RCGP Quality Team Development programme: an illuminative evaluation

Challenges in Implementing Community-Based Healthcare Teams in a Low-Income Country Context: Lessons From Ethiopia's Family Health Teams

BACKGROUND

Addressing chronic diseases and intra-urban health disparities in low- and middle-income countries (LMICs) requires new health service models. Team-based healthcare models can improve management of chronic diseases/complex conditions. There is interest in integrating community health workers (CHWs) into these teams, given their effectiveness in reaching underserved populations. However healthcare team models are difficult to effectively implement, and there is little experience with team-based models in LMICs and with CHW-integrated models more generally. Our study aims to understand the determinants related to the poor adoption of Ethiopia's family health teams (FHTs); and, raise considerations for initiating CHW-integrated healthcare team models in LMIC cities.

METHODS

Using the Consolidated Framework for Implementation Research (CFIR), we examine organizational-level factors related to implementation climate and readiness (work processes/incentives/resources/leadership) and system-level factors (policy guidelines/governance/financing) that affected adoption of FHTs in two Ethiopian cities. Using semi-structured interviews/focus groups, we sought implementation perspectives from 33 FHT members and 18 administrators. We used framework analysis to deductively code data to CFIR domains.

RESULTS

Factors associated with implementation climate and readiness negatively impacted FHT adoption. Failure to tap into financial, political, and performance motivations of key stakeholders/FHT members contributed to low willingness to participate, while resource constraints restricted capacity to implement. Workload issues combined with no financial incentives/perceived benefit contributed to poor adoption among clinical professionals. Meanwhile, staffing constraints and unavailability of medicines/supplies/transport contributed to poor implementation readiness, further decreasing willingness among clinical professionals/managers to prioritize non-clinic based activities. The federally-driven program failed to provide budgetary incentives or tap into political motivations of municipal/health centre administrators.

CONCLUSION

Lessons from Ethiopia's challenges in implementing its FHT program suggest that LMICs interested in adopting CHW-integrated healthcare team models should closely consider health system readiness (budgets, staffing, equipment/medicines) as well as incentivization strategies (financial, professional, political) to drive organizational change.

Exploiting Inter-Organizational Relationships in Health Care: A Bibliometric Analysis and Literature Review

Inter-organizational relationships are high on the health policy agenda. Scholars and practitioners have provided heterogeneous views about the triggers of collaborative practices and the success factors that underpin the sustainability of inter-organizational relationships in the health care domain. The article proposes a literature review aimed at systematizing current scientific research that contextualizes inter-organizational relationships to health care. A mixed approach was undertaken, which consisted of a bibliometric analysis followed by a narrative literature review. A tailored search strategy on Elsevier’s Scopus yielded 411 relevant records, which were carefully screened for inclusion in this study. After screening, 105 papers were found to be consistent with the study purposes and included in this literature review. The findings emphasize that the establishment and implementation of inter-organizational relationships in health care are affected by several ambiguities, which concern both the governance and the structuring of collaborative relationships. The viability and the success of inter-organizational relationships depend on the ability of both central and peripheral partners to acknowledge and address such ambiguities. Failure to do so involves an opportunistic participation to inter-organizational relationships. This endangers conflicting behaviors rather than collaboration among partners.

Quality Indicators for the Diagnosis and Management of Acute Bacterial Rhinosinusitis

Background

Acute bacterial rhinosinusitis (ABRS) is a highly prevalent disease that is treated by a variety of specialties, including but not limited to, family physicians, emergency physicians, otolaryngology—head and neck surgeons, infectious disease specialists, and allergy and immunologists. Unfortunately, despite high-quality guidelines, variable and substandard care continues to be demonstrated in the treatment of ABRS.

Objective

This study aimed to develop ABRS-specific quality indicators (QIs) to evaluate the diagnosis and management that reduces symptoms, improves quality of life, and prevents complications.

Methods

A guideline-based approach, proposed by Kötter et al., was used to develop QIs for ABRS. Candidate indicators (CIs) were extracted from 4 guiding documents and evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Each CI and its supporting evidence was summarized and reviewed by an expert panel based on validity, reliability, and feasibility of measurement. Final QIs were selected from CIs utilizing the modified RAND/University of California at Los Angeles appropriateness methodology.

Results

Twenty-nine CIs were identified after literature review and evaluated by our panel. Of these, 5 CIs reached consensus as being appropriate QIs, with 1 requiring additional discussion. After a second round of evaluations, the panel selected 7 QIs as appropriate measures of high-quality care.

Conclusion

This study proposes 7 QIs for the diagnosis and management of patients with ABRS. These QIs can serve multiple purposes, including documenting the quality of care; comparing institutions and providers; prioritizing quality improvement initiatives; supporting accountability, regulation, and accreditation; and determining pay for performance initiatives.

Assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: An integrative review

Background

Interdisciplinary team working is of paramount importance in the reform of primary care in order to provide cost-effective and comprehensive care. However, international research shows that it is not routine practice in many healthcare jurisdictions. It is imperative to understand levers and barriers to the implementation process. This review examines interdisciplinary team working in practice, in primary care, from the perspective of service providers and analyses 1 barriers and facilitators to implementation of interdisciplinary teams in primary care and 2 the main research gaps.

Methods and findings

An integrative review following the PRISMA guidelines was conducted. Following a search of 10 international databases, 8,827 titles were screened for relevance and 49 met the criteria. Quality of evidence was appraised using predetermined criteria. Data were analysed following the principles of framework analysis using Normalisation Process Theory (NPT), which has four constructs: sense making, enrolment, enactment, and appraisal. The literature is dominated by a focus on interdisciplinary working between physicians and nurses. There is a dearth of evidence about all NPT constructs apart from enactment. Physicians play a key role in encouraging the enrolment of others in primary care team working and in enabling effective divisions of labour in the team. The experience of interdisciplinary working emerged as a lever for its implementation, particularly where communication and respect were strong between professionals.

Conclusion

A key lever for interdisciplinary team working in primary care is to get professionals working together and to learn from each other in practice. However, the evidence base is limited as it does not reflect the experiences of all primary care professionals and it is primarily about the enactment of team working. We need to know much more about the experiences of the full network of primary care professionals regarding all aspects of implementation work.

Systematic review registration

International Prospective Register of Systematic Reviews PROSPERO 2015: CRD42015019362.

Roadmap for developing a national quality indicator set for general practice

Purpose

– The purpose of this paper is to describe a national, comprehensive quality indicator set to support delivering high-quality clinical care in Irish general practice.

Design/methodology/approach

– Potential general practice quality indicators were identified through a literature review. A modified two-stage Delphi process was used to rationalise international indicators into an indicator set, involving both experts from key stakeholder groups (general practitioners (GPs), practice nurses, practice managers, patient and health policy representatives) and predominantly randomly selected GPs. An illustrative evaluation approach was used to road test the indicator set and supporting materials.

Findings

– In total, 80 panellists completed the two Delphi rounds and staff in 13 volunteer practices participated in the road test. The original 171 indicators was reduced to 147 during the Delphi process and further reduced to 68 indicators during the road test. The indicators were set out in 14 sub-domains across three areas (practice infrastructure, practice processes and procedures, and practice staff). Practice staff planned 77 quality improvement activities after their assessment against the indicators and 31 (40 per cent) were completed with 44 (57 per cent) ongoing and two (3 per cent) not advanced after a six-month road test. A General Practice Indicators of Quality indicator set and support materials were produced at the conclusion.

Practical implications

– It is important and relatively easy to customise existing quality indicators to a particular setting. The development process can be used to raise awareness, build capacity and drive quality improvement activity in general practices.

Originality/value

– The authors describe in detail a method to develop general practice quality indicators for a regional or national population from existing validated indicators using consensus, action research and an illuminative evaluation.

Can the theoretical domains framework account for the implementation of clinical quality interventions?

BACKGROUND

The health care quality improvement movement is a complex enterprise. Implementing clinical quality initiatives requires attitude and behaviour change on the part of clinicians, but this has proven to be difficult. In an attempt to solve this kind of behavioural challenge, the theoretical domains framework (TDF) has been developed. The TDF consists of 14 domains from psychological and organisational theory said to influence behaviour change. No systematic research has been conducted into the ways in which clinical quality initiatives map on to the domains of the framework. We therefore conducted a qualitative mapping experiment to determine to what extent, and in what ways, the TDF is relevant to the implementation of clinical quality interventions.

METHODS

We conducted a thematic synthesis of the qualitative literature exploring clinicians' perceptions of various clinical quality interventions. We analysed and synthesised 50 studies in total, in five domains of clinical quality interventions: clinical quality interventions in general, structural interventions, audit-type interventions, interventions aimed at making practice more evidence-based, and risk management interventions. Data were analysed thematically, followed by synthesis of these themes into categories and concepts, which were then mapped to the domains of the TDF.

RESULTS

Our results suggest that the TDF is highly relevant to the implementation of clinical quality interventions. It can be used to map most, if not all, of the attitudinal and behavioural barriers and facilitators of uptake of clinical quality interventions. Each of these 14 domains appeared to be relevant to many different types of clinical quality interventions. One possible additional domain might relate to perceived trustworthiness of those instituting clinical quality interventions.

CONCLUSIONS

The TDF can be usefully applied to a wide range of clinical quality interventions. Because all 14 of the domains emerged as relevant, and we did not identify any obvious differences between different kinds of clinical quality interventions, our findings support an initially broad approach to identifying barriers and facilitators, followed by a "drilling down" to what is most contextually salient. In future, it may be possible to establish a model of clinical quality policy implementation using the TDF.

Assessing organisational development in European primary care using a group-based method: a feasibility study of the Maturity Matrix

PURPOSE

The Maturity Matrix is a tool designed in the U.K. to assess family practice organisational development and to stimulate quality improvement. It is practice-led, formative and undertaken by a practice team with the help of trained facilitators. The aim of this study is to assess the Maturity Matrix as a tool and an organisational development measure in European family practice settings.

DESIGN/METHODOLOGY/APPROACH

Using a convenience sample of 153 practices and 11 facilitators based in the U.K., Germany, The Netherlands, Switzerland and Slovenia, feasibility was assessed against six criteria: completion; coverage; distribution; scaling; translation; and missing data. Information sources were responses to evaluation questionnaires by facilitators and completed Maturity Matrix profiles.

FINDINGS

All practices taking part completed the Maturity Matrix sessions successfully. The Netherlands, the U.K. and Germany site staff suggested including additional dimensions: interface between primary and secondary care; access; and management of expendable materials. Maturity Matrix scores were normally distributed in each country. Scaling properties, translation and missing data suggested that the following dimensions are most robust across the participating countries: clinical performance audit; prescribing; meetings; and continuing professional development. Practice size did not make a significant difference to the Maturity Matrix profile scores.

ORIGINALITY/VALUE

The study suggests that the Maturity Matrix is a feasible and valuable tool, helping practices to review organisational development as it relates to healthcare quality. Future research should focus on developing dimensions that are generic across European primary care settings.

Understanding change in medical practice: the role of shared meaning in preventive treatment

Health care organizations are experiencing a rising demand for change in the organization of preventive health services. Many initiatives designed to cater for change fail to achieve their aim. To understand how organizational dynamics in health care organizations influence the adoption of new initiatives, I explored the implementation of motivational interviewing, a health behavior concept that was introduced into ten general practice clinics in Denmark. Within an institutional framework I explored how modern ideas of prevention related to this concept were translated into medical practices. Using a qualitative multiple-case study design, I examined the institutionalization process in different clinical settings. I found that clinics constructed various types of preventive routines and thereby imposed new meaning on the health behavior concept. In adopting the concept, clinics developed a new routine against the background of existing practice, (re)producing an alternative, self-contained routine that diverged from their usual medical practice.

Which quality and outcomes framework (QOF) clinical indicators are applicable for British Forces Germany Health Service (BFG HS) primary care?

OBJECTIVES

To determine which QOF clinical indicators are applicable for BFG HS primary care.

METHOD

In depth cross-sectional survey of BFG HS general practitioners. Participants were requested to assess all 19 QOF clinical domains (80 clinical indicators) and to indicate to what extent these were applicable for BFG HS (Likert scale 1-5). Response rate was documented. Cronbach's alpha reliability was calculated and a comparison of the mean responses of training and non-training practices was made.

RESULTS

The response rate was 80% (28/35). Cronbach's alpha was 0.91.The mean score for both training practices and non-training practices was 3.9. Based on the mean score the applicable indicators were (in descending order): Hypothyroidism (mean 4.6, 95% confidence interval 4.5-4.8), Hypertension (4.6, 4.5-4.8), Asthma (4.3, 4.2-4.5), Diabetes mellitus (4.3, 4.2-4.3), Obesity (4.1, 4.0-4.2), Chronic Heart Disease (4.1, 3.9-4.2), Epilepsy (4.0, 3.9-4.2) and Smoking (4.0, 3.7-4.2). Problematic were (descending means): Cancer (3.9, 3.6-4.2), Stroke and TIA (3.8, 3.7-4.0), Atrial fibrillation (3.6, 3.3-3.8), Learning disabilities (3.5, 3.1- 4.0), Chronic kidney disease (3.5, 3.3-3.8), Chronic Obstructive Pulmonary Disease (3.5, 3.3-3.7), Mental health (3.5, 3.3-3.6), Heart failure (3.4, 3.1-3.7), Depression (3.2, 2.8-3.5) and Palliative care (3.2, 2.7-3.6). Not applicable was Dementia (2.4, 2.0-2.8).

CONCLUSION

This study shows that several but not all QOF clinical indicators are applicable in BFG HS. Therefore QOF cannot be directly transferred to BFH HS and an adapted quality framework is required.

Primary Medical Care Provider Accreditation (PMCPA): pilot evaluation

BACKGROUND

While practice-level or team accreditation is not new to primary care in the UK and there are organisational indicators in the Quality and Outcomes Framework (QOF) organisational domain, there is no universal system of accreditation of the quality of organisational aspects of care in the UK.

AIM

To describe the development, content and piloting of version 1 of the Primary Medical Care Provider Accreditation (PMCPA) scheme, which includes 112 separate criteria across six domains: health inequalities and health promotion; provider management; premises, records, equipment, and medicines management; provider teams; learning organisation; and patient experience/involvement, and to present the results from the pilot service evaluation focusing on the achievement of the 30 core criteria and feedback from practice staff.

DESIGN OF STUDY

Observational service evaluation using evidence uploaded onto an extranet system in support of 30 core summative pilot PMCPA accreditation criteria.

SETTING

Thirty-six nationally representative practices across England, between June and December 2008.

METHOD

STUDY POPULATION

interviews with GPs, practice managers, nurses and other relevant staff from the participating practices were conducted, audiotaped, transcribed, and analysed using a thematic approach. For each practice, the number of core criteria that had received either a 'good' or 'satisfactory' rating from a RCGP-trained assessment team, was counted and expressed as a percentage.

RESULTS

Thirty-two practices completed the scheme, with nine practices passing 100% of core criteria (range: 27-100%). There were no statistical differences in achievement between practices of different sizes and in different localities. Practice feedback highlighted seven key issues: (1) overall view of PMCPA; (2) the role of accreditation; (3) different motivations for taking part; (4) practice managers dominated the workload associated with implementing the scheme; (5) facilitators for implementation; (6) patient benefit--relevance of PMCPA to quality improvement; (7) recommendations for improving the scheme.

CONCLUSION

Version 1 of PMCPA has been piloted as a primary care accreditation scheme and shown to be relevant to different types of practice. The scheme is undergoing revision in accordance with the findings from the pilot and ongoing consultation.

GP and staff evaluation of the maturity matrix as a tool to assess and improve organisational development in primary care

PURPOSE

This paper aims to evaluate the maturity matrix (MM) a facilitated formative self-assessment tool for organisational development in primary care) on satisfaction, differences between GP and staff, the extent to which practice teams worked on goals set, and to identify suggestions for change to MM.

DESIGN/METHODOLOGY/APPROACH

The approach taken was a cross-sectional survey administered to all participants by mail in 57 family practices, 278 participants, (143 GPs; 135 staff) in Denmark, one year after participating in the MM project.

FINDINGS

At practice level 44 returned at least one questionnaire. At participant level, 144 returned the questionnaire: 82 GPs; 62 staff. A total of 93 gave positive statements on satisfaction with MM, 16 stated initial expectations were not met, 79 would recommend MM to colleagues. Differences between GPs and staff were only statistically significant regarding "increased insight into organisation of work after participation in the MM project". There was a tendency that GPs were more positive and likely to give an opinion. A total of 22 planned how to meet the goals set at the first MM meeting and 18 felt that they achieved them. In 24 out of 44 practices MM was stated to contribute new ways of working. A total of 12 of 144 stated that they needed more follow-up support.

PRACTICAL IMPLICATIONS

The results indicate that MM is a workable method to assess and gain insight into practice organisation with no major differences between GPs and staff.

ORIGINALITY/VALUE

The paper examines participants views' on MM one year after introduction.

Interventions to improve team effectiveness: a systematic review

OBJECTIVES

To review the literature on interventions to improve team effectiveness and identify their 'evidence based'-level.

METHODS

Major data bases (PubMed, Web of Science, PsycInfo and Cochrane Library) were systematically searched for all relevant papers. Inclusion criteria were: peer-reviewed papers, published in English between January 1990 and April 2008, which present empirically based studies focussing on interventions to improve team effectiveness in health care. A data abstraction form was developed to summarize each paper. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.

RESULTS

Forty-eight papers were included in this review. Three categories of interventions were identified: training, tools, and organisational interventions. Target groups were mostly multidisciplinary teams in acute care. The majority of the studies found a positive association between the intervention and non-technical team skills. Most articles presented research with a low level of evidence. Positive results in combination with a moderate or high level of evidence were found for some specific interventions: Simulation training, Crew Resource Management training, Team-based training and projects on Continuous quality improvement.

CONCLUSIONS

There are only some studies available with high quality evidence on interventions to improve team effectiveness. These studies show that team training can improve the effectiveness of multidisciplinary teams in acute (hospital) care.

More than the sum of its parts? A qualitative research synthesis on multi-disciplinary primary care teams

This qualitative research synthesis reviews interpretive scholarly papers on multi-disciplinary primary care teams. A bibliographic search was conducted in electronic databases: Medline, Embase, and the Web of Science Citation Index, and in the references of retrieved papers. The research consists of a taxonomic analysis of 19 qualitative studies about primary care teams published in peer-reviewed journals between 2001 and July 2008 in English and French. Nineteen qualitative studies were synthesized. Two major concerns emerged: (1) strategies for organizational change toward effective co-operative practice, and (2) dimensions of team interactions and work relations. The authors conclude that qualitative results suggest common strategies to improve the development of primary care teams, while identifying dimensions of team interactions that remain problematic. A fundamental aspect of team formation appears to be overlooked, i.e., the construction of a collective identity, which would involve the whole team in a shared ideal of co-operative practice. The adoption of discourse analysis is suggested as a more sophisticated qualitative methodology to explore this issue.

Implementing change in primary care practices using electronic medical records: a conceptual framework

Background

Implementing change in primary care is difficult, and little practical guidance is available to assist small primary care practices. Methods to structure care and develop new roles are often needed to implement an evidence-based practice that improves care. This study explored the process of change used to implement clinical guidelines for primary and secondary prevention of cardiovascular disease in primary care practices that used a common electronic medical record (EMR).

Methods

Multiple conceptual frameworks informed the design of this study designed to explain the complex phenomena of implementing change in primary care practice. Qualitative methods were used to examine the processes of change that practice members used to implement the guidelines. Purposive sampling in eight primary care practices within the Practice Partner Research Network-Translating Researching into Practice (PPRNet-TRIP II) clinical trial yielded 28 staff members and clinicians who were interviewed regarding how change in practice occurred while implementing clinical guidelines for primary and secondary prevention of cardiovascular disease and strokes.

Results

A conceptual framework for implementing clinical guidelines into primary care practice was developed through this research. Seven concepts and their relationships were modelled within this framework: leaders setting a vision with clear goals for staff to embrace; involving the team to enable the goals and vision for the practice to be achieved; enhancing communication systems to reinforce goals for patient care; developing the team to enable the staff to contribute toward practice improvement; taking small steps, encouraging practices' tests of small changes in practice; assimilating the electronic medical record to maximize clinical effectiveness, enhancing practices' use of the electronic tool they have invested in for patient care improvement; and providing feedback within a culture of improvement, leading to an iterative cycle of goal setting by leaders.

Conclusion

This conceptual framework provides a mental model which can serve as a guide for practice leaders implementing clinical guidelines in primary care practice using electronic medical records. Using the concepts as implementation and evaluation criteria, program developers and teams can stimulate improvements in their practice settings. Investing in collaborative team development of clinicians and staff may enable the practice environment to be more adaptive to change and improvement.

Do primary care professionals work as a team: a qualitative study

Teamworking is a vital element in the delivery of primary healthcare. There is evidence that well organised multidisciplinary teams are more effective in developing quality of care. Personal Medical Services (PMS) is a health reform that allows general practices more autonomy and flexibility in delivering quality based primary care. Practices in the locality where this study was conducted were offered resources to employ additional staff. Such arrangements provided the opportunity to expand and develop Primary Care Teams. In this qualitative study, semi-structured interviews were conducted with primary care professionals in 21 second wave PMS practices. Some participants felt they had used PMS to build their teams and develop quality based patient care. For other practices teamworking was limited by the absence of a common goal, recruitment difficulties, inadequate communication and hierarchical structures, and prevented practices from moving forward with clear direction. The study indicates that changing the contractual arrangements does not necessarily improve teamworking. It highlights the need for more sustained educational and quality improvement initiatives to encourage greater collaboration and understanding between healthcare professionals.

Review of performance assessment and improvement in ambulatory medical care

Health care plans often consider quality of care as a means of containing rising health costs. The assessment of physician and group practice performance has become increasingly widespread in ambulatory care. This article reviews the three main methods used to improve and assess performance: practice audits, peer-review groups and practice visits. The focus is on Europe - which countries use which methods - and on the following aspects: which authorities or bodies are responsible for setting up and running the systems, are the systems mandatory or voluntary, who takes part in assessments and what is their motivation, are patients views taken into account. Many countries run parallel systems managed by authorities working at different hierarchical levels (national, regional or local). The reasons that underlie the choice of a particular system are discussed. They are mostly related to the national health care system and to cultural factors.

Organizational assessment in general practice: a systematic review and implications for quality improvement

BACKGROUND

Quality improvement of organizational aspects in general practice is receiving increasing attention. In particular, the impact of effective organization on preventative care has been recognized. Organizational assessments are typically used as part of professionally led accreditation schemes where there is a tension between externally led quality assurance and internally led quality improvement. The aim of this article is to inform the debate by reviewing the international-peer-reviewed literature on organizational assessments used in general practice settings.

DESIGN

Systematic literature review.

METHODS

The literature was searched for articles relating to organizational assessment. Titles and abstracts were examined by two independent reviewers and relevant articles obtained. Bibliographies were examined for follow-up references. Data were extracted on the development and use of assessment methods.

RESULTS

Thirteen papers describing five organizational assessment instruments were included for detailed appraisal.

CONCLUSION

This review discovered a developing field containing different approaches to the measurement of organizational aspects of general practice. Whilst professionally led accreditation is well-developed and dependent on externally led quality assurance, approaches to internally led quality improvement are less well-developed. There is a need for organizational assessment tools designed for the purpose of stimulating internal development.