status quo of quo vadis? - KCE

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42 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76 3 EPA INSTRUMENT: APPLICABILITY IN THE BELGIAN CONTEXT 3.1 INTRODUCTION The EQuiP working party (European Association for Quality in General Practice/Family Medicine) is a working group within the WONCA association (World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians). 136 Six European countries from this party, namely Belgium (Flanders), France, Germany, the Netherlands, Switzerland (German speaking part) and the UK (England and Wales) joined their efforts to develop the European Practice Assessment (EPA) instrument. The EPA procedure assesses the organisation of a practice. The five domains are ínfrastructure´, ´people´, ínformation´, ´financial management´ and ´quality and safety´. Every domain is subdivided in so-called dimensions. The indicators of the dimensions were selected after a literature review and consensus techniques within the EQUIP group. The domain ´quality and safety´ assesses how the practice minimizes risks for patients and doctors and how the practice handles patient complaints. The domain ínformation´ includes such as protection of the privacy, practice brochure, specialized information for physicians aspects and other practice members. Within the domain ínfrastructure´ aspects on premises, medical equipment and accessibility of the practice are evaluated. The working conditions, the training and education, perspective of the patients and staff members are assessed in the domain ´people´. Finally, the domain ´financial management´ includes aspects on financial leadership and planning. The EPA instrument was developed and initially tested with more than 270 practices in Europe, including 30 voluntary Flemish practices 73, 137 A European forum used the feedback of the participating practices to improve the instrument in 2005-2006. The revised final English version of EPA was available in February 2007 and translated for this project (see below). The computerised system of EPA is Visotool®, now hosted at the AQUA Institut in Göttingen, Germany. 104 Currently, no instrument is available in Belgium to assess the practice organisation and management and this project chose the EPA instrument for the following reasons: • A former pilot test showed the interest of EPA for a sample of voluntary Belgian GP practices; • EPA is nowadays the only validated European instrument for organisational audit in general practice; • This instrument could allow comparisons within and between European countries; • There is an IT infrastructure and acceptable know-how in Germany to run the instrument; • EPA and EPA–like instruments are already used in larger accreditation systems in The Netherlands, Germany and Switzerland. The aim of this part of the study was to test the feasibility and acceptability of the final version of the EPA instrument in Belgium. This chapter describes the process and the results of the EPA procedure in participating practices and explores the barriers and suggestions for implementation.
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 43 3.2 METHODOLOGY 3.2.1 EPA instrument The EPA procedure consists of questionnaires, a practice visit and a structured interview. In each practice, a GP completes the registration form with administrative data, practice characteristics, the names and job function of all the colleagues. After entering these baseline data in Visotool ® , personalised questionnaires are delivered to the practice, together with a letter of explanation and additional study material. The practice returns four completed questionnaires to the facilitators before the visit: • A questionnaire for the principal doctor (or the practice manager) (60 items); • A questionnaire for every GP or medical doctor working in the practice (21 items); • A questionnaire for all other staff, including non-doctors and ancillary staff (29 items); • A questionnaire for patients; completed by 40 patients in the waiting room (32 items). The participating main GP or practice manager takes care that all questionnaires are completed. The future visitor enters all questionnaires in Visotool ® . The preparation takes 1 to 8 weeks. Details of the questionnaires are in the appendix 10. The schedule of the visit is adapted to each practice but a theoretical example can be described as follows. The visitor arrives between 9:00 and 10:00 a.m. The external visitor uses UMTS/GPRS technology on a dedicated laptop to enter additional data ón the spot´. Until 11:00 a.m., all 132 items of the observer’s checklist are completed. At 11:00 a.m., the ‘main GP’ reserves one hour for the structured interview. Between 12:00 and 1:30 p.m., the visitor has time to enter all data in Visotool ® . Between 1:30 p.m. and 3:00 p.m., the practice stops all non-urgent activities for the team meeting with the feedback (see table in appendix 10 for more details on questionnaires and indicators). The researchers of this project translated the entire instrument including items, questionnaires, instruction forms and letters for correspondence into Dutch and French. They checked afterwards twice all translations. AQUA specialists organised a training session of two days for all visitors and coordinators, using the visitation software (Visotool ® ) and exercise role-plays. 3.2.2 Sampling Sampling aimed at recruiting a representative sample of Belgian GPs, with the following distribution: 10 GPs working in a single-handed practices, 6 duo and 4 group practices, equal distribution of gender; 20 GPs in Flanders and 20 in the Walloon region. (See appendix 9 for national statistics on GP characteristics). The databases of Domus Medica and of SESA (Centre d'études socio-économiques de la Santé de l'Université Catholique de Louvain) were used to select a random sample of GPs from three provinces (Antwerpen, Hainaut and Namur). This selection of provinces facilitated the data collection and the representativeness of rural and (sub-)urban areas. The first 20 GPs who answered to the invitation were enrolled in the study, taking into account the distribution profile described as above. After two weeks, telephone calls surveyed 30 non-responders in Flanders.
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