Effectiveness of a quality-improvement program in improving management of primary care practices

Background:

The European Practice Assessment program provides feedback and outreach visits to primary care practices to facilitate quality improvement in five domains (infrastructure, people, information, finance, and quality and safety). We examined the effectiveness of this program in improving management in primary care practices in Germany, with a focus on the domain of quality and safety.

Methods:

In a before–after study, 102 primary care practices completed a practice assessment using the European Practice Assessment instrument at baseline and three years later (intervention group). A comparative group of 102 practices was included that completed their first assessment using this instrument at the time of the intervention group’s second assessment. Mean scores were based on the proportion of indicators for which a positive response was achieved by all of the practices, on a scale of 0 to 100.

Results:

We found significant improvements in all domains between the first and second assessments in the intervention group. In the domain of quality and safety, improvements in scores (mean scores were based on the proportion of indicators for which a positive response was achieved by all of the practices, on a scale of 0 to 100) were observed in the following dimensions: complaint management (from a mean score of 51.2 at first assessment to 80.7 at second assessment); analysis of critical incidents (from 79.1 to 89.6); and quality development, quality policy (from 40.7 to 55.6). Overall scores at the time of the second assessment were significantly higher in the intervention group than in the comparative group.

Interpretation:

Primary care practices that completed the European Practice Assessment instrument twice over a three-year period showed improvements in practice management. Our findings show the value of the quality-improvement cycle in the context of practice assessment and the use of established organizational standards for practice management with the Europeaen Practice Assessment.A variety of quality-improvement initiatives in health care management have been implemented in most health care systems.^1,2 Countries such as Australia, New Zealand, the United Kingdom and the United States have a long tradition in, and established standards for, quality management in primary care. In Canada, such initiatives in primary care are in their infancy, despite support by the federal Primary Health Care Transition Fund since 2000.³ In Ontario, a comprehensive book was recently issued that provides recommendations on practice management and clinical indicators for improving quality in primary care settings in the province.⁴ The indicators were adopted and refined from the Royal New Zealand College of General Practitioners, the Royal Australian College of General Practitioners’ National Expert Committee on Standards for General Practices, the TOPAS–Europe Association European Practice Assessment, the United Kingdom’s Quality and Outcomes Framework and the Canadian Institute for Health Information.In Germany, similar developments took place. In 2005, the German government stipulated that health care providers implement a system of annual assessment of quality management.⁵ One of the systems available to practices is the European Practice Assessment (www.epa-qm.de), a validated instrument based on quality indicators for assessing practice management.⁶ The five key domains of the European Practice Assessment instrument and their respective dimensions are described in Figure 1.Open in a separate windowFigure 1:The domains and dimensions (and number of indicators) of the European Practice Assessment instrument used to measure the quality of practice management in primary care practices. For an example of how the pentagon shape is used to provide feedback to individual practices, see Appendix 1 (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.110412/-/DC1). GP = general practitioner.The European Practice Assessment is used to help general practices both assess and improve their quality of practice management set against predefined criteria with embedded quality indicators. The improvement process is ongoing (e.g., through plan–do–study–act cycles⁷): each step is reviewed and redesigned with a view to improving the quality of the end product, thereby fostering continuous improvement.⁸ The multifaceted strategy has three essential components: assessment and feedback using validated instruments based on quality indicators; external support through an outreach educational visit by a trained visitor (physician or nurse) to support the practice in improving areas of management identified by the practice;⁹ and formal accreditation by an external organization.Three requirements have to be fulfilled by practices to receive accreditation: achieve a positive response for more than 50% of the indicators; meet predefined safety indicators (e.g., the vaccination status of staff regarding hepatitis B vaccination is recorded and medical equipment is checked regularly according to national regulations); and highlight areas for continuous quality improvement.Accreditation is one method for assessing and benchmarking the performance of general practice care across a broad range of clinical and organizational domains. It describes a formal process of self-assessment and external and independent peer review to encourage best management practice and can result in recommendations for continuous improvement of safety and quality in the practice.⁸ Practice accreditation can be used for different purposes: quality control, regulation, quality improvement, providing data on performance, and marketing.⁸ In Germany, it is used for quality improvement, leading to a certificate.We conducted a study to determine whether improvements in practice management occurred in general practices that completed the European Practice Assessment twice over three years, compared with general practices that completed the European Practice Assessment once. We focused our analysis on the domain of quality and safety, expecting an association between practice organization and quality improvement.^10,11 We hypothesized that the initial use of the European Practice Assessment and reassessment with it three years later would result in improved scores in the dimensions and indicators within the domain of quality and safety.