European Practice Assessment Research Articles

Is patient loyalty associated with quality of care? Results of a patient survey over primary care in Switzerland

The study aimed to evaluate quality of care and to determine which aspects are associated with the willingness to recommend the general practitioner (GP) as a part of patient loyalty. This was an exploratory study which collected patient data from ambulatory care in the German part of Switzerland between 2013 and 2016. Primary care in Switzerland. Included patients from 79 primary care practices who volunteered to participate in the quality management system European Practice Assessment. Patients were afterwards asked to complete the European Task Force on Patient Evaluations of General Practice Care instrument. Describing influencing factors of quality of care on recommendation of the GP from the perspective of the patients. Patient perspective on quality of care. Survey respondent rate was 81.3%. Over 69% of the respondents were willing to recommend their GP. 'Listening to you' (94.2%) and 'interest in your personal situation' (93.0%) as a part of the domain 'relationship and communication' were rated as the highest quality criteria. The lowest rate was found for 'being able to speak to the GP on the telephone' (30.0%) and 'waiting time in the waiting room' (50.6%). Patient loyalty, in terms of willingness to recommend the GP, was strongly associated with most of the items under the 'relationship and communication' section but also with having more physician's assistants in the practice. The results are important for understanding patients' priorities with regard to general practice care. Patient assessment allows us to identify possible areas for quality improvement within the practice and could provide feedback.

If you can\u2019t measure it- you can\u2019t change it \u2013 a longitudinal study on improving quality of care in hospitals and health centers in rural Kenya

BackgroundThe Kenyan Ministry of Health- Department of Standards and Regulations sought to operationalize the Kenya Quality Assurance Model for Health. To this end an integrated quality management system based on validated indicators derived from the Kenya Quality Model for Health (KQMH) was developed and adapted to the area of Reproductive and Maternal and Neonatal Health, implemented and analysed.MethodsAn integrated quality management (QM) approach was developed based on European Practice Assessment (EPA) modified to the Kenyan context. It relies on a multi-perspective, multifaceted and repeated indicator based assessment, covering the 6 World Health Organization (WHO) building blocks. The adaptation process made use of a ten step modified RAND/UCLA appropriateness Method. To measure the 303 structure, process, outcome indicators five data collection tools were developed: surveys for patients and staff, a self-assessment, facilitator assessment, a manager interview guide. The assessment process was supported by a specially developed software (VISOTOOL®) that allows detailed feedback to facility staff, benchmarking and facilitates improvement plans. A longitudinal study design was used with 10 facilities (6 hospitals; 4 Health centers) selected out of 36 applications. Data was summarized using means and standard deviations (SDs). Categorical data was presented as frequency counts and percentages.ResultsA baseline assessment (T1) was carried out, a reassessment (T2) after 1.5 years. Results from the first and second assessment after a relatively short period of 1.5 years of improvement activities are striking, in particular in the domain ‘Quality and Safety’ (20.02%; p < 0.0001) with the dimensions: use of clinical guidelines (34,18%; p < 0.0336); Infection control (23,61%; p < 0.0001). Marked improvements were found in the domains ‘Clinical Care’ (10.08%; p = 0.0108), ‘Management’ (13.10%: p < 0.0001), ‘Interface In/out-patients’ (13.87%; p = 0.0246), and in total (14.64%; p < 0.0001). Exemplarily drilling down the domain ‘clinical care’ significant improvements were observed in the dimensions ‘Antenatal care’ (26.84%; p = 0.0059) and ‘Survivors of gender-based violence’ (11.20%; p = 0.0092). The least marked changes or even a -not significant- decline of some was found in the dimensions ‘delivery’ and ‘postnatal care’.ConclusionsThis comprehensive quality improvement approach breathes life into the process of collecting data for indicators and creates ownership among users and providers of health services. It offers a reflection on the relevance of evidence-based quality improvement for health system strengthening and has the potential to lay a solid ground for further certification and accreditation.

Quality management: where is the evidence? Developing an indicator-based approach in Kenya.

IntroductionThe 2030 Sustainable Development Agenda emphasizes the importance of quality of care in the drive to achieve universal health coverage. Despite recent progress, challenges in service delivery, efficiency and resource utilization in the health sector remain.ObjectiveThe Ministry of Health Department of Standards and Regulations sought to operationalize the Kenya Quality Assurance Model for Health. To this end, the European Practice Assessment (EPA) was adapted to the area of Reproductive and Maternal and Neonatal Health.MethodsThe adaptation process made use of a ten step-modified RAND Corporation/University of California Los Angeles (UCLA) Appropriateness Method. The steps included a scoping workshop, definition of five critical domains of quality in the Kenyan context (‘People, Management, Clinical Care, Quality & Safety, Interface between inpatients and outpatients care’), a review of policy documents, management and clinical guidelines, grey and scientific literature to identify indicators in use in the Kenyan health system and an expert panel process to rate their feasibility and validity.ResultsThe resulting 278 indicators, clustered across the five domains, were broken-down into 29 dimensions and assigned measure specifications. A set of data collection tools were developed to furnish the indicators and piloted at two health facilities. They were subsequently finalized for use in 30 health facilities in 3 counties.ConclusionsThe integrative and indicator-based aspects of the EPA process could be readily adapted to facilitate the operationalization of a practical quality assurance approach in Kenya.

Does a quality management system improve quality in primary care practices in Switzerland? A longitudinal study

ObjectivesTo examine the effectiveness of the quality management programme—European Practice Assessment—in primary care in Switzerland.DesignLongitudinal study with three points of measurement.SettingPrimary care practices in Switzerland.ParticipantsIn total, 45 of 91 primary...

Integrated Quality Management System (IQMS): ein Modell zur Förderung der Qualität der reproduktiven Gesundheitsversorgung im ländlichen Kenia

To develop a model aiming to improve the quality of services for reproductive health care in rural Kenya and designed to measure the quality of reproductive health services in such a way that allows these services to identify measures for improving their performance. The Integrated Quality Management System (IQMS) was developed on the basis of a pre-existing and validated model for quality promotion, namely the European Practice Assessment (EPA). The methodology for quality assessment and feedback of assessment results to the service teams was adopted from the EPA model. Quality assessment methodology included data assessment through staff, patient surveys and service visitation. Quality is assessed by indicators, and so indicators had to be developed that were appropriate for assessing reproductive health care in rural Kenya. A search of the Kenyan and international literature was conducted to identify potential indicators. These were then rated for their relevance and clarity by a panel of Kenyan experts. 260 indicators were rated as relevant and assigned to 29 quality dimensions and 5 domains. The implementation of IQMS in ten facilities showed that IQMS is a feasible model for assessing the quality of reproductive health services in rural Kenya. IQMS enables these services to identify quality improvement targets and necessary improvement measures. Both strengths and limitations of IQMS will be discussed.

Job satisfaction of practice assistants in general practice in Germany: an observational study

Job satisfaction of practice staff is important for optimal health care delivery and for minimizing the turnover of non-medical professions. To document the job satisfaction of practice assistants in German general practice and to explore associations between job satisfaction, staff characteristics and culture in general practice organizations. The study was based on data from the European Practice Assessment accreditation scheme for general practices and used an observational design. The study population consisted of 1158 practice assistants from 345 general practices across Germany. Job satisfaction was measured with the 10-item Warr-Cook-Wall questionnaire. Organizational culture was evaluated with four items. A linear regression analysis was performed in which each of the job satisfaction items was handled as dependent variable. Out of 1716 staff member questionnaires handed out to practice assistants, 1158 questionnaires were completed (response rate: 67.5%). Practice assistants were most satisfied with their colleagues and least satisfied with their income. Higher job satisfaction was associated with issues of organizational culture, particularly a good working atmosphere, opportunities to suggest and influence areas for improvement and clear responsibilities within the practice team. Prioritizing initiatives to maintain high levels of, or to improve the job satisfaction of practice assistants, is important for recruitment and retention. It will also help to improve working conditions for both practice assistants and GPs and create an environment to provide better quality care.

Association between family doctors’ practices characteristics and patient evaluation of care

BackgroundPatients’ evaluations of primary care are influenced by three major dimensions: patients’, family doctors’ and practices’ characteristics. A lot of primary care practices use possibilities of new information technologies, such as chronic patients’ electronic registers, clinical guideline support systems, electronic medical records and clinical decision system. The aim of this study was to determine possible effects of quality characteristics of family doctors’ practices on patients’ satisfaction. MethodsThis observational cross-sectional study in 36 randomly selected family doctors’ practices, stratified to practices’ size and urbanization was performed between 2008 and 2009. Each practice included 100 randomly selected adult patients: 30 high-risk patients for CVD, but without a history of CVD, 30 patients with an established coronary disease, and 40 healthy adult patients (aged 18–45 years). Data was collected with a questionnaire, used in European Practice Assessment of Cardiovascular risk management (EPA Cardio study), and with European Patients Evaluation of general practice care (EUROPEP) questionnaire. ResultsFinal sample consisted of 2482 patients (68.9% response rate). Higher satisfaction scores were associated with worse self-rated patients’ health status, with patients visiting practices where quality report was provided, where clinical audit in the past 12 months existed, where number of population attending practice quarterly was lower, where systematic reviewing of prescribed medication was not available, where annual report was not provided, where doctor did not have access to medical literature, and where patients’ attendance rate for preventive check-ups was not available. Patients with higher risk for CVD were also more satisfied. ConclusionThe effect of practice characteristics associated with organisational access to services, chronic patients’ management and some quality improvement factors is unclear and not always in favour of higher satisfaction score. Further studies are needed.

Practice accreditation: the European perspective

Accreditation has different meanings in different healthcare settings.1 A complex picture emerges from reviews of healthcare accreditation schemes worldwide but two key features are common — promoting change and professional development.2 Accreditation in primary care settings is generally seen as a way of assessing and benchmarking the performance of general practice care across a broad range of clinical and organisational domains.3 It describes a formal process of self-assessment and external and independent peer review to encourage best practice and can result in recommendations for continuous quality improvement of safety and quality.4 Buetow and Wellingham have suggested five ways in which accreditation may be used.3 These are quality control (mandatory, externally set, minimum predetermined acceptable standards), mandatory regulation (legal or safety standards), continuous quality improvement (to demonstrate excellence above a minimum standard), information giving (to enable comparison between providers by patients and policy makers), and marketing (to showcase services available). Compared with hospital environments, which have a long history of accreditation, general practices have been considered more difficult and less important to accredit.5 However quality problems, caused in part by system failures6 rather than individuals,7 have led to a growing emphasis on the team or organisation as the unit of analysis in quality improvement initiatives. Despite this, with notable exceptions such as the evidence base underpinning the use of the European Practice Assessment (EPA) programme8 there is still a relatively limited evidence base demonstrating the effectiveness, cost effectiveness, and appropriateness of accreditation.9,10,11 A representative from each member country of the European Association of Quality in General Practice (EQuiP) was asked to complete a detailed survey in December 2011 about their country's health system, and practice accreditation scheme, achieving a 100% response rate. Nine countries have practice accreditation …

Evaluation of job satisfaction of practice staff and general practitioners: an exploratory study

BackgroundPrimary care teams' job satisfaction is an important issue in quality of care. The purpose of our study was to evaluate the job satisfaction of general practitioners (GPs) and non-physician staff and to explore the elements that may impact on overall job satisfaction for GPs and non-physician staff separately.MethodsThe study was based on data from the European Practice Assessment and used an observational design. Job satisfaction was measured with the 10-items Warr-Cook-Wall questionnaire with 7-point-Likert scales. Job satisfaction of GPs and non-physician staff was compared and impact on overall job satisfaction was analysed with stepwise linear regression analyses for both samples separately.ResultsThe study population consisted of 2878 non-physician staff (mean age: 38 years) and 676 GPs (mean age: 50 years). The actual mean working time per week of GPs was 50.0 hours and of practice staff 26.0 hours. Both were satisfied with colleagues and fellow workers (mean = 5.99 and mean = 6.18 respectively) and mostly dissatisfied with their income (mean = 4.40 and mean = 4.79 respectively). For GPs the opportunity to use their abilities (β = 0.638) and for non-physician staff recognition for their work (β = 0.691) showed the highest scores of explained variance (R2 = 0.406 and R2 = 0.477 respectively) regarding overall job satisfaction.ConclusionsNon-physician staff evaluate their job satisfaction higher than GPs except recognition for work. Job satisfaction of members of primary care teams is important because poor satisfaction is associated with suboptimal healthcare delivery, poor clinical outcomes and higher turnover of staff.

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

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. 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. 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. 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.

Patients' evaluations of European general practice--revisited after 11 years

In the last decade many things have changed in healthcare systems, primary care practices and populations. To describe evaluations of general practice care by patients with a chronic illness in 2009 and compare these with a previous study done in 1998. A descriptive analysis of patients' evaluations, using data from the European practice assessment Cardio study on cardiovascular patients in eight European countries in 2009. We compared these evaluations with a subgroup of patients with self-defined chronic illness from the study in 1998, using a linear regression model. Patients' evaluation of general practice using the EUROPEP questionnaire. The EUROPEP is a 23-item validated measure of patient evaluations of general practice care. In 2009, 7472 patients from 251 practices participated in the study with an overall response rate of 49.6%. The percentage of patients with positive evaluations (good/excellent) was 80% or higher for all items, except for the waiting time. More positive evaluations were found in older patients, patients with a longer attachment to the practice, patients with a higher self-evaluation of their health, patients with fewer mental health problems and less pain/discomfort. The comparison between 1998 and 2009 showed no overall trends for all countries combined. Whereas English patients became fairly more positive about general practice in 2009, German patients became slightly less positive, although still more positive than English patients. Overall, the patients' evaluations of general practice were very positive in family practice care in the years 1998 and 2009. The trends over the years need to be carefully interpreted over time.

Is the job satisfaction of primary care team members associated with patient satisfaction?

BackgroundPrevious research has shown a correlation between physician job satisfaction and patient satisfaction with quality of care, but the connection between job satisfaction of other primary care team members and...

Benchmarking in der ambulanten Versorgung am Beispiel des Europäischen Praxisassessments (EPA)

The European Practice Assessment (EPA) is a comprehensive quality management which consists of 220 indicators covering 5 domains (infrastructure, people, information, finance, and quality and safety). The aim of the project presented was to evaluate EPA as an instrument for benchmarking in ambulatory care practices. A before-and-after design with a comparison group was chosen. One hundred and two practices conducted EPA at baseline (t1) and at the 3-year follow-up (t2). A further 209 practices began EPA at t2 (comparison group). Since both practice groups differed in several variables (age of GP, location and size of practice), a matched-pair design based on propensity scores was applied leading to a subgroup of 102 comparable practices (out of the 209 practices). Data analysis was carried out using Z scores of the EPA domains. The results showed significant improvements in all domains between t1 and t2 as well as between the comparison group and t2. Furthermore, the results demonstrate that the implementation of total quality management and the re-assessment of the EPA procedure can lead to significant improvements in almost all domains.

Die Arbeitszufriedenheit von Allgemeinmedizinern

In Germany there is a lack of general practitioners (GP) that is forecasted to grow. Against this background a study of job satisfaction is of major interest. The purpose of this study was to analyse the job satisfaction of German GPs. The study is based on data from an observational study in 676 primary care physicians in Germany between 2004 and 2007 taking part in the European Practice Assessment (EPA). The evaluation of job satisfaction was one part of EPA. Job satisfaction was measured with the 10-item Warr-Cook-Wall (WCW) scale. The possible answers ranged from 1 (extreme dissatisfaction) to 7 (extreme satisfaction). Furthermore the characteristics of GPs (gender, age, working hours) were analysed. Overall from the 676 primary care physicians 523 were GPs and took part in the survey. Job satisfaction was low by "income", "hours of work" and "mental working condition". A high degree of satisfaction was reported for "colleagues and fellow workers". Mainly working hours had a significant influence of job satisfaction followed by age and gender. Overall, the results show good values of satisfaction with job situation. However there is space for improvement within the field of payment and working condition. Against this background of the lack of GPs it is important to consider these aspects of job satisfaction for GPs.

Can we import quality tools? a feasibility study of European practice assessment in a country with less organised general practice

BackgroundQuality is on the agenda of European general practice (GP). European researchers have, in collaboration, developed tools to assess quality of GPs. In this feasibility study, we tested the European Practice Assessment (EPA) in a one-off project in Belgium, where general practice has a low level of GP organisation.MethodsA framework for feasibility analysis included describing the recruiting of participants, a brief telephone study survey among non-responders, organisational and logistic problems. Using field notes and focus groups, we studied the participants' opinions.ResultsIn this study, only 36 of 1000 invited practices agreed to participate. Co-ordination, administrative work, practice visits and organisational problems required several days per practice. The researchers further encountered technical problems, for instance when entering the data and uploading to the web-based server. In subsequent qualitative analysis using two focus groups, most participant GPs expressed a positive feeling after the EPA procedure. In the short period of follow-up, only a few GPs reported improvements after the visit. The participant GPs suggested that follow-up and coaching would probably facilitate the implementation of changes.ConclusionThis feasibility study shows that prior interest in EPA is low in the GP community. We encountered a number of logistic and organisational problems. It proved attractive to participants, but it can be augmented by coaching of participants in more than a one-off project to identify and achieve targets for quality improvement. In the absence of commitment of the government, a network of universities and one scientific organisation will offer EPA as a service to training practices.

European Practice Assessment of Cardiovascular risk management (EPA Cardio): protocol of an international observational study in primary care

BackgroundDespite important improvements in available prevention and treatment, cardiovascular diseases (CVD) remain an important cause of morbidity and mortality. Not all high-risk patients and patients with CVD have healthy lifestyles and receive the best possible healthcare. Internationally comparative data are needed to compare cardiovascular risk management in different countries, and to examine the impact of improvement programs and others factors.ObjectivesThis study aims to provide internationally comparative data on cardiovascular risk management provided in primary care and on health-related lifestyles of patients in Europe. The study will also explore the views of doctors and patients on innovative preventive services for CVDs.Design and methodsAn observational cross-sectional study is planned. In 10 European countries, stratified samples of 36 practices per country will be recruited. In each practice, three samples of 15 patients each will be sampled: patients with coronary heart disease, patients at high risk for CVD, and healthy adult patients. The quality of cardiovascular risk management has been specified in terms of 44 performance indicators that resulted from an international Delphi-procedure with general practitioners. Most indicators are based on medical records, and some on a structured interview with a contact person of the practice. Lifestyle (smoking, physical exercise, diet) will be measured with previously validated questionnaires that are completed by patients. Additional measures include practice characteristics and exposure to programs to improve cardiovascular care.

Testing a European set of indicators for the evaluation of the management of primary care practices

Effective practice management is an important prerequisite for offering good clinical care. Internationally valid, reliable and feasible indicators and instruments are needed to describe and compare the management of primary care practices in Europe. This paper describes development and evaluation of the European Practice Assessment instrument and indicators (Engels Y, Campbell S, Dautzenberg M et al. Developing a framework of, and quality indicators for, general practice management in Europe. Fam Pract 2005; 22(2): 215-22). The study design was a validation and feasibility study set in 273 general practices in Austria, Belgium, France, Germany, Israel, The Netherlands, Slovenia, Switzerland and the UK. Use was made of a set of 62 valid quality indicators derived previously from an international Delphi procedure. The EPA instrument, based on this set of indicators, was used to collect data in the 273 practices. This instrument consists of self-completed questionnaires for doctors, staff managers and patients. In addition, there is an interview schedule for use by an outreach visitor, to be held with the lead GP or manager, and a visitor checklist. The instrument was analysed using expert review by the project partners, factor and reliability analyses, ANOVA analyses and by determining intraclass correlations. Fifty-seven indicators were found to be valid, feasible, reliable and discriminative in all participating countries. The instrument was able to determine differences in practice management within and between countries. All (but one) practices completed the assessment procedure. The data collection method appeared to be feasible, although some aspects can be improved. The EPA instrument provides feedback to practices that facilitates quality improvement and can compare primary care practices on a national and an international level.

Thermodynamic analysis of the aluminum silicate triple point

<h3>Background:</h3> 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. <h3>Methods:</h3> 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 group9s 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. <h3>Results:</h3> 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. <h3>Interpretation:</h3> 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.