status quo of quo vadis? - KCE

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58 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76 The role of each stakeholder can not be precisely defined from this scientific project but the scheme suggests that scientific bodies are important for the development of tools and indicators whilst other stakeholders are important for the development of IT infrastructure. Patient organisations may become more important in the debate on quality as is observed in surrounding countries. 4.3.4 Emphasis on the GP practice Four of the five countries studied focused on quality development at the level of the practice. This is today one important missing link in general practice quality development in Belgium. As group practices and primary care teams are emerging, the practice and practice team level will become more important. Although there is a trend towards group practices, most GPs in Belgium today still work in single-handed practices. Any quality development project should target both types of practices, keeping in mind the equity principle i.e., all patients must benefit from quality development initiatives. 4.3.5 Internal and external drivers for change An essential point is to show to individual GPs what they win from the quality development approach in their practice. The foreign experiences show the need for a careful balance between the formative and summative use of any future scheme for quality development. The UK example largely shows the unintended consequences of a summative approach ´we come to see how you are doing´ (see chapter 2.3.6). The Australian approach is essentially different and addresses the general practice as a business. Here the essential question is ´how well am I doing?´ The available literature does not give any firm answer about the optimal balance between internal and external drivers for change. 4.3.6 Organizational capacity of the practices for quality development; manpower and IT The EPA study highlighted the lack of capacity of the practices. Most Belgian GPs, in particular when working in single-handed practices, do not benefit from any ancillary support (e.g., secretary, practice assistant). Many tasks needed for a quality development project require an extra effort from the GP him/herself. This may hamper the feasibility of quality development initiatives in the practice. The introduction of GP models that include ancillary workforce within the practices is a way forward. In The Netherlands, the practice assistant plays a major role in quality activities and the GP can also delegate simple medical acts to him/her. In the UK, all GP practices, even single-handed, have medical and administrative personnel to support the GP in his/her medical and administrative work. These examples call for a reconsideration of the current organisation of the Belgian GP practices: they have to switch from a model where the GP performs all tasks to a model where he can delegate specific tasks to co-workers who have different skills. IT infrastructure is essential for the collection of clinical indicators but in Belgium IT systems effectively supporting quality development projects are not yet available. The current IT systems use different software packages that are not systematically adapted to routine data extraction. 140 Entering data should be easy for the practitioner and ancillary personnel and integrated in his/her usual electronic medical record to optimize the data collection 141,142 . All software packages need to allow data extraction for measuring quality indicators. The IT packages used in general practice should therefore adhere to these conditions before their certification. A more formal approval is therefore rapidly needed. The UK and Dutch experiences show that IT support and a financial aid to the practices allow the development of a performing IT infrastructure in a short period of time.
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 59 The measurement of indicators also depends on the quality of the data recorded during the consultations. All practices should use an electronic medical record. The GPs are responsible for recording in a standardised way the data that will be used for quality measurement. As an illustration, the correct diagnosis is required to identify any group of patients at risk. The Belgian experience of Resoprim showed the difficulty to extract data for quality from GP electronic records 143. 4.3.7 Development of a set of quality indicators Small projects, using a limited number of indicators may help GPs get started with quality development. The feedback they will receive can lead them to the use of the quality cycle. Practices should own their quality project and perhaps choose the indicators with the biggest win (in terms of acceptability, feasibility, reliability, validity and sensitivity to change). It must be bared in mind that indicators need to reflect a common aspect of care for which there is potential for development. 4.3.7.1 Types of indicators The countries analyzed in this report use a balanced set of indicators. Structural indicators deal with the premises and the resources of the practices, organizational indicators highlight how the practice is organized and the satisfaction of the workers in the practice. Patient satisfaction indicators describe the perception of the services by the patients. Besides these indicators, the use of clinical indicators becomes more prominent. The UK developed an impressive number of clinical indicators. In Australia clinical indicators have not been introduced yet and in the Netherlands the practice accreditation scheme has only a very limited number of clinical indicators. 4.3.7.2 Development of a balanced set of indicators for Belgium A well balanced set of indicators is fundamental for being accepted by the GPs in Belgium and its development requires a preliminary agreement on priorities. The development of the sets of indicators should follow the process described in the conceptual framework formerly developed by the KCE (see appendix 11). Universities, scientific bodies and possibly insurance bodies have a role to play. The source of indicators needs a careful attention. The clinical indicators can be derived from Belgian clinical guidelines and scientific bodies have the knowledge to propose some of them. The transfer of indicators between countries is a second option, taking care of the necessary adaptations. 144 Organizational indicators are proposed in the EPA instrument. The feasibility test showed that the entire set of indicators did not perfectly fit the Belgian situation. However, this comprehensive set is a valid source for the development of a Belgian national set as other organizational indicators (for example from the Dutch scientific professional body, NHG). 4.3.8 Role of the scientific GP bodies The involvement of the profession in the development of quality initiatives is of major importance. The Belgian scientific GP bodies and academic departments have the knowledge, the link with the practitioners and sometimes also an experience in managing large scale projects. They are key partners for setting the quality agenda and to develop tools and indicators in collaboration with other stakeholders. 4.3.9 Importance of an independent trustworthy body The heart of the system is the link between an independent body and the GP practices. An IT platform collects the data from the practices and an independent body provides feedback and support to the practices for the implementation of quality initiatives. This independent body has to be perceived as legitimate by the GPs. Independent bodies facilitate the handling of GP data in Australia, the Netherlands, Germany and the UK. Furthermore they are an interface between practices and the Health authorities.
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