Clinical Governance Practice Self-Assessment Toolkit (CGPSAT)
Developed in partnership, via a multi-representational Task and Finish Group, the new Clinical Governance Practice Self-Assessment Toolkit (CGPSAT) has been updated to reflect the Health and Quality Care Standards 2023, and the NHS (General Medical Services Contracts) (Wales) Regulations 2023 (2023 Regulations) with the underpinning Unified GMS (General Medical Services) Contract which came into effect on 1 October 2023. The role of the CGPSAT in the unified-contract-assurance-framework_0.pdf (gov.wales) has been acknowledged.
More information about the development of the new CGPSAT, including general information tips on use can be found in the introduction chapter below.
What has changed?
The most significant changes are:
- The digital platforms have been updated; the self-rating scales form is now on Caforb, and the guidance is here.
- The online guidance and resources will be continuously updated throughout the year.
- The number of matrices/self-rating scales to be completed have halved.
- The self-rating scales are now based on how well a Practice can demonstrate it is embedding learning as business as usual.
- Practices can use their existing processes/documents to build their effective system of clinical governance, based on the 12 Quality Standards.
- Practices are not required to upload evidence of achievement, just a practice development plan. The Health Board may choose to review these plans and discuss progress at practice governance visits.
The new CGPSAT consists of two components:
An Online Form (Caforb) for practices to input:
• Self-rating scales and matrices aligned to the 12 Quality Standards 2023.
• A voluntary record of evidence to support self-rating.
• Upload of evidence should a Practice choose to e.g. share good practice.
• Online template suggestion for recording a Practice Improvement Plan.
• Declarations of accuracy for submission.
Access CGPSAT form here
An online Toolkit of guidance hosted on this page containing:
• 12 Chapters, each aligned to one of the 12 Quality Standards 2023.
• 23 matrices focussing on key features of clinical governance.
• Each matrix contains resources to support a Practice to improve performance against the 12 Quality Standards 2023.
• Live chapters updated regularly, as new guidance and resources become available.
Access Toolkit Guidance Chapters below
The Clinical Governance Practice Self-Assessment Toolkit applies to all General Practices in Wales, which includes all General Medical Services Contractors (GMS), Alternative Providers of Medical Services (APMS) Practices and GP (General Practitioner) practices managed by Health Boards.
The CGPSAT revision is based on an interpretation of the 12 Quality Standards 2023 in the context of General Practice. Alignment of the new standards to the 2015 version of the CGPSAT was attempted but not possible, as previous matrices often covered more than one standard, and some no longer fit neatly into any.
Practices are required to
- review their previous CGPSAT responses (if available).
- enter a self-rating ‘level’ for each matrix in the CGPSAT (consider what would be the ‘average’ or ‘typical’ rating for the topics covered by the matrix, and not focus on the best or worst).
- write a Practice Development Plan, focussing on those matrices to prioritise.
- complete final submission by 31st March.