Refinement of indicators and criteria in a quality tool for assessing quality in primary care in Canada: a Delphi panel study.

PURPOSE: Primary care is the cornerstone of the health care system and increasingly countries are developing indicators for assessing quality in primary care practices. The 'Quality Tool', developed in Ontario, Canada, provides a framework for assessing practices and consists of indicators and criteria. The purpose of this study was to validate the indicators and simplify the Quality Tool. METHODS: This study involved a systematic comparison of indicators in the Quality Tool with those in other local and international tools to determine common indicators to include as valid in the Quality Tool. A Delphi process was used to help reach consensus for inclusion of any indicators that were not included in the comparison exercise. SETTING: Primary care in Ontario, Canada. SUBJECTS: Key informants were those with known expertise and experience in quality assessment in primary care. MAIN OUTCOME: Validated set of indicators for inclusion in an updated Quality Tool. RESULTS: Twenty-three stakeholders participated in the Delphi panel. Forty-four indicators were included as valid after the systematic comparison of similar indicators in other assessment tools. Of the 63 indicators brought to the Delphi panel, 37 were included as valid, 15 were excluded and 11 became criteria for other included indicators. CONCLUSIONS: The study resulted in a set of 81 validated primary care indicators. The validation of the indicators provided a strong foundation for the next version of the Quality Tool and may be used for quality assessment in primary care.

Developing an institute of medicine-aligned framework for categorizing primary care indicators for quality assessment.

The Institute of Medicine (IOM) framework has been used frequently to assess and monitor quality in secondary and tertiary care, but not in primary care. This article describes and proposes a conceptual framework for categorizing primary care indicators that align with the IOM's six aims for quality in healthcare performance (Safe, Effective, Patient-Centred, Timely, Efficient and Equitable.) Using an iterative process, the authors developed and compared a primary care framework for categorizing indicators in the Quality in Family Practice Book of Tools (QBT) with the IOM aims and other local healthcare systems frameworks (Integrated and Continuous, Appropriate Practice Resources). They also compared, cross-matched and analyzed their QBT categories and indicators with other international primary care assessment tools. And they compared the QBT titles and descriptions of groups of indicators with those published in the international tools.

Helping primary care teams emerge through a quality improvement program.

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.

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.

PROBLEM ADDRESSED: The new family health teams (FHTs) in Ontario were designed to enable interprofessional collaborative practice in primary care; however, many health professionals have not been trained in an interprofessional environment. OBJECTIVE OF PROGRAM: To provide health professional learners with an interprofessional practice experience in primary care that models teamwork and collaborative practice skills. PROGRAM DESCRIPTION: The 2 academic teaching units of the FHT at McMaster University in Hamilton, Ont, employ 6 types of health professionals and provide learning environments for family medicine residents and students in a variety of health care professions. Learners engage in formal interprofessional education activities and mixed professional and learner clinical consultations. They are immersed in an established interprofessional practice environment, where all team members are valued and contribute collaboratively to patient care and clinic administration. Other contributors to the success of the program include the physical layout of the clinics, the electronic medical record communications system, and support from leadership for the additional clinical time commitment of delivering interprofessional education. CONCLUSION: This academic FHT has developed a program of interprofessional education based partly on planned activities and logistic enablers, and largely on immersing learners in a culture of long-standing interprofessional collaboration.

Patient satisfaction with access in two interprofessional academic family medicine clinics.

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.