Beyond quality improvement: exploring why primary care teams engage in a voluntary audit and feedback program

BackgroundCoordination is critical to successful team-based health care. Most clinicians, however, are not trained in effective coordination or teamwork. Audit and feedback (A&F) could improve team coordination, if designed with teams in mind.AimThe effectiveness of a multifaceted, A&F-plus-debrief intervention was tested to establish whether it improved coordination in primary care teams compared with controls.Design & settingCase-control trial within US Veterans Health Administration medical centres.MethodThirty-four primary care teams selected from four geographically distinct hospitals were compared with 34 administratively matched control teams. Intervention-arm teams received monthly A&F reports about key coordination behaviours and structured debriefings over 7 months. Control teams were followed exclusively via their clinical records. Outcome measures included a coordination composite and its component indicators (appointments starting on time, timely recall scheduling, emergency department utilisation, and electronic patient portal enrolment). Predictors included intervention arm, extent of exposure to intervention, and degree of multiple team membership (MTM).ResultsIntervention teams did not significantly improve over control teams, even after adjusting for MTM. Follow-up analyses indicated cross-team variability in intervention fidelity; although all intervention teams received feedback reports, not all teams attended all debriefings. Compared with their respective baselines, teams with high debriefing exposure improved significantly. Teams with high debriefing exposure improved significantly more than teams with low exposure. Low exposure teams significantly increased patient portal enrolment.ConclusionTeam-based A&F, including adequate reflection time, can improve coordination; however, the effect is dose dependent. Consistency of debriefing appears more critical than proportion of team members attending a debriefing for ensuring implementation fidelity and effectiveness.

Download Full-text

The impact of audit and feedback to support change behaviour in healthcare organisations - a cross-sectional qualitative study of primary care centre managers

BMC Health Services Research ◽

10.1186/s12913-021-06645-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Anna H. Glenngård ◽

Anders Anell

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Audit And Feedback ◽

Primary Care Centre ◽

Research Approach ◽

Care Centre ◽

Bottom Up ◽

Complex Change ◽

Facilitators And Barriers ◽

The Impact

Abstract Background This article addresses the role of audit and feedback (A&F) to support change behaviour and quality improvement work in healthcare organisations. It contributes to the sparse literature on primary care centre (PCC) managers´ views on A&F practices, taking into account the broad scope of primary care. The purpose was to explore if and how different types of A&F support change behaviour by influencing different forms of motivation and learning, and what contextual facilitators and barriers enable or obstruct change behaviour in primary care. Methods A qualitative research approach was used. We explored views about the impact of A&F across managers of 27 PCCs, in five Swedish regions, through semi-structured interviews. A purposeful sampling was used to identify both regions and PCC managers, in order to explore multiple perspectives. We used the COM-B framework, which describes how Capability, Opportunity and Motivation interact and generate change behaviour and how different factors might act as facilitators or barriers, when collecting and analysing data. Results Existing forms of A&F were perceived as coercive top-down interventions to secure adherence to contractual obligations, financial targets and clinical guidelines. Support to bottom-up approaches and more complex change at team and organisational levels was perceived as limited. We identified five contextual factors that matter for the impact of A&F on change behaviour and quality improvement work: performance of organisations, continuity in staff, size of organisations, flexibility in leadership and management, and flexibility offered by the external environment. Conclusions External A&F, perceived as coercive by recipients of feedback, can have an impact on change behaviour through ‘know-what’ and ‘know-why’ types of knowledge and ‘have-to’ commitment but provide limited support to complex change. ‘Want-to’ commitment and bottom-up driven processes are important for more complex change. Similar to previous research, identified facilitators and barriers of change consisted of factors that are difficult to influence by A&F activities. Future research is needed on how to ensure co-development of A&F models that are perceived as legitimate by health care professionals and useful to support more complex change.

Download Full-text

Post-discharge care following acute kidney injury: quality improvement in primary care

BMJ Open Quality ◽

10.1136/bmjoq-2019-000891 ◽

2020 ◽

Vol 9 (4) ◽

pp. e000891

Author(s):

Susan J Howard ◽

Rebecca Elvey ◽

Julius Ohrnberger ◽

Alex J Turner ◽

Laura Anselmi ◽

...

Keyword(s):

Primary Care ◽

Acute Kidney Injury ◽

Patient Safety ◽

Quality Improvement ◽

Health Outcomes ◽

Kidney Injury ◽

Audit And Feedback ◽

Improvement Project ◽

General Practices ◽

The Impact

BackgroundOver the past decade, targeting acute kidney injury (AKI) has become a priority to improve patient safety and health outcomes. Illness complicated by AKI is common and is associated with adverse outcomes including high rates of unplanned hospital readmission. Through national patient safety directives, NHS England has mandated the implementation of an AKI clinical decision support system in hospitals. In order to improve care following AKI, hospitals have also been incentivised to improve discharge summaries and general practices are recommended to establish registers of people who have had an episode of illness complicated by AKI. However, to date, there is limited evidence surrounding the development and impact of interventions following AKI.DesignWe conducted a quality improvement project in primary care aiming to improve the management of patients following an episode of hospital care complicated by AKI. All 31 general practices within a single NHS Clinical Commissioning Group were incentivised by a locally commissioned service to engage in audit and feedback, education training and to develop an action plan at each practice to improve management of AKI.ResultsAKI coding in general practice increased from 28% of cases in 2015/2016 to 50% in 2017/2018. Coding of AKI was associated with significant improvements in downstream patient management in terms of conducting a medication review within 1 month of hospital discharge, monitoring kidney function within 3 months and providing written information about AKI to patients. However, there was no effect on unplanned hospitalisation and mortality.ConclusionThe findings suggest that the quality improvement intervention successfully engaged a primary care workforce in AKI-related care, but that a higher intensity intervention is likely to be required to improve health outcomes. Development of a real-time audit tool is necessary to better understand and minimise the impact of the high mortality rate following AKI.

Download Full-text

Conditions and barriers for quality improvement work: a qualitative study of how professionals and health centre managers experience audit and feedback practices in Swedish primary care

BMC Family Practice ◽

10.1186/s12875-021-01462-4 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Eva Arvidsson ◽

Sofia Dahlin ◽

Anders Anell

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Qualitative Content Analysis ◽

Health Centre ◽

Audit And Feedback ◽

Macro Level ◽

Care Experience ◽

Professional Perspective ◽

Health Centres ◽

Clinical Measures

Abstract Background High quality primary care is expected to be the basis of many health care systems. Expectations on primary care are rising as societies age and the burden of chronic disease grows. To stimulate adherence to guidelines and quality improvement, audit and feedback to professionals is often used, but the effects vary. Even with carefully designed audit and feedback practices, barriers related to contextual conditions may prevent quality improvement efforts. The purpose of this study was to explore how professionals and health centre managers in Swedish primary care experience existing forms of audit and feedback, and conditions and barriers for quality improvement, and to explore views on the future use of clinical performance data for quality improvement. Methods We used an explorative qualitative design. Focus groups were conducted with health centre managers, physicians and other health professionals at seven health centres. The interviews were audio recorded, transcribed and analysed using qualitative content analysis. Results Four different types of audit and feedback that regularly occurred at the health centres were identified. The main part of the audit and feedback was “external”, from the regional purchasers and funders, and from the owners of the health centres. This audit and feedback focused on non-clinical measures such as revenues, utilisation of resources, and the volume of production. The participants in our study did not perceive that existing audit and feedback practices contributed to improved quality in general. This, along with lack of time for quality improvement, lack of autonomy and lack of quality improvement initiatives at the system (macro) level, were considered barriers to quality improvement at the health centres. Conclusions Professionals and health centre managers did not experience audit and feedback practices and existing conditions in Swedish primary care as supportive of quality improvement work. From a professional perspective, audit and feedback with a focus on clinical measures, as well as autonomy for professionals, are necessary to create motivation and space for quality improvement work. Such initiatives also need to be supported by quality improvement efforts at the system (macro) level, which favour transformation to a primary care based system.

Download Full-text

Conditions and Barriers for Quality Improvement Work. A Qualitative Study of How Professionals and Health Centre Managers Experience Audit and Feedback Practices in Swedish Primary Care

10.21203/rs.3.rs-154101/v1 ◽

2021 ◽

Author(s):

Eva Arvidsson ◽

Sofia Dahlin ◽

Anders Anell

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Clinical Performance ◽

Health Centre ◽

Audit And Feedback ◽

Macro Level ◽

Care Experience ◽

Professional Perspective ◽

Health Centres ◽

Clinical Measures

Abstract BackgroundHigh quality primary care is expected to be the basis of many health care systems. Expectations on primary care are rising as societies age and the burden of chronic disease grows. To stimulate adherence to guidelines and quality improvement, audit and feedback to professionals is often used, but the effects vary. Even with carefully designed audit and feedback practices, barriers related to contextual conditions may prevent quality improvement efforts. The purpose of this study was to explore how professionals and health centre managers in Swedish primary care experience existing forms of audit and feedback, and conditions and barriers for quality improvement, and to explore views on the future use of clinical performance data for quality improvement. MethodsWe used an explorative qualitative design. Focus groups were conducted with health centre managers, physicians and other health professionals at seven health centres. The interviews were audio recorded, transcribed and analysed using qualitative content analysis.ResultsFour different types of audit and feedback that regularly occurred at the health centres were identified. The main part of the audit and feedback was “external”, from the regional purchasers and funders, and from the owners of the health centres. This audit and feedback focused on non-clinical measures such as revenues, utilisation of resources, and the volume of production. The participants in our study did not perceive that existing audit and feedback practices contributed to improved quality in general. This, along with lack of time for quality improvement, lack of autonomy and lack of quality improvement initiatives at the system (macro) level, were considered barriers to quality improvement at the health centres.ConclusionsProfessionals and health centre managers did not experience audit and feedback practices and existing conditions in Swedish primary care as supportive of quality improvement work. From a professional perspective, audit and feedback with a focus on clinical measures, as well as autonomy for professionals, are necessary to create motivation and space for quality improvement work. Such initiatives also need to be supported by quality improvement efforts at the system (macro) level, which would favour transformation to a primary care based system.

Download Full-text

Interprofessional advanced access – a quality improvement protocol for expanding access to primary care services

BMC Health Services Research ◽

10.1186/s12913-021-06839-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Isabelle Gaboury ◽

Mylaine Breton ◽

Kathy Perreault ◽

François Bordeleau ◽

Sarah Descôteaux ◽

...

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Social Services ◽

Nurse Practitioners ◽

Practice Facilitation ◽

Care Services ◽

Primary Care Services ◽

Primary Care Teams ◽

Access To Primary Care ◽

Advanced Access

Abstract Background The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. Methods Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. Discussion Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec’s ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.

Download Full-text

The importance of significant event analysis

InnovAiT Education and inspiration for general practice ◽

10.1177/1755738020941231 ◽

2020 ◽

Vol 13 (10) ◽

pp. 613-617

Author(s):

Nicola Cooper-Moss ◽

Neil Smith ◽

Professor Umesh Chauhan

Keyword(s):

Primary Care ◽

General Practice ◽

Quality Improvement ◽

Clinical Reasoning ◽

Healthcare Systems ◽

Event Analysis ◽

Quality Improvement Activity ◽

Primary Care Teams ◽

Team Based Learning ◽

Future Patient

Significant event analysis (SEA) is a structured quality improvement activity that is well established in general practice. Participation in SEA prompts primary care teams to reflect on their clinical reasoning, to highlight exemplary care, and to identify any potential improvements in both practice and wider healthcare systems. This article provides an overview of the SEA process and the events surrounding a SEA meeting. Cancer care examples are used to demonstrate how SEA can be used to enhance team-based learning and improve future patient care.

Download Full-text

Engaging Patients in Primary Care Quality Improvement Initiatives: Facilitators and Barriers

American Journal of Medical Quality ◽

10.1177/1062860619842938 ◽

2019 ◽

Vol 35 (1) ◽

pp. 52-62

Author(s):

Nancy Pandhi ◽

Nora Jacobson ◽

Madison Crowder ◽

Andrew Quanbeck ◽

Mollie Hass ◽

...

Keyword(s):

Primary Care ◽

Quality Improvement ◽

Patient Engagement ◽

Patient Activation ◽

Care Quality ◽

Effective Strategies ◽

Primary Care Quality ◽

Primary Care Teams ◽

Communication Difficulties ◽

Facilitators And Barriers

Health care transformation calls for patient engagement in quality improvement (PEQI), yet practice participation remains low. This pilot study of 8 primary care clinics at 7 statewide locations sought to determine the most effective strategies for disseminating a previously successful single-system PEQI intervention. Qualitative data were obtained through site visits, interviews, observations, and journaling. All material pertaining to barriers, recruitment/retention, and implementation was extracted, compared, and categorized. Five teams partially completed the intervention and 3 finished. These 3 teams did not ask for shorter trainings and were assigned a quality improvement (QI) coach. Multiple barriers to recruitment, implementation, and retention were noted at the organizational and clinic/team level, including turnover, shifting priorities, cross-level communication difficulties, lack of QI knowledge, and confusion between patient engagement and patient activation. These findings suggest that QI facilitation and dedicated time can help primary care teams identify and overcome barriers to PEQI.

Download Full-text