Tina Eriksson

Survey of 5 European countries suggests that more elements of patient-centered medical homes could improve primary care

The patient-centered medical home is a US model for comprehensive care. This model features a personal physician or registered nurse who is augmented by a proactive team and information technology. Such a model could prove useful for advanced European systems as they strive to improve primary care, particularly for chronically ill patients. We surveyed 6,428 chronically ill patients and 152 primary care providers in five European countries to assess aspects of the patient-centered medical home. Although most patients reported that they had a personal physician and no problems in contacting the practice after hours, for example, other aspects of the patient-centered medical home, such as provision of written self-management support to patients, were not as widespread. We conclude that despite strong organizational structures, European primary care systems need additional efforts to recognize chronically ill patients as partners in care and can embrace patient-centered medical homes to improve care for European patients.

Facilitating organisational development using a group-based formative assessment and benchmarking method: design and implementation of the International Family Practice Maturity Matrix

Introduction Well-organised practices deliver higher-quality care. Yet there has been very little effort so far to help primary care organisations achieve higher levels of team performance and to help them identify and prioritise areas where quality improvement efforts should be concentrated. No attempt at all has been made to achieve a method which would be capable of providing comparisons—and the stimulus for further improvement—at an international level. Methods The development of the International Family Practice Maturity Matrix took place in three phases: (1) selection and refinement of organisational dimensions; (2) development of incremental scales based on a recognised theoretical framework; and (3) testing the feasibility of the approach on an international basis, including generation of an automated web-based benchmarking system. Results This work has demonstrated the feasibility of developing an organisational assessment tool for primary care organisations that is sufficiently generic to cross international borders and is applicable across a diverse range of health settings, from state-organised systems to insurer-based health economies. It proved possible to introduce this assessment method in 11 countries in Europe and one in Africa, and to generate comparison benchmarks based on the data collected. The evaluation of the assessment process was uniformly positive with the view that the approach efficiently enables the identification of priorities for organisational development and quality improvement at the same time as motivating change by virtue of the group dynamics. Conclusions We are not aware of any other organisational assessment method for primary care which has been ‘born international,’ and that has involved attention to theory, dimension selection and item refinement. The principal aims were to achieve an organisational assessment which gains added value by using interaction, engagement comparative benchmarks: aims which have been achieved. The next step is to achieve wider implementation and to ensure that those who undertake the assessment method ensure linkages are made to planned investment in organisational development and quality improvement. Knowing the problems is only half the story.

Quality improvement in general practice: enabling general practitioners to judge ethical dilemmas

Quality improvement (QI) is fundamental to maintaining high standards of health care. Significant debate exists concerning the necessity for an ethical approval system for those QI projects that push the boundaries, appearing more similar to research than QI. The authors discuss this issue identifying the core ethical issues in family medicine (FM), drawing upon the fundamental principles of medical ethics, including principles of autonomy, utility, justice and non-maleficence. Recent debate concerning the application of QI ethics boards is discussed with relevance to primary care and issues such as general practitioner (GP) intentions, the impact of QI on patients and the use of confidential patient data and the impact of dissemination. The authors conclude that a system of QI ethical approval leaves many issues unresolved and potentially creates several barriers to implementing QI. To ensure ethical QI work is generated within FM it is essential for GPs to learn about and engage in more ethical reflection so that they can better judge and resolve these issues.

Teaching quality improvement in family medicine

Quality improvement (QI) includes the combined and continuous efforts of healthcare professionals, patients and their families, researchers, payers, planners and educators to make changes that will lead to better patient outcomes, system performance and professional development.1 QI needs to be taught at all levels of medical education and in all aspects of medical care.2 In family medicine, quality of healthcare extends to all aspects of family doctors’ work: primary care management, community orientation, specific problem-solving skills, comprehensive approach, personcentred care and holistic approach.3 The Educational Agenda developed by the European Academy of Teachers in General Practice/Family Medicine (EURACT)4 covers most of these aspects. However, it is not clear if this agenda includes techniques and competencies of QI. Namely, QI as a separate topic is not specifically mentioned or incorporated in the agenda. This is in contrast with the document set out in the USA by the Accreditation Council for Graduate Medical Education (ACGME) in 1999 involving ‘practice-based learning and improvement’ as the centre of six doctors’ core competences.5 So what happens within the different European countries? Until now, very little was known about the inclusion, content and outcomes of teaching QI topics within the medical curricula in the various countries.6–11 Engels et al published an extensive overview of the situation of teaching QI in the Netherlands in 2007.2 A teaching QI working group was formed in 2008 as part of the European Association for Quality and Safety in General Practice/Family Medicine (EQuiP; a WONCA Europe network organisation). One of the aims of this group was to provide a comprehensive overview of how and at which levels QI is actually taught in European countries. This stimulated the discussion on themes and topics that should be taught and at what educational level they could be introduced in the medical teaching curriculum.

Documenting organisational development in general practice using a group-based assessment method: the Maturity Matrix

Objective The Maturity Matrix (MM) comprises a formative evaluation instrument for primary care practices to self-assess their degree of organisational development in a group setting, guided by an external facilitator. The practice teams discuss organisational development, score their own performance and set improvement goals for the following year. The objective of this project was to introduce a translated and culturally adapted version of the MM in Denmark, to test its feasibility, to promote and document organisational change in general practices and to analyse associations between the recorded change(s) and structural factors in practices and the factors associated with the MM process. Setting MM was used by general practices in three counties in Denmark, in two assessment sessions 1 year apart. First rounds of MM visits were carried out in 2006–2007 in 60 practice teams (320 participants (163 GPs, 157 staff)) and the second round in 2007–2008. A total of 48 practice teams (228 participants (117 GPs; 111 staff) participated in both sessions. Method The MM sessions were the primary intervention. Moreover, in about half of the practices, the facilitator reminded practice teams of their goals by sending them the written report of the initial session and contacted the practices regularly by telephone reminding them of the goals they had set. Those practice teams had password-protected access to their own and benchmark data. Results Where the minimum possible is 0 and maximum possible is 8, the mean overall MM score increased from 4.4 to 5.3 (difference=0.9, 95%, CI 0.76 to 1.06) from first to second sessions, indicating that development had taken place as measured by this group-based self-evaluation method. There was some evidence that lower-scoring dimensions were prioritised and more limited evidence that the prioritisation and interventions between meetings were helpful to achieve changes. Conclusions This study provides evidence that MM worked well in general practices in Denmark. Practice teams appeared to be learning about the process, directing their efforts more efficiently after a years experience of the project. This experience also informs the further improvement of the facilitation and follow-up components of the intervention.

Developing organisational maturity: Considering the role of culture typologies for primary care practices

It is increasingly recognised that structural changes alone will not secure significant gains in healthcare performance and more emphasis needs to be placed on developing cultural changes to improve the processes of care. As a consequence, questions are increasingly being asked about the nature of organisations – are they capable of ‘learning’, of developing, do they have positive ‘cultural’ characteristics and an interest in organisational maturity? If organisations can possess cultural characteristics that lead to better systems of providing care, can we understand and use these characteristics to stimulate a culture of change within general practice? The term ‘organisational maturity’ has entered the healthcare literature since the development of tools such as the UK Maturity Matrix, the International Family Practice Maturity Matrix (www.maturitymatrix.co.uk) and the Manchester Patient Safety Framework (MaPSaF) which identify the cultural characteristics of more ‘mature’ organisations to motivate organisations to bring about cultural changes. These tools conceptualise different levels of organisational maturity on a scale of development and are based on a theory by Westrum of a ‘typology of cultures’. Within this theory Westrum described three types of cultures present within organisations that display increasing levels of organisational maturity. Using this typology we aim to identify the characteristics of mature organisations and apply them to the fundamental organisational aspects of general practice. In doing this we are providing guidelines for primary care practices to develop their culture into one that is more organisationally mature. First, however, let us understand the term ‘organisational culture’ and the role it plays in improving care.