the ability to look at their own data quality and patient care whenever they need to, for 

example in relation to the New GMS Contract. Responses are displayed in a format that allows 

the user to analyse the patient record, using filters to review various criteria. This can be done 

either through the datasheet, or by drilling down through the various graphical displays. 

The Training 

The CHART training module takes place over a half or full day and is run on an individual 

scheme basis. During the training, facilitators will be shown how to download the software and 

query libraries and how to use the software to customise HQL queries. Analysis of responses 

and how to use the CHART display functionality to identify data quality issues is also covered 

in some detail, as is how to train practice staff to use the software. On completion of the 

training, facilitators will have access to the CHART software and CHART query libraries on the 

PRIMIS secure website. 

Further information on the subject matter included in this training is available in the form of 

printed CHART instructions and a computer-based tutorial. These are provided to facilitators 

during the training. 


CHART 



The training will provide facilitators with: 

• the skills to download and install CHART software and query libraries 

• an understanding of the functionality of the software 

• the skills to analyse and interpret the query responses when viewed using CHART 

software 

• the ability to train practice staff in the use of the software 

• an understanding of the confidentiality aspects of the software. 


Before attending the CHART training module, facilitators should have attended the 

following PRIMIS training and have completed some data quality improvement work with 

their local practices: 





Facilitators attending this training module would also find the following training modules of 

interest: 






CHART 





Background 

The NHS is constantly changing due to the political agenda. Recent changes to the GP 

contract and the increased priority for use of information technology in the NHS are affecting 

the culture of primary care, with emphasis on recording data on the computer as opposed to 

paper-based records. 

This training module follows on from the Data Analysis, Interpretation and Feedback module 

and is designed to assist the information facilitator in helping practices to manage change, and 

develop and implement action plans. Following on from the facilitator’s initial feedback session, 

the practice can identify areas where data quality issues have been highlighted. It gives a 

platform to start from in deciding: 

• where are they now? 

• where do they want to get to? 

• how are they going to get there? 

One method for instigating change is to raise dissatisfaction with the current situation, in this 

case in the quality of the practice’s data. This should be a whole practice process with all 

members of staff involved. There are various techniques that a facilitator may use with a 

practice. Some examples are given in the box below: 

Suggested Information Management tasks for practice use 

• Planning data collection and storage processes 

• Understanding how members of the practice team use data 

• Developing data entry policies and procedures 

• Monitoring information handling systems 

The Training 

The training takes place over a full day and is run on either an individual scheme or group 

basis. The training consists of a presentation about the stages of change management and 

several exercises to be undertaken by the participants during the training; it covers the 


• reducing resistance to change 

• knowing what causes change 

• raising dissatisfaction with the current way of doing things 

• reaching agreement on a common way forward 

• identifying who is involved in the change process 




• building confidence that the target is achievable 

• implementing the change and the new ways of working 

• understanding how change affects the people involved 

• addressing issues that will hinder the implementation of change• 

• using practical management tools and techniques 

• supporting the changes 

• embracing the new methods 

• skills needed for a change agent. 





• an understanding of change management theory 

• an understanding of change management techniques 

• an understanding of how to support the development, implementation and review of 

practice based action plans 

• an understanding of their role as a change agent 

References and further reading 



New GMS Contract 2003 – Investing in General Practice 

www.nhsconfed.org 

Good practice guidelines for practice electronic patient records. GPC/DoH 



Brooks B, Upton T. Managing Change in the NHS. Maidenhead: Open University Press; 1999. 

Drucker P. Managing the Non-Profit Organisation. Oxford: Butterworth-Heinemann; 1992. 

Handy C. Understanding Organisations. London: Penguin; 1985. 

Kolb DA et al. Organisational Psychology: An experiential approach. Paramus, NJ: Prentice- 

Hall; 1974. 

Lewin K. Group Decisions and Social Change. In: Readings in Social Psychology. Maccoby 

EE, Newcomb TM, Hartley EL, eds. New York: Holt, Rinehart, and Winston; 1965. 




Pringle M et al. Managing Change in Primary Care. Abingdon: Radcliffe Medical Press; 1991. 

Schein E. Organisational Psychology. Paramus, NJ: Prentice Hall; 1980. 

Teasdale K. Managing the Changes in Health Care. Wolfe; 1992. 

Pease A. Language: How to read others’ thoughts by their gestures. London: Sheldon Press; 

1997 

Brookfield S. Understanding and Facilitating Adult Learning. Maidenhead: Open University 

Press; 1986. 


Facilitators attending the Action Planning and Supporting Change training module would 

also find the following training modules of interest: 













Background 

Information Governance is a broad-based approach to looking at all aspects of how 

information is processed by NHS organisations – how it is Held, Obtained, Recorded, Used 

and Shared (HORUS). And just like other governance initiatives, e.g. research, corporate and 

clinical governance, information governance is about setting standards – standards for 

handling information in a confidential and secure manner. These standards are derived from 

law, policy and agreed best practice, such as: 

• the Common Law Duty of Confidence 

• the Data Protection Act 1998 

• the Freedom of Information Act 2000 

• the NHS Code of Conduct for Confidentiality 

• the Caldicott Report 1997 

• Information Security Management – BS7799 

• records management – HSC 1999/053 

• a strategy for information quality assurance 

Broadly speaking, information governance can be divided into five main components: 

confidentiality and consent 

data protection 

IM&T security 

records management 

information quality assurance 

Confidentiality and Consent 

Under the common law duty of confidence, patient information is generally held under legal 

and ethical obligations of confidentiality. Information provided in confidence should not be used 

or disclosed in a form that might identify a patient without his or her consent. There are a 

number of important exceptions, but these obligations apply in most circumstances. 

Data Protection 

The Data Protection Act 1998 is built around a set of enforceable principles. These are 

intended to protect personal privacy, to encourage good practice in the handling of personal 

information, and to give individuals a right of access to information about themselves, for 

example to their own health or financial records. The Data Protection Act applies to all bodies 

that process personal information, not only to public authorities. 




IM&T Security 

The NHS and its partners handle vast quantities of sensitive information every day, including 

both clinical and non-clinical information. Comprehensive policy and guidance on information 

security and relevant risk management need to be in place, thereby ensuring that all 

reasonable care and safeguards to protect both the physical security of information technology 

and the data contained have been taken. This is often referred to as CIA – protecting the 

Confidentiality, Integrity and Availability of NHS systems and the data held within them. 

Records Management 

An organisation’s records represent the organisation’s corporate memory, providing evidence 

of actions and decisions, while also supporting daily functions and operations. Records support 

policy formation and managerial decision-making; they protect the interests of the organisation, 

and also the rights of patients, staff and members of the public. 

Information Quality Assurance 

All health care is information-driven, be it for the provision of direct clinical care of the patient, 

for disease surveillance, for medical research or for health care management. Any threat to the 

quality of that information is therefore a direct risk to the quality of the service provided by the 

NHS and those who access that service. Clearly, setting standards for assuring good data 

quality is an important element of information governance. 

The Information Governance Toolkit, which provides a route map for the achievement of best 

practice in information governance for NHS organisations, makes it a requirement for general 

practices to participate in a recognised scheme of data quality, such as PRIMIS, or to 

undertake regular detailed in-house checks on data quality. 

These five key areas, including the relevant legislation, policy and guidance, are covered in the 

PRIMIS Information Governance training module. 

Information Governance and the PRIMIS Process 

Throughout the PRIMIS process, there are many aspects of the work where information 

governance needs to be considered. These include: 

• data quality - an important component of information governance 

• confidentiality agreements with participating practices 

• protocols for sharing named practice data 

• confidentiality safeguards inherent within MIQUEST 

• using report style MIQUEST queries run as a local enquirer, such as CHART 

• records management policies 

• access to the computers in general practice 

• confidentiality and security of information held on computers. 




The Training 

The training takes place over a full day and is run on either an individual scheme or group 

basis. The aim of the Information Governance module is to provide information facilitators with 

an overview of the relevant information governance legislation, policy and guidance, placing it 

in the context of the PRIMIS process and their role as information facilitators. 



A refresher module is also available, which provides an overview of legislation, policy and 

guidance only. This is designed for information facilitators who have already attended the full 

training module session but who wish to keep up to date with the latest information 

governance standards. 



• an awareness of the key factors that need to be taken into account in relation to 

information governance 

• an understanding of how information governance interacts with the PRIMIS 

process 

• an awareness of relevant security and confidentiality legislation 

• an understanding of the impact of information governance on the role of the 

facilitator 

• an awareness of the Caldicott principles and definitions 

• an understanding of risk management and analysis. 


Between You and Me, Protecting Personal Information. NHS Information Authority 2001 

(Caldicott toolkit Document reference No: 2001-1A-730) 

www.nhsia.nhs.uk/caldicott 

General Medical Council. Confidentiality: Providing and Protecting Information, 2000 

Guidelines for Professional Practice, 1966. United Kingdom Central Council for Nursing, 

Midwifery and Health Visiting (UKCC). 

Code of Conduct 2000. Association of Medical Secretaries, Practice Managers, Administrators 

and Receptionists (AMSPAR). 

Clinical Records in Primary Care: Access and Confidentiality 1999. The Royal College of 

General Practitioners 

www.rcgp.org.uk 




Information Policy Unit 

www.dh.gov.uk/PolicyAndGuidance/InformationPolicy/fs/en 

Data Protection Registrar 

www.dataprotection.gov.uk 

British Medical Association 

www.bma.org.uk 

NHS Lifehouse – Protecting named and anonymised patient data, Department of Health 

www.dh.gov.uk/PolicyAndGuidance/ResearchAndDevelopment/NHSLightHouseProject/NHSLig 

htHouseProjectArticle/fs/en?CONTENT_ID=4049404&chk=Dsc0AS 


Facilitators attending the Information Governance training module would also find the 





• CHART 









Background 

“Going paperless has been a major hurdle for many. It is the golden egg of medical 

information technology and many believe offers great promise for medical care. UK 

primary care computing leads the way in the world. It has a long history stretching back 

over 20 years. The systems have been developed, primarily by experienced GPs, into 

medical records that are more sophisticated and more comprehensive than those in other 

countries. The ‘cradle to grave’ NHS record, the need for lifelong total care and the 

registered list of patients have given us the opportunity to explore what computer systems 

can do. However, their full potential has been recognised by only the dedicated few, with 

most just using the computer for basic data collection. Now, UK general practice has 

changed. The increasing bureaucracy, the need for accountability and the removal of the 

legal impediments mean that every practice now has to move towards fuller 

computerisation and the paperless practice.” 

Glyn Hayes, August 2001, in Going Paperless, Shaw N, Radcliffe Medical Press 

Questions to consider before attending this module:• 

• Do you know what the legal position is for practices regarding the keeping of 

wholly electronic patient health records? 

• Are you aware of your PCO's responsibilities with regard to approving 

applications to maintain electronic patient health records? 

• Do you know who is responsible for the approval and accreditation process at 

your PCT? 

• Are you able to offer help and guidance to your practices? 

• Do you know anything about scanned image file formats? 

This training module is intended for those facilitators who are working with practices moving 

towards developing electronic patient health records. Many practices have already made 

considerable inroads into moving away from paper-based recording. However, they will all be 

at differing stages and need differing individual help and guidance. 

The latest guidance published by the Royal College of General Practitioners, the British 

Medical Association and the Department of Health forms the basis for much of the Path to 

Paperless training session. Experiences learned and shared by other facilitators are also 

included. 




The Training 

The training takes place over a full day, is run on a group workshop basis and covers the 


What is the Electronic Patient Record? 

This covers a brief history of the growing capabilities and use of IT systems in general practice 

and the landmark legislation permitting the keeping of electronic-only patient health records. 

The advantages for the patient and the health professionals of using electronic patient health 

records are analysed, as well as any perceived barriers. The capabilities of the electronic 

patient health record are discussed, together with some proven techniques and tools for 

helping a practice to plan and undertake this fundamental change in the way they operate. 

Approval process for going paperless 

In-depth information on the accreditation and approval process is included in the training. The 

skills required to transfer written legacy notes are outlined with the focus on the need to plan to 

achieve a quality result. An example exploring the sources of data flowing into a fictitious 

practice is used to demonstrate the importance of data flow mapping tools in preparing to 

become paperless. 

References are made to the sections of the Quality and Outcomes Framework of the New 

GMS Contract that have a bearing on records management. 

Practical Tips 

Advice on the scanning of documents and capturing of images for inclusion in the patient’s 

electronic health record is given, together with some necessary recommendations on such 

things as suitable file formats. 





• an awareness of the background and history of electronic records in primary care 

• an awareness of the information governance issues that need to be considered when 

supporting practices in the transition to using electronic patient records 

• an understanding of the benefits to PCOs, practices and patients in the use of 

electronic patient records 

• an understanding of the processes required to summarise medical records 

• an understanding of the need for an ongoing data input and maintenance policy 

• an awareness of the other elements related to “e-commerce” and the NHS 





Good Practice Guidelines for General Practice Electronic Records (Version 3), The Joint 

Computing Group of the General Practitioners Committee and the Royal College of General 

Practitioners, 2003. 



The Computer Misuse Act 1990, Data Protection Act 1998, Human Rights Act, Freedom of 

Information Act, Health and Social Care Act 

www.hmso.gov.uk 

www.dh.gov.uk 


A proposed generic scheme for approving paperless practice – Guidance for GPs, 2001. GPC. 


The NHS Confidentiality Code of Practice 


onsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4069253&chk=jftKB%2B 



Morris DE. General Practice: Going Paperless (2004) 

careerfocus.bmjjournals.com/cgi/reprint/328/7439/97.pdf 

Shaw N. Going Paperless, a guide to computerisation in primary care. Abingdon: Radcliffe 

Medical Press; 2001. 


Facilitators attending the Path to Paperless training module would also find the 

following PRIMIS training modules of interest: 






Please note: many of the above training modules overlap with one another and offer 

a certain amount of core content and studying. 








Background 

In 2003 the National Patient Safety Agency (NPSA) commissioned the University of 

Nottingham to carry out research aimed at: 

• identifying the important safety issues regarding GP computer systems 

• assessing systems in terms of these safety features 

• determining GPs’ knowledge, use and training needs in relation to computerised 

safety features 

• working with stakeholders to produce specifications for GP computer suppliers 

• developing training for GPs and practice staff 

Research Findings 

The research concluded that GP computer systems have considerable potential to help ensure 

patient safety, but that this potential is sometimes limited by systems not having adequate 

functionality, and by user knowledge or skills, including practitioners not always making full use 

of safety features that currently exist and issues with consistency in recording morbidity data. 

As part of the research process, interviews were carried out with various stakeholders 

including doctors, system suppliers and system users. Through these interviews, it was found 

that some of the limiting factors, as shown below, are common to those that arise when 

working with information management in primary care. 

Factors that limit the use of the clinical system in ensuring patient safety 

• a need to ensure that users record data so that system functionality is available when 

required 

• a need to ensure that users have accurate and safe information to guide decisionmaking 

• the need to make best use of computerised systems for ensuring that intended 

actions such as patient referrals and medication monitoring are complete 

• a need for GPs to be better trained in the effective use of their computer systems 




The stakeholder interviews also identified other areas of concern with current clinical systems 

and their usage: 

The Training 

• the need for a drug dictionary for the NHS to improve communication between 

systems 

• the need for drug ontologies that provide sensible alerts and decision support 

• the need to develop audit trails 

• ensuring that account is taken of human ergonomics in the design of computerised 

alerts 

• the need for healthcare staff to be trained in the safe and effective use of systems 

• the need to produce safety specific regulations, requirements and guidelines 

• the need to build a safety culture and raise safety awareness in primary care. 

The NPSA commissioned PRIMIS to develop a training module for information facilitators. The 

training takes place over a full day and is run on a group workshop basis. It includes 

presentation of the research findings and discussion around the following topics: 

Known clinical system features and problems 

• Hazard alerts for contraindicated drugs, drug interactions, allergies, frequency of 

dose and the need for monitoring 

• Safety checks for repeat prescribing 

• Decision support software 

• Avoiding spurious or irrelevant alerts 

• Avoiding overriding critical alerts 

• The use of audit trails 

• Call and recall systems for patient monitoring 

• Alerts for missed referrals and abnormal results 

• The effect of poor-quality data on the effectiveness of safety features 

All the currently used systems have a number of in-built warning messages that are designed 

to alert the user to a potential hazard if the chosen course of action is pursued. Unfortunately, 

these messages are of differing sensitivity, appearance, visibility and reliability. 

Other areas where data quality can affect patient care 

• Tracking if patients attended referral 

• Tracking lab test requests/results 

• Identifying patients at risk 




Patient safety in the GMS Contract 

• Clinical quality indicators and those identified for additional services all support 

patient care and patient safety 

• Organisational indicators also identify issues that are related to patient safety, 

specifically in records and information about patients and medicines management 

• Some contractual and statutory requirements are also relevant to patient safety. 





• an awareness of the role of the National Patient Safety Agency 

• an understanding of the potential impact of data quality on patient safety 

• an awareness of the functionality of safety features inherent in GP clinical computer 

systems as identified by the University of Nottingham’s research 

• an awareness of the range of tools used to identify areas of risk to patient safety 

• an understanding of the knowledge required to support practices to improve data 

quality and implement change. 

References and further reading 


www.primis.nottingham.ac.uk/pages/download_template.asp?r=Guidelines_Sept01.pdf 



National Patient Safety Agency 

www.npsa.nhs.uk 

An Organisation with a memory, Department of Health, 2000. 

Seven steps to Patient safety: A guide for NHS Staff, National Patient Safety Agency, 2003. 

Yantis G, Lownhaupt, M. This time it’s personal. E-Health Insider. 19 Jan 2005. 

www.e-health-insider.com/comment_and_analysis/index.cfm?ID=45 

Protti DJ. Computers Can Reduce Errors And Improve Patient Safety. 

www.informatics.nhs.uk/item/1225 

Avery AJ, Savelyich BS, Teasdale S. Improving the safety features of general practice 

computer systems. Informatics in Primary Care. 2003; 11:203-6. 




Fernando B, Savelyich BS, Avery AJ et al. Prescribing safety features of general practice 

computer systems: evaluation using simulated test cases. British Medical Journal 2004; 

328:1171-2 

Avery AJ, Savelyich BSP, Sheikh A et al. Identifying and establishing consensus on the most 

important safety features of GP computer systems: e-Delphi study. Informatics in Primary 

Care. 2005;3:11 


Facilitators attending the Data Quality and Patient Safety training module would also 

find the following PRIMIS training modules of interest: 









Background 

The new GMS contract represents a landmark in the development of UK general practice. 

It provides demonstrable benefits to GMS practices to primary healthcare professionals, to 

the NHS and - most importantly - to patients. These, coupled with the largest sustained 

investment in primary care ever made, will create the platform for a step change in 

improved health and health services, boosting morale and creating greater and fairer 

rewards for GPs. 

Department of Health press release 

http://www.nhsconfed.org/press/releases/walesgms.asp 

The contract provides a major focus on quality and outcomes. Practices have the opportunity 

to receive additional funding to support aspiration to achievement of a range of quality 

standards. The new quality framework rewards practices for delivering quality care with extra 

incentives to encourage even higher standards. 

The four domains included in the Quality and Outcomes Framework 

• Clinical standards, covering coronary heart disease including left ventricular 

dysfunction, stroke or transient ischaemic attacks, hypertension, diabetes, 

chronic obstructive pulmonary disease (COPD), epilepsy, cancer, mental health, 

hypothyroidism and asthma 

• Organisational standards, covering records and information about patients, 

information for patients, education and training, practice management and 

medicines management 

• Experience of patients covering the services provided, how they are provided 

and their involvement in service development plans. This includes patient 

satisfaction surveys and consultation length 

• Additional services covering cervical screening, child health surveillance, 

maternity services and contraceptive services 

The framework contains four domains as outlined in the box below. Each domain contains a 

range of areas described by key indicators, which describe different aspects of performance. 

The aim of this training module is to provide information facilitators with an understanding of 

the implications of the Quality and Outcomes Framework, to explain the key terminology, and 

to provide knowledge of the structure, process and outcomes of each clinical domain. 




The Training 

The training takes place over a full day and is run on a group workshop basis. It covers the 


Introduction to the Quality and Outcomes Framework 

The principles of the four domains and ten clinical indicators are explained in terms of 

structure, process and outcome. 

Structure: 

Process: 

Outcome: 

How the disease registers are constructed 

The interventions, treatment and requirements for each clinical domain 

Monitoring patient health by proxy of achievement of targets and the 

management of data recording 

The organisational indicators 

The organisational indicators underpin the core philosophy of the PRIMIS data quality training 

and the information facilitator’s role. The training looks at each of the organisational indicators 

and discusses the processes in place to collect data and ensure quality. 

The clinical domains 

The structure of each clinical domain disease register is discussed examining the inclusion and 

exclusion criteria in terms of appropriate diagnosis codes, including medication and date 

ranges. The issues around data quality and validation of diagnosis are highlighted. 

The clinical indicators 

The structure and management of the disease registers require that data recording is kept to a 

minimum suitable for an accurate assessment of patient care and does not distort the 

consultation through over emphasis on data collection. 

The indicators are examined in terms of data quality and recording issues, and how these 

might affect validation processes such as QMAS. 

Exception reporting 

Practices are able to record reasons why a patient may not have been given appropriate 

treatment or allow certain patients not to be included on disease registers. There are two broad 

types of exception reporting available: an entire indicator group exception and a single 

indicator exception. 

The concept of exception reporting and the rules around when an exception may be applied 

are explained both in terms of disease register structure and clinical indicator process. 




Calculations 

The calculations within the Quality and Outcomes Framework require an understanding of 

which patients or groups of patients are included in denominator and numerator populations for 

each indicator. This is explained through practical examples. 

Action Planning 

The training is summarised through the development of an action plan identifying where the 

information facilitator may influence or help practices target issues around disease registers, 

patient monitoring, exceptions and organisational issues. 

The tools and resources available to help with this process, such as the PRIMIS Data Quality 

query set and CHART, are also discussed. 



• an understanding of the implications of the Quality and Outcomes Framework 

• an understanding of the key terminology contained in the Quality and Outcomes 

Framework 

• an understanding of the structure, process and outcomes for each of the clinical 

indicators 

• an awareness of the ten disease areas in the clinical domains 

• an understanding of numerators and denominators and the various exception 

codes 

• an awareness of ongoing monitoring and interventions 

• an awareness of the data collection and organisational issues 

• an understanding of outcome, review and maximum tolerated doses 




Good Practice Guidelines for General Practice Electronic Records (Version 3. The Joint 

Computing Group of the General Practitioners Committee and the Royal College of General 

Practitioners; 2003. 



The Computer Misuse Act 1990, Data Protection Act 1998, Human Rights Act, Freedom of 

Information Act, Health and Social Care Act 

www.hmso.gov.uk 

www.dh.gov.uk 


www.nhsia.nhs.uk/caldicott/pages/links.asp 




Preservation, Retention and Destruction of GP General Medical Services records relating to 

patients. HSC 1998/217 

A proposed generic scheme for approving paperless practice – Guidance for GPs, GPC, 2001. 


The NHS Confidentiality Code of Practice 


onsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4069253&chk=jftKB%2B 


Facilitators attending the Supporting Quality Outcomes training module would also find 

the following PRIMIS training modules of interest: 





Please note: many of the above training modules overlap and offer a certain amount 

of core content and study. It would benefit the facilitator to have undertaken these 

previous modules to provide a rounded understanding of information management 

before undertaking this training module, although this is not a necessity. 





Background 

The New GMS Contract incorporated significant changes to the provision of primary health 

services, including the categorisation of services. PCOs are placed under a new legal duty to 

ensure that patients receive access to the full range of primary medical services. The 

categorisation and provision arrangements for services under the new Contract include the 

following: 

• Practices will be required to provide essential services 

These cover the management of patients who are ill or believe themselves to be ill, 

with conditions from which recovery is generally expected, for the duration of that 

condition, including relevant health promotion advice and referral as appropriate, 

reflecting patient choice wherever practicable; the general management of patients 

who are terminally ill; and the management of chronic disease in the manner 

determined by the practice, in discussion with the patient. 

• Practices will have a preferential right to provide additional services 

These cover cervical screening, contraceptive services, vaccinations and 

immunisations, child health surveillance, maternity services (excluding intra partum 

care) and the minor surgery procedures of curettage, cautery, cryocautery of warts 

and verrucae, and other skin lesions. 

Practices may opt out of providing additional services with the agreement of their 

PCO. 

• The PCO will commission enhanced services, of which there are three types: 

Directed – under national direction with national specifications and benchmark 

pricing, which all PCOs must commission to cover their relevant population. For 

example, improved access to GMS, child vaccinations and immunisations and 

advanced minor surgery. 

National – with national minimum specifications and benchmark pricing, but not 

directed. For example, anticoagulation monitoring and enhanced care of the 

homeless. 

Local – developed locally. For example, enhanced medical care of asylum seekers 

and area-wide home visiting schemes. 

• There are also new arrangements for out-of-hours care and services for nonregistered 

patients. 

Through the new contract more emphasis is placed on rewarding quality and outcomes, with 

payments based on recorded data. The need for high quality clinical data has never been 

greater. 

The implementation of the new contract raises many information management issues. This 

training module is intended to raise information facilitators’ awareness of these issues, 

particularly around enhanced services. 




The Training 

The training takes place over a full day and is run on a group workshop basis. It covers 

explanations of the different services and practical exercises that highlight the information 

management issues with commissioning and monitoring an enhanced service. It highlights how 

the facilitator is able to support both the practices and the PCO. 

The main sections of the training course are as follows: 

• What are essential, additional and enhanced services? 

An explanation of each type of service and how they apply to primary care, 

including when and who should carry them out. What is meant by a preferred 

service provider. 

• The Financial Provision for Services 

A brief look at the statement for financial entitlement and an explanation of how the 

services are funded, including a discussion of the differences between GMS and 

PMS practices. 

• Identifying issues around providing a clinical specification 

This practical exercise looks at the difficulty in providing an accurate clinical 

specification and issues that need to be considered for both practices and PCOs in 

recording and extracting clinical data. 

• The provision of a service by an outside provider 

This practical exercise raises the items for consideration by a team or outside 

supplier providing services for a practice, and the practice for whom those services 

are being supplied. The exercise and following debate highlight issues of concern 

to PCOs, practices and facilitators around the provision and monitoring of these 

services. 

• What can the facilitator do? 

A summary of the previous issues and a discussion on how the issues raised relate 

to an information facilitator, and how the facilitator can help practices and PCOs 

with their information management requirements. 







The training will provide information facilitators with knowledge and understanding of: 

• flexible provision of services within the New GMS Contract, and allocation of 

resources 

• categorisation of the full range of primary medical services 

• data and information requirements of the full range of primary medical services 

• audit and review requirements of the full range of primary medical services 

• outline requirements of the services 

• appraisal criteria requirements for the services 

• involvement of various primary care team members 

• role of the facilitator in supporting both practices and PCOs. 

Further reading 



New GMS contract 2003 Supplementary Documents 

Statement of Finance Entitlements 

www.dh.gov.uk 

Contract Regulations 

www.legislation.hmso.gov.uk/si/si2004/20040291.htm 





Facilitators attending the Supporting Quality Services training module would also find 

the following PRIMIS training modules of interest: 










Please note: many of the above training modules overlap and offer a certain amount 

of core content and study. It would benefit the facilitator to have undertaken these 







Background 

The New GMS Contract, and in particular the Quality and Outcomes Framework (QOF), is 

designed to reward health care providers for the quality of care they provide rather than the 

quantity. The incentives for practices to deliver good chronic disease management across a 

range of diseases are strong both clinically and financially. 

In order for practices to deliver good quality care to their patients as required under the QOF, 

they need to work constructively with their PCO. The PCO can assist practices by identifying 

areas that need further support at practice level and areas that require a cross-practice 

approach. 

Part of that process is the QOF Assessment Visit, the first of which were carried out between 

October 2004 and January 2005. 

The first part of this process is the collection of data, 75% of which can be collected by means 

of an automated process of data collection and points calculation. These are the data items 

recorded in the patient’s electronic record and used by the clinical system’s own tool for 

calculating points. These data are sent to a centralised Quality Management Analysis System 

(QMAS) on a monthly basis for analysis. The remaining 25% is not collectable in this way as 

the data do not feature in an easily identifiable way within the clinical record. The PCO must 

proactively collect these data in partnership with practices. These items of data need to be 

collected in advance of any meeting with the practice for a meaningful discussion and 

development of action plans. In addition, there are other strands of information regularly fed to 

the PCO about practices that can be brought together to inform the discussion about the QOF. 

The Training 

The training takes place over a full day and is run on a group workshop basis. It covers the 


Overview of the QOF and QMAS 

The recording and reviewing arrangements of the New GMS Contract and an awareness of 

the data needed to support the reporting and verification process are discussed. 

The annual review principles and timetable 

This includes discussion on the role and make up of the visiting team and a look at the review 

visit timetable and confidentiality issues. 

Supporting data and evidence 

Tools and techniques at the disposal of facilitators to support practices during the review 

process are discussed, together with a look at some possible post-review outcomes. 







The training will provide information facilitators with knowledge and understanding of: 

• the recording and reviewing arrangements of the new GMS contract 

• data available to support the reporting and verification process 

• change management theory and techniques 

• how to facilitate and support the development, implementation and review of 

practice-based action plans 

• the tools available to provide good quality data in their role as a change agent and 

facilitator 




Annual QOF Review Guidance 

http://www.dh.gov.uk/assetRoot/04/08/21/71/04082171.PDF 

Good Practice Guidelines for GP EPR (v3) 

http://www.rcgp.org.uk/clinspec/docs/goodpracticeguidelineselectronicrecords.pdf 

NHS Code of Confidentiality 

www.dh.gov.uk/PolicyAndGuidance 

BMA – nGMS Quality and Outcomes Framework 

www.bma.org.uk/ap.nsf/Content/QualityOutcomes 

BMA – nGMS QOF visits and patient confidentiality 

www.bma.org.uk/ap.nsf/Content/QOFvisits1104 

Confidentiality and Disclosure of Information, General Medical Services, Personal Medical 

Services, and Alternative Provider Medical Services code of practice 

www.dh.gov.uk/PublicationsAndStatistics 

NatPaCT QOF Training Menu 

www.natpact.nhs.uk/qof/assessortraining/ 

NatPaCT Primary Care Contracting 

www.natpact.nhs.uk/primarycarecontracting/ 

NPfIT: QMAS 

www.npfit.nhs.uk/programmes/qmas/ 

PRIMIS resource area of website – Supporting Quality Review 






Facilitators attending the Supporting Quality Review training module would also find the 

following PRIMIS training modules of interest: 




• CHART 






Please note: many of the above training modules overlap and offer a certain amount of 

core content and study. It would benefit the facilitator to have undertaken these 










Background 

“Healthcare is an information-rich activity, in that it involves the collection, use and 

disclosure of large quantities of sensitive personal data. Such information is not only 

required by health professionals directly involved in patient treatment, but also the 

many groups who indirectly contribute to the delivery of quality healthcare. 

Administrators, policy makers, researchers, educators, public health bodies and 

auditors are just some of the groups that require access to patient data to ensure that 

high quality, cost-effective medical treatment is delivered in a timely and appropriate 

manner. Making this information available, without compromising the patients’ rights [to 

privacy], is a complex task.” 

Medical Records Use and Abuse, Heidi Tranberg and Jem Rashbass 

Better information leading to better health and care for every patient is at the heart of the 

National Programme for IT. With programmes such as the NHS CRS, which aims to transform 

the way health and social care information is managed by giving health and care professionals 

access to patients’ information where and when it is needed, the emphasis on data and 

information within the NHS has never been greater. It is recognised that currently health 

information is held as a mixture of paper-based and computer records that cannot easily be 

shared. Even records held electronically are effectively ‘locked away’ on computers that cannot 

talk to one another. 

Although great progress has been made over recent years, we are still some way from the 

ideal of a fully integrated health care record. In the meantime, for healthcare information to be 

used for planning purposes, it is imperative that the data, the building blocks that together can 

give the required information, are accurate. Additionally, the way in which the information is 

interpreted needs to take into account the sources of data and the methods of recording and 

extraction. The aim of this module is to help information facilitators and other PCO staff 

understand how to use aggregated primary care data appropriately and avoid some of the 

common pitfalls. 

The Training 

The training takes place over a full day and is run on either an individual scheme or a group 

workshop basis. It is open to PCO staff as well as PRIMIS information facilitators. It comprises 

presentation, discussion and group work exercises on the following topics: 

The information management cycle 

This explores the difference between data and information and how the same information can 

be interpreted differently when viewed away from the context of direct patient care. 




Methods of recording data in primary care and how to improve quality 

The attributes of high quality data are explored together with how we may test for quality, 

looking at data flows within and outside of the practice. Data recording and extraction methods 

are reviewed and the limitations of such methods and the problems of analysing data out of 

context are discussed. 

Who uses primary care data and what are their needs? 

An important part of the training is to identify who within the group has access to what data 

and to explore how they are used. One of the problems practices face is that the same data 

are being requested from many different sources and for many different purposes. This 

exercise aims to initiate discussions around removing duplication and avoiding “reinventing the 

wheel”. 

An important discussion is to identify the difference between a perceived requirement (what 

you think you want) and an actual need. 

Which data are appropriate to use and which are not? 

Data are often analysed and used without adequate reference to appropriate legislation. This 

exercise explores if the current or proposed information requirements identified by the group 

comply with law and what (if any) changes in practice may be required. 

Problems and pitfalls in data analysis 

The way in which data are manipulated or used inappropriately is explored and a summary of 

the common pitfalls and mistakes made in analysing and interpreting data is provided. 




The training will provide information facilitators and PCO staff with an understanding of: 

• the issues around the recording, extraction and analysis of primary care data 

• the dangers of using primary care data without a proper assessment of data quality 

and context 

• the ways in which information derived from primary care data can be used 

appropriately and legitimately 

• the ways in which a data quality and information strategy can be supported at PCT 

level. 





Tranberg H, Rashbass J. Medical Records Use and Abuse. Abingdon: Radcliffe Publishing 

Ltd.; 2004. 


www.connectingforhealth.nhs.uk 

Patient confidentiality and Access to Health Records guidance. Department of Health. 

www.dh.gov.uk/PolicyAndGuidance/InformationPolicy/PatientConfidentialityAndCaldicottGuardi 

ans/fs/en 

Data Protection Act 


Freedom of Information Act 

www.informationcommissioner.gov.uk (Freedom of Information Act 2000) 


Facilitators attending the Primary Care Data Uses and Abuses training module would 

also find the following PRIMIS training modules of interest: 

• Quality Data Quality Outcomes 






Please note: many of the above training modules overlap and offer a certain amount of 

core content and study. It would benefit the facilitator to have undertaken these 







Glossary 


Glossary 

Adult Learning Approach 

A training approach which takes account of the learner’s prior knowledge and experience and 

involves them in planning their own training programme. 

Beta testing 

Operational testing of query sets by facilitators in live general practice sites. 

CHART 

Care and Health Analysis in Real Time. A software program developed by PRIMIS and based 

on Excel that enables the quick and easy viewing of data from clinical queries. Designed to be 

used in-house by general practice staff. 

Choose and Book 

A programme to allow patients, in partnership with health and care professionals, to book first 

outpatient appointments at the most appropriate date, time and place for the patient. 

Chronic Disease Registers 

Lists of patients who have been diagnosed with a particular chronic disease, such as asthma 

or diabetes. 

Clinical Governance 

A framework through which NHS organisations are accountable for continually improving the 

quality of their services and safeguarding high standards of care by creating an environment in 

which excellence in clinical care will flourish. 

Clusters 

A group of strategic health authorities working together by region to implement the new 

technology and information systems of the National Programme for IT. 

EPR 

Electronic Patient Records. A record containing a patient’s personal details, plus information 

about their diagnosis, condition and treatment in an electronic format; also sometimes called 

EHR (Electronic Health Records). 

ETP 

Electronic Transmission of Prescriptions. A scheme to enable GPs to send prescriptions 

electronically to pharmacies. 

GMS 

General Medical Services. The rules used to manage payments to family doctors as part of the 

GPs’ contract. 



Glossary 

GP to GP Transfer 

A project to develop the technical ability to transfer patient records electronically when a 

patient changes practices. 

ICD10 Terminology 

International Classification of Diseases version 10. The international standard diagnostic 

classification for all general epidemiological and many health management purposes. 

Information facilitator 

A person employed by a PCO whose role is to provide general practice staff with support and 

training to enable them to improve the provision of patient care through the effective use of 

their information systems. 


A broad-based approach to looking at all aspects of how information is processed by NHS 

organisations, including how it is held, obtained, recorded, used and shared. 

MIQUEST 

Morbidity Information QUery and Export SynTax. Software to enable enquirers to execute 

queries and extract data from different types of general medical practice computer systems 

using a common query language and providing a common output format. 

nGMS Contract 

The New GMS Contract is the mechanism for providing funding to individual GP practices and 

was introduced in 2003. It has two elements of funding: a basic payment for every practice and 

further payments for specified quality measures and outcomes. 


On 1 April 2005, the National Programme for Information Technology (see NPfIT) joined with 

the IS/IT services from the NHSIA to form a single new organisation - NHS Connecting for 

Health. 

NHS CRS 

NHS Care Records Service. Currently under development. This will be an electronic store of 

over 50 million health and care records which can be accessed by health professionals where 

and when they are needed. It will also give patients secure internet access to their own health 

record. 

NHS Plan 

The NHS Plan recognises that the NHS has achieved much but needs to keep pace with 

change to meet patient needs. Increased investment and modernisation are the steps 

described in the document (published July 2000). 


Glossary 


NPfIT 

The National Programme for Information Technology, delivered by the Department of Health 

agency, NHS Connecting for Health, is responsible for procurement and delivery of the multibillion 

pound investment in new information and technology systems to modernise the NHS. 

NSF 

National Service Framework. A set of minimum national standards for clinical quality and 

access to services for the major care and disease groups. 

PCO 

Primary Care Organisation. A generic term to mean Primary Care Trust, Teaching Primary 

Care Trust, Primary Care Partnership, etc. Organisations responsible for commissioning all 

health care in their community. 

PDQ 

PRIMIS Data Quality query set. A set of HQL queries that allows a practice to start to identify 

areas where there are quality issues with the data recorded on the clinical system. 

PMS 

Payment schemes intended to give GPs, nurses and community trusts the opportunity to 

provide new, more flexible ways of offering primary care services that are sensitive to local 

needs. 


Primary Care Information Services. A free service to primary care organisations to help them 

improve patient care through the effective use of their clinical computer systems. 

PRIMIS CAS 

PRIMIS Comparative Analysis Service. Data analyses designed to assist primary care 

organisations with their clinical audit, clinical governance and commissioning requirements, by 

providing comparative data of specified clinical topics with national results. 

QMAS 

Quality Management and Analysis System. A system to give GP practices feedback on the 

quality of care delivered to patients measured against national achievement targets detailed in 

the new GMS contract, which sets out the way GPs work and the way they are financially 

rewarded. 

QOF 

Quality and Outcomes Framework. Part of the New GMS Contract, a tool for improving the 

services being delivered by general practice by targeting the key areas of clinical care, 

organisation, patient experience and additional services. 



Glossary 

Read Code 

A thesaurus of clinical terms linked to alpha numeric codes that allow the user to record a wide 

range of topics in categories such as signs and symptoms, treatments and therapies, 

investigations, occupations, diagnoses and drugs and appliances, in a way that can be 

retrieved and analysed. 

RFA 99 

Requirements for Accreditation. A specified core set of requirements, which all GP systems 

should be capable of performing. 

Rush 

An Excel-based program developed by PRIMIS to allow comparative results of the query sets 

to be shown in a graphical form. 

SNOMED CT 

A coding scheme that covers the terminology requirements of all areas of health care, 

including medicine, nursing and the professions allied to medicine, as well as social services 

and administration terms. 

TNA 

Training Needs Assessment. An analysis tool for identifying an individual’s training needs, in 

line with job or organisational goals.

Facilitator Handbook 2005 - PRIMIS

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