Linda Hilts

Rehabilitation in a primary care setting for persons with chronic illness – a randomized controlled trial

Aim The primary objective of this study was to determine whether adults with a chronic illness within a primary care setting who received a rehabilitation intervention in this setting showed greater improvement in health status and had fewer hospital admissions and emergency room visits compared with adults who do not receive the intervention. Background More than half of Canadians (16 million people) live with chronic illness. Persons with chronic illness in primary care, especially older persons who are most at risk for functional decline, are currently not receiving effective management. Methods A randomized controlled trial was used. A rehabilitation multi-component intervention was delivered by a physiotherapist (PT) and occupational therapist in a primary care setting and included collaborative goal setting for rehabilitation needs, a six-week chronic disease self-management (SM) workshop, referral to community programs and a web-based education programme. Findings Three hundred and three patients participated, n = 152 intervention group and n = 151 in the control group. There was a significant difference between the groups for planned hospital days ( F = 6.3, P = 0.00) with an adjusted difference 0.60 day per person, and increased satisfaction with rehabilitation services however no difference on health status or emergency room visits. This rehabilitation intervention which had a strong SM component prevented planned hospitalizations that resulted in a conservative estimated cost saving from reduced hospitalizations of

Helping primary care teams emerge through a quality improvement program.

65 000. Future research needs to examine which patient groups with chronic illness show positive responses to rehabilitation and self-management.

Patient satisfaction with access in two interprofessional academic family medicine clinics

BACKGROUND Approaches to improving the quality of health care recognize the need for systems and cultures that facilitate optimal care. Interpersonal relationships and dynamics are a key factor in transforming a system to one that can achieve quality. The Quality in Family Practice (QIFP) program encompasses clinical and practice management using a comprehensive tool of family practice indicators. OBJECTIVE The objective of this study was to explore and describe the views of staff regarding changes in the clinical practice environment at two affiliated academic primary care clinics (comprising one Family Health Team, FHT) who participated in QIFP. METHODS An FHT in Hamilton, Canada, worked through the quality tool in 2008/2009. A qualitative exploratory case study approach was employed to examine staff perceptions of the process of participating. Semi-structured interviews were conducted in early 2010 with 43 FHT staff with representation from physicians, nurses, allied health professionals, support staff and managers. Interviews were audio-taped and transcribed verbatim. A modified template approach was used for coding, with a complexity theory perspective of analysis. RESULTS Themes included importance of leadership, changes to practice environment, changes to communication, an increased understanding of team roles and relationships, strengthened teamwork, flattening of hierarchy through empowerment, changes in clinical care and clinical impacts, challenges and rewards and sustainability. CONCLUSION The program resulted in perceived changes to relationships, teamwork and morale. Addressing issues of leadership, role clarity, empowerment, flattening of hierarchy and teamwork may go a long way in establishing and maintaining a quality culture.

Practice-based collection of quality indicator data for a comprehensive quality assessment programme in Canadian family practices

BACKGROUND Satisfaction with access to primary care is one component of overall patient satisfaction. The objectives of this paper were to describe patient satisfaction with access in interprofessional family practices and to examine predictors of being less than satisfied with access. METHODS A survey was mailed to 770 randomly selected patients in two academic interprofessional family practices in Hamilton, Canada. Most items were positively worded statements on a five-point scale from strongly agree to strongly disagree. Outcomes were the proportion of respondents agreeing with statements regarding access. For items where > or =25% of respondents did not agree, we examined socio-demographic predictors of disagreement using multiple variable logistic regression. RESULTS The response rate was 49.9% (384/770). One-quarter or more of respondents did not agree that they received an explanation if the appointment was delayed at the office, obtain urgent appointments, obtain prescription refills without a visit or that wait times at the office were reasonable. Predictors of not agreeing included younger age, being married or single, more educated, employed and of non-white ethnicity. Less than 10 minutes was the most satisfactory wait time for the appointment to begin; however, the most common wait time reported was 11-20 minutes. One-quarter of respondents had visited the weekend/holiday clinic in the past 12 months; however, use was not associated with perceived ability to obtain an appointment in 1-2 days. CONCLUSIONS While satisfaction was generally high, some aspects of access could be improved by changes in practice organization or patient education regarding expectations.

Development of a program for improving interprofessional relationships through intentional conversations in primary care.

Introduction Quality improvement in primary care can be facilitated by the ability to measure indicators in practice. This paper reports on the process and impacts of data collection on indicators of a quality assessment tool in seven interprofessional group family practices in Ontario, Canada. Methods The programme addressed indicators and collected data across multiple domains of practice including clinical quality, physical factors, and patient and staff perceptions. A system audit of the practice, a patient survey, a staff satisfaction survey and chart audits (on hypothyroidism and hyperlipidaemia) were designed to measure selected indicators across the domains. Practices were trained and collected their own data. Practices provided feedback on the process and impacts during a postprogramme workshop and on a survey 1 year later. Results Four-hundred charts audits were completed for each of hyperlipidaemia and hypothyroidism, 319 patient satisfaction surveys were administered in four practices, and the staff satisfaction survey was completed by 77 staff in six practices. Most practices demonstrated indicators of privacy, access and safety. There was more variability in indicators relating to staff professional development and team involvement in meetings. Patient satisfaction with providers was rated highly, whereas some aspects of practice access were rated lower. Practices approached the challenge of participation by engaging multidisciplinary team members and dividing tasks. Most practices reported continued participation in various quality improvement initiatives 1 year later. Conclusions Using a set of indicators, structured processes and training, family practices find the process of gathering and reviewing their data useful for quality improvement.

Interprofessional education in academic family medicine teaching units A functional program and culture

Healthcare organizations can be conceptualized as networks of continuously evolving relationships expressed as ongoing conversations. These conversations and relationships, which are shaped by the culture and leadership of health care teams (Suchman, 2001), can have an impact on clinical outcomes (Kaplan et al., 1989; Williams et al., 1998) and workforce health and satisfaction (Revans, 1996). Interventions to enhance these relationships, such as mentoring and programs that foster reflection, dialogue, and creativity, thus have the potential to positively impact the health of communities, organizational function, and staff wellbeing.