status quo of quo vadis? - KCE

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50 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76 Moi je pense qu’il faut le proposer à un plus grand nombre possible, le canal des GLEMS est un bon canal. Je serais partisan de le préconiser aux autres. C’est un outil intéressant, on en retire toujours quelque chose. C’est un outil de réflexion.´ 3.3.3 Outcome evaluation 3.3.3.1 Results of the EPA procedure The response rate for the questionnaires sent to the participating practices was more than 80%. The high score for the domain ‘information’ (73%) was mainly the result of the high number of participants using an electronic medical record, internet access for all the practice members, and the presence of clear written information to patients on the practice characteristics. The dimensions ‘prevention’ and ‘information for patients on medical care’ yielded 46% and 47% respectively, due to the lack of any prevention program and the absence of patient information leaflets. The domain ‘people’ had the second best score, with a mean of 75%. Patient satisfaction reached nearly 90%; the job satisfaction score of the non-GP practice members was 80%; the GPs’ satisfaction was 76%. The domain ‘infrastructure’, with a mean score of 62%, included two extremes: a high level for computer safety (89%) versus a low level for the management of medical and non-medical materials and for the facilities for disabled people, babies and children. The domain ‘financial management’ had a mean score of 58%. Practices often do not have any financial plan, defined allocation of the financial responsibilities or active control of the cash flow. The domain ‘quality and safety’ had a mean score of 41%. Although in daily practice medical materials are sterilised and sharp objects collected in special containers, most practices did not have any written and controlled procedures about infection prevention, critical incident analysis, patients’ complaint management and yearly check of the medical and non-medical materials. The feedback given in Visotool refers to the five domains. The results are presented in a pentagraph (figure 3). The continuous line (red) and a dashed line (blue) represent the results of all indicators for an individual practice (red) and the mean results of all practices (blue). The closer the lines are to the domain names, the better are the results in this domain. The results of any practice can be compared to all practices in the same setting (urban/rural), with practices of the same type (single-handed/group) or within any other predefined selection. Figure 3: example EPA feedback pentagraph generated by Visotool ®
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 51 3.4 DISCUSSION: EPA IN BELGIUM? 3.4.1 Organisational load for implementing the EPA procedure The recruitment of the practices was difficult. Thousand letters and 60 phone calls could only recruit 43 interested practices. Participants were therefore highly selfselected and most of them were active in academic and/or professional bodies. The provision of human resources planned initially was insufficient. The coordination, administrative work, preparation of the visit, visits to the practices, solving of practical problems and communication with Germany required a few days per practice. Supplementary unplanned administrative support was necessary. The training of the facilitating team included the knowledge of basic concepts of EPA, of the procedures and communication skills. Those preliminary data show that non-GP visitors perform equally well as GP visitors and that they are well accepted. The participants concluded that only one visit, as performed here, is not enough to foster quality improvement initiatives. There is a need for further coaching as in Australia and in the Netherlands. However, this pilot study made the GPs more sensitive to quality development in their practice. The price for the EPA project is estimated below. Assuming that handbooks and procedures are adapted to the Belgian context, the hypothesis is that in the first year practices are enrolled and collect data. During the second and third year, tutors coach the practices (approximately 2 days of face to face contacts with the practice). The price of external human resources could be estimated around 600 Euro per practice per year. Moreover overhead, location, IT infrastructure and data engineering (for instance by the AQUA institute) need to be added to the budget. The costs for the entire project may be approximately 1000 Euro per year per practice. Assuming that a GP serves about 1000 inhabitants, this would be one euro per patient per practice per year. Table 5. A worked out example for the manpower needed for a three year project. The adaptation of the instruments, the human resources needed to set up IT platforms and data handling are not considered in this table. Role FTE First year GP coordinator 0.5 administrative support 0.5 Tutor 1 Second year GP coordinator 0.5 administrative support 0.5 Tutor 1.5 Third year GP coordinator 0.5 administrative support 0.5 Tutor 2 3.4.2 Perception of the visitors and participant GPs The conclusions are limited by the sample size of the project (field notes and focus groups) but the participating GPs valued the feedback of the visit, including the analysis of not previously studied domains. This confirms the evaluation of the former EPA project in Flanders in 2004. 137 Few practices planned implementation of change. A better follow-up after the visit and the use of EPA within a broader quality development system could enhance this process. In this project, EPA was a one time project, without any subsequent activities.
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