Quality Assurance Policy

Quality Assurance Policy

Bromley-by-Bow Health Partnership

Last Reviewed: August 2025

Next Review: August 2027

  1. Policy Statement

At Bromley-by-Bow Health Partnership (BBBHP) we are committed to delivering safe, effective, responsive, caring, and well-led healthcare services in line with the Care Quality Commission’s (CQC) Key Lines of Enquiry (KLOEs). This Quality Assurance Policy outlines our commitment to continuous improvement and clinical excellence across all aspects of our service.

  1. Purpose and Scope

This policy applies to all staff employed by BBBHP including GPs, nurses, healthcare assistants, administrative, and management staff. It covers all services provided within the practice, including general consultations, chronic disease management, procedures (including but not limited to LARC fitting and joint injections), prescribing, and patient support services.

  1. Quality Standards

The policies, systems and processes in place in our Practice reflect our professional and legal responsibilities and follow recognised standards of good practice. We evaluate our Practice on a regular basis, through audit, peer review and patient feedback and monitor the effectiveness of our quality assurance procedures.

  1. Quality Assurance Mechanisms
  2. Clinical Audit
  • Regular clinical audits are conducted to assess and improve clinical performance.
  • Audits may include prescribing patterns, chronic disease reviews, referrals, safeguarding processes, and infection control.
  1. Significant Event Analysis (SEA)
  • We have a structured SEA process: any team member who identifies a concern is responsible for completing an SEA for all incidents, near misses and complaints.
  • SEAs are presented at the appropriate team meeting and learning is collated annually by the clinical leads and practice managers, discussed on their sites and at the clinical governance meeting.
  1. Patient Feedback
  • We actively seek patient feedback through:
    • Patient surveys (e.g. Friends and Family Test).
    • Complaints and compliments.
    • Patient engagement.
  • Feedback is reviewed regularly and used to drive improvements.
  1. Staff Training and Development
  • All staff complete mandatory training, including:
    • Basic Life Support
    • Safeguarding (Children and Adults)
    • Infection Control
    • GDPR and Confidentiality
  • Continuing Professional Development (CPD) is supported and monitored for clinical and non-clinical staff.
  1. Appraisal and Supervision
  • All staff receive annual internal reviews and regular informal supervision, allowing the practice to support personal development plans as well as organisational aims
  • GPs also participate in annual NHS Appraisal and five-year Revalidation cycles.

 

  1. Policies and Protocols
  • Clinical and administrative policies are reviewed annually or as needed.
  • All staff are expected to be aware of and able to locate, read and acknowledge key policies.
  1. Roles and Responsibilities
Role Responsibility
Practice Manager Oversee policy implementation, monitor compliance,  and coordinate training for staff on their site.
Clinical Lead GP Ensure clinical audits, significant event reviews, and evidence-based practice – we have one GP Clinical Lead per site. They also attend our Clinical Governance and Safety Committee.
All Staff Adhere to practice policies, participate in relevant , SEAs, training, and quality reviews.
  1. Monitoring and Review
  • This QA policy is annually or sooner if required.
  • Clinical meetings are held weekly per site to discuss audit results, clinical cases, significant events and associated learning, hot topics, and quality issues.
  • Whole practice meetings are held monthly per site and include updates for all staff, including policy updates and patient feedback
  • The Clinical Governance and Safety Committee meets monthly with representation from all sites
  • Compliance is monitored using:
    • Key Performance Indicators (KPIs) via the use of dashboards
    • CQC inspection reports
    • Internal and external audit findings
  1. Confidentiality and Data Protection
  • All QA processes comply with UK GDPR and NHS data protection policies.
  • Patient information is handled confidentially and only accessed on a need-to-know basis.
  1. Compliance with CQC Standards

We use the CQC’s Key Lines of Enquiry (KLOEs) to self-assess and improve our services:

Domain Examples of QA Evidence
Safe SEA reports, safeguarding audits, infection control logs
Effective Clinical audits, NICE guidance adherence, referral tracking
Caring Patient and staff surveys, complaints reviews, PPG engagement
Responsive Access audits, appointment availability analysis
Well-led Staff training matrix, meeting minutes, leadership structure
  1. Continuous Improvement

Our culture promotes learning, openness, and innovation. Staff are encouraged to suggest improvements, and changes are tracked for impact. We strive to ensure our services evolve to meet the needs of our patient population.

  1. Approval and Review
Name Role Signature Date
Kerry Greenan Clinical Governance and Safety Lead KG 28/08/2025