Helle Riisgaard

Successful task delegation in general practice – a way to maintain primary health care in the future

Traditionally, the hospitals in Denmark have served as medical units for diagnosing, treating and caring for patients, but these years, various clinical functions formerly undertaken in outpatient clinics, are moved from the hospital sector to general practice [1] in order to maintain the health care system cost-effective [2]. Consequently, general practitioners (GPs) are urged to rethink the working structure without compromising on the quality of care. Taking the clinical perspective, previous research has found that the practice staff, primarily nurses, can substitute for GPs in providing good quality health care to patients [3] and that the patient satisfaction is equally high and, in some cases, even higher when tasks are delegated internally [4]. Seen from a working environmental perspective, recent research has found that a high degree of task delegation is associated with a high degree of job satisfaction among the staff and that there is a tendency of a similar pattern in the case of GPs [5]. Job satisfaction is found to be associated with good quality care and is therefore important to the patients’ care as well. This indicates that neither GPs nor their staff should be afraid of delegating more tasks to the staff in general practice. Nevertheless, there is a substantial variation in the degree to which general practitioners delegate tasks to their staff, and there may be several reasons for this. First of all, education needs to be addressed to a higher degree [6]. The importance of the adequate level of training when delegating tasks from GPs to their staff has been emphasised by GPs [7], patients [8] and by staff members themselves [9]. It is therefore essential that the health authorities are willing to support GPs financially in training their staff adequately [3], whether it is in the shape of continuing education or time for internal supervision in general practice. Moreover, practice staff in extended roles should be taken into consideration when planning the incentives schemes reimbursing GPs [3]. Additionally, the lack of consultation rooms is a major barrier to extending the role of the staff. Hence, before initiating this process, the number of rooms required should be obtained. It will be interesting to see whether the ongoing collective bargaining between the health authorities and the Organisation of General Practitioners (PLO) in Denmark will result in allocation of funds to the barriers emphasised earlier. However, initiatives ensuring a successful task delegation in general practice cannot be facilitated unless GPs and their staff are all supportive of the concept. Therefore, an important precondition is a culture supporting the planned changes in the working pattern. A cultural change is a long process, and it necessitates working on common core values [6]. Hence, GPs and their staff need to find the time for this cultural work, for example, by planning after-hours meetings and maybe inviting a professional facilitator to support the process. Furthermore, patients should be addressed as well. To ensure their acceptance, GPs have to prepare them properly before delegating their care, for instance by introducing them to the nurse prospectively managing (parts of) their care in a joint consultation. Thus, it is crucial that GPs, their staff and patients are all prepared properly in order to ensure a successful task delegation in general practice as this may be the best way to maintain primary healthcare in the future.

Associations between degrees of task delegation and job satisfaction of general practitioners and their staff: a cross-sectional study

BackgroundIn recent years, the healthcare system in the western world has undergone a structural development caused by changes in demography and pattern of disease. In order to maintain the healthcare system cost-effective, new tasks are placed in general practice urging the general practitioners to rethink the working structure without compromising the quality of care. However, there is a substantial variation in the degree to which general practitioners delegate tasks to their staff, and it is not known how these various degrees of task delegation influence the job satisfaction of general practitioners and their staff.MethodsWe performed a cross-sectional study based on two electronic questionnaires, one for general practitioners and one for their staff. Both questionnaires were divided into two parts, a part exploring the degree of task delegation regarding management of patients with chronic obstructive pulmonary disease in general practice and a part concerning the general job satisfaction and motivation to work.ResultsWe found a significant association between perceived “maximal degree” of task delegation in management of patients with chronic obstructive pulmonary disease and the staff’s overall job satisfaction. The odds ratio of the staff’s satisfaction with the working environment displayed a tendency that there is also an association with “maximal degree” of task delegation. In the analysis of the general practitioners, the odds ratios of the results indicate that there is a tendency that “maximal degree” of task delegation is associated with overall job satisfaction, satisfaction with the challenges in work, and satisfaction with the working environment.ConclusionsWe conclude that a high degree of task delegation is significantly associated with overall job satisfaction of the staff, and that there is a tendency that a high degree of task delegation is associated with the general practitioners’ and the staff’s satisfaction with the working environment as well as with general practitioners’ overall job satisfaction and satisfaction with challenges in work. To qualify future delegation processes within general practice, further research could explore the reasons for our findings.

How GPs implement clinical guidelines in everyday clinical practice—a qualitative interview study

BACKGROUND Clinical guidelines are considered to be essential for improving quality and safety of health care. However, interventions to promote implementation of guidelines have demonstrated only partial effectiveness and the reasons for this apparent failure are not yet fully understood. OBJECTIVE To investigate how GPs implement clinical guidelines in everyday clinical practice and how implementation approaches differ between practices. METHODS Individual semi-structured open-ended interviews with seven GPs who were purposefully sampled with regard to gender, age and practice form. Interviews were recorded, transcribed verbatim and then analysed using systematic text condensation. RESULTS Analysis of the interviews revealed three different approaches to the implementation of guidelines in clinical practice. In some practices the GPs prioritized time and resources on collective implementation activities and organized their everyday practice to support these activities. In other practices GPs discussed guidelines collectively but left the application up to the individual GP whilst others again saw no need for discussion or collective activities depending entirely on the individual GPs decision on whether and how to manage implementation. CONCLUSION Approaches to implementation of clinical guidelines vary substantially between practices. Supporting activities should take this into account.

Work motivation, task delegation and job satisfaction of general practice staff: a cross-sectional study

Abstract Background. Recent research has shown that a high degree of task delegation is associated with the practise staff’s overall job satisfaction, and this association is important to explore since job satisfaction is related to medical as well as patient-perceived quality of care. Objectives. This study aimed: (1) to investigate associations between degrees of task delegation in the management of chronic disease in general practice, with chronic obstructive pulmonary disease (COPD) as a case and the staff’s work motivation, (2) to investigate associations between the work motivation of the staff and their job satisfaction. Methods. The study was based on a questionnaire to which 621 members of the practice staff responded. The questionnaire consisted of a part concerning degree of task delegation in the management of COPD in their respective practice and another part being about their job satisfaction and motivation to work. Results. In the first analysis, we found that ‘maximal degree’ of task delegation was significantly associated with the staff perceiving themselves to have a large degree of variation in tasks, odds ratio (OR) = 4.26, confidence interval (CI) = 1.09, 16.62. In the second analysis, we found that this perceived large degree of variation in tasks was significantly associated with their overall job satisfaction, OR = 2.81, confidence interval = 1.71, 4.61. Conclusion. The results suggest that general practitioners could delegate highly complex tasks in the management of COPD to their staff without influencing the staff’s work motivation, and thereby their job satisfaction, negatively, as long as they ensure sufficient variation in the tasks.

Variation in general practitioners' information-seeking behaviour: a cross-sectional study on the influence of gender, age and practice form

Abstract Objective: To assess general practitioners’ (GPs’) information-seeking behaviour and perceived importance of sources of scientific medical information and to investigate associations with GP characteristics. Design: A national cross-sectional survey was distributed electronically in December 2013. Setting: Danish general practice. Subjects: A population of 3440 GPs (corresponding to approximately 96% of all Danish GPs). Main outcome measures: GPs’ use and perceived importance of information sources. Multilevel mixed-effects logit models were used to investigate associations with GP characteristics after adjusting for relevant covariates. Results: A total of 1580 GPs (46.4%) responded to the questionnaire. GPs’ information-seeking behaviour is associated with gender, age and practice form. Single-handed GPs use their colleagues as an information source significantly less than GPs working in partnership practices and they do not use other sources more frequently. Compared with their younger colleagues, GPs aged above 44 years are less likely to seek information from colleagues, guidelines and websites, but more likely to seek information from medical journals. Male and female GPs seek information equally frequently. However, whereas male GPs are more likely than female GPs to find that pharmaceutical sales representative and non-refundable CME meetings are important, they are less likely to find that colleagues, refundable CME meetings, guidelines and websites are important. Conclusion: Results from this study indicate that GP characteristics should be taken into consideration when disseminating scientific medical information, to ensure that patients receive medically updated, high-quality care. KEY POINTS Research indicates that information-seeking behaviour is associated with GP characteristics. Further insights could provide opportunities for targeting information dissemination strategies. Single-handed GPs seek information from colleagues less frequently than GPs in partnerships and do not use other sources more frequently. GPs aged above 44 years do not seek information as frequently as their younger colleagues and prefer other information sources. Male and female GPs seek information equally frequently, but do not consider information sources equally important in keeping medically updated.

Are formalised implementation activities associated with aspects of quality of care in general practice? A cross-sectional study

Background There is a substantial variation in how different general practices manage knowledge implementation, including the degree to which activities are collectively and formally organised. Yet, it is unclear how these differences in implementation activities affect quality of care. Aim To investigate if there are associations between specific formalised knowledge implementation activities and quality of care in general practices, exemplified by the use of spirometry testing. Design & setting A nationwide cross-sectional study combining survey and register data in Denmark. Method An electronic questionnaire was distributed to GPs, and data on spirometry testing among first-time users of medication against obstructive lung diseases were obtained from national registers. Associations were investigated using multilevel mixed-effect logit models. Results GPs from 1114 practices (58%) responded, and 33 788 patients were linked to a responding practice. In partnership practices, the frequency of interdisciplinary and GP meetings affected the quality of care. Interdisciplinary and GP meetings held on a weekly basis were significantly associated with a higher level of quality of care and this was measured by the odds ratio (OR) of patients having spirometry. The development of practice protocols and standard recordings in the electronic medical record (EMR) for a range of disease areas compared with few or no areas at all also impacted the quality of care level provided. The effect of formalised implementation activities was not as evident in single-handed practices as in partnerships. Conclusion This study provides valuable knowledge for GPs who aim to organise their practice in a way that supports implementation and quality improvement most effectively. Also, results may be useful for managers of implementation strategies and quality improvement initiatives when planning future activities.

Task delegation in general practice: A study from Denmark

Abstracts from the EGPRN meeting in Antwerp, Belgium, 18th – 21st October, 2012. Theme: ‘Research on Patient-centred Interprofessional Collaboration in Primary Care’