The survey visit as a key evaluative event in accreditation-a qualitative study of survey visit experiences among surveyors and general practice professionals.

BACKGROUND: Accreditation is a widely employed quality assurance concept in health care and the survey visit is the central method for assessing participating organisations' compliance with accreditation standards. Despite this, research on the survey visit as a method for assessing compliance is scarce. In Denmark a mandatory accreditation programme was introduced for general practice clinics in 2016. We performed a qualitative, explorative study of the reflections and actions of surveyors and general practice professionals (GPs and staff) concerning the production of information about compliance with the accreditation standards in relation to the survey visit. METHODS: We conducted qualitative interviews with GPs and staff from general practices in two Danish regions before and after their survey visit. We also interviewed the surveyors. We observed survey visits to qualify the interviews and analysis. All interviews were audio recorded, transcribed, and analysed using an integrative approach. RESULTS: The surveyors combined documents, questioning of the professionals, and visual impressions of the clinic to assess compliance. They sought to de-dramatise the survey visit and to generate a natural conversation with attention to workflows. Trust in the professionals' statements was fundamental to the surveyors' approach, and they were confident in their ability to assess compliance. Their level of scrutiny was influenced by their observations and the quality of documents. The general practice professionals had generally sought to comply with the standards and to give an authentic portrait of the clinic. The few cases of misrepresention concerned standards that the professionals found too excessive. CONCLUSION: The validity of the survey visit as a method to assess compliance was highly dependent on the professionals' willingness to convey a realistic picture of their practice. Since they were generally willing to do so, the trust-based approach seemed suitable for identifying cases of non-compliance caused by insufficient understanding of the standards. However, it can be difficult for the surveyors to detect when the professionals engage in misrepresentation due to disagreements with the standards. Thus, when adopting a trust-based approach to the survey visit, it seems particularly important to ensure that the professionals view the standards as meaningful and manageable.

Use of alternative consultation forms in Danish general practice in the initial phase of the COVID-19 pandemic - a qualitative study.

BACKGROUND: Attempts to manage the COVID-19 pandemic have led to radical reorganisations of health care systems worldwide. General practitioners (GPs) provide the vast majority of patient care, and knowledge of their experiences with providing care for regular health issues during a pandemic is scarce. Hence, in a Danish context we explored how GPs experienced reorganising their work in an attempt to uphold sufficient patient care while contributing to minimizing the spread of COVID-19. Further, in relation to this, we examined what guided GPs' choices between telephone, video and face-to-face consultations. METHODS: This study consisted of qualitative interviews with 13 GPs. They were interviewed twice, approximately three months apart in the initial phase of the pandemic, and they took daily notes for 20 days. All interviews were audio recorded, transcribed, and inductively analysed. RESULTS: The GPs re-organised their clinical work profoundly. Most consultations were converted to video or telephone, postponed or cancelled. The use of video first rose, but soon declined, once again replaced by an increased use of face-to-face consultations. When choosing between consultation forms, the GPs took into account the need to minimise the risk of COVID-19, the central guidelines, and their own preference for face-to-face consultations. There were variations over time and between the GPs regarding which health issues were dealt with by using video and/or the telephone. For some health issues, the GPs generally deemed it acceptable to use video or telephone, postpone or cancel appointments for a short term, and in a crisis situation. They experienced relational and technical limitations with video consultation, while diagnostic uncertainty was not regarded as a prominent issue CONCLUSION: This study demonstrates how the GPs experienced telephone and video consultations as being useful in a pandemic situation when face-to-face consultations had to be severely restricted. The GPs did, however, identify several limitations similar to those known in non-pandemic times. The weighing of pros and cons and their willingness to use these alternatives shifted and generally diminished when face-to-face consultations were once again deemed viable. In case of future pandemics, such alternatives seem valuable, at least for a short term.

Experiences of accreditation impact in general practice - a qualitative study among general practitioners and their staff.

BACKGROUND: Accreditation is a widespread tool for quality management in health care. However, there is lack of research on the impact of accreditation, particularly in general practice. This study explores how general practitioners and their staff experienced the impact of a mandatory accreditation program in Denmark. METHODS: Qualitative interviews with general practitioners and staff from 11 clinics. The respondents were interviewed twice: during preparation and after the survey visit. The interviews were analyzed using thematic analysis, and all specific changes and other types of impact were extracted from the transcribed interview data from each clinic. RESULTS: The impact of accreditation varied markedly among the clinics as did the participants' overall assessments of accreditation. Concerning specific changes in behavior and physical infrastructure, some clinics had only implemented a few minor changes in response to accreditation, some had made a relatively moderate number of changes, and a few clinics had made relatively many changes including a few pronounced ones. Further, some participants experienced that accreditation had enhanced knowledge sharing or upgraded competencies, and increased job satisfaction. However, the workload related to accreditation was emphasized as a problem by a majority of the professionals and for a few, accreditation had influenced job satisfaction negatively. CONCLUSION: Accreditation may affect general practice clinics in very different ways. In spite of several examples of positive impact, the results suggest that it is difficult to design a mandatory accreditation program for general practice in which most professionals experience that the benefits of accreditation equal the resources used in the process.

Understanding accreditation standards in general practice - a qualitative study.

BACKGROUND: Accreditation is a widely adopted tool for quality control and quality improvement in health care, which has increasingly been employed for general practice. However, there is lack of knowledge of how accreditation is received and experienced by health professionals in general practice. This study explores how general practitioners (GPs) and their staff experienced the comprehensibility of accreditation standards and how they worked to increase their understanding of the standards. The study was conducted in Denmark where accreditation was mandatory in general practice from 2016 to 2018. METHODS: The study consists of qualitative interviews with general practitioners and staff from 11 general practices that were strategically sampled among practices set to receive their survey visit in 2017. Participants were interviewed twice; once during the preparation phase and once after the survey visit. GPs and staff were interviewed separately. The interviews were analysed inductively using thematic analysis. RESULTS: Understanding the requirements of the accreditation standards was a major challenge for the professionals when preparing for the accreditation survey visit. The participants attempted to increase their understanding of the standards in several ways including the use of regional support options and seeking out experts and colleagues. However, participants had mixed experiences with the various support options and many found the sense making work frustrating and time consuming. CONCLUSION: The results point to the importance of considering the level of specificity in accreditation standards and how to ensure an organisational set-up that can offer appropriate support to primary care clinics in terms of understanding what is required to meet the standards.

Influences of peer facilitation in general practice - a qualitative study.

BACKGROUND: Practice facilitation is increasingly used to support guideline implementation and practice development in primary care and there is a need to explore how this implementation approach works in real-life settings. We focus on a facilitation intervention from the perspective of the visited practices to gain a more detailed understanding of how peer facilitation influenced practices and how they valued the facilitation. METHODS: The facilitation intervention was conducted in general practice in the Capital Region of Denmark with the purpose of supporting the implementation of chronic disease management programmes. We carried out a qualitative study, where we observed 30 facilitation visits in 13 practice settings and interviewed the visited practices after their first and last visits. We then performed a thematic analysis. RESULTS: Most of the respondents reported that facilitation visits had increased their knowledge and skills as well as their motivation and confidence to change. These positive influences were ascribed to a) the facilitation approach b) the credibility and know-how associated with the facilitators' being peers c) the recurring visits providing protected time and invoking a sense of commitment. Despite these positive influences, both the facilitation and the change process were impeded by several challenges, e.g. competing priorities, heavy workload, problems with information technology and in some cases inadequate facilitation. CONCLUSION: Practice facilitation is a multifaceted, interactive approach that may affect participants in several ways. It is important to attune the expectations of all the involved actors through elaborate discussions of needs, capabilities, wishes, and approaches, and to adapt facilitation interventions according to an analysis of influential contextual conditions and change opportunities.

Role enactment of facilitation in primary care - a qualitative study.

BACKGROUND: Facilitation is a widely used implementation method in quality improvement. Reviews reveal a variety of understandings of facilitation and facilitator roles. Research suggests that facilitation interventions should be flexible and tailored to the needs and circumstances of the receiving organisations. The complexity of the facilitation field and diversity of potential facilitator roles fosters a need to investigate in detail how facilitation is enacted. Hence, the purpose of this study was to explore the enactment of external peer facilitation in general practice in order to create a stronger basis for discussing and refining facilitation as an implementation method. METHODS: The facilitation intervention under study was conducted in general practice in the Capital Region of Denmark in order to support an overall strategy for implementing chronic disease management programmes. We observed 30 facilitation visits in 13 practice settings and had interviews and focus groups with facilitators. We applied an explorative approach in data collection and analysis, and conducted an inductive thematic analysis. RESULTS: The facilitators mainly enacted four facilitator roles: teacher, super user, peer and process manager. Thus, apart from trying to keep the process structured and focused the facilitators were engaged in didactic presentations and hands-on learning as they tried to pass on factual information and experienced based knowledge as well as their own enthusiasm towards implementing practice changes. While occasional challenges were observed with enacting these roles, more importantly we found that a coaching based role which was also envisioned in the intervention design was only sparsely enacted meaning that the facilitators did not enable substantial internal group discussions during their facilitation visits. CONCLUSION: Facilitation is a complex phenomenon both conceptually and in practice. This study complements existing research by showing how facilitation can be enacted in various ways and by suggesting that some facilitator roles are more likely to be enacted than others, depending on the context and intervention design and the professional background of the facilitators. This complexity requires caution when comparing and evaluating facilitation studies and highlights a need for precision and clarity about goals, roles, and competences when designing, conducting, and reporting facilitation interventions.

Almost half of the Danish general practitioners have negative a priori attitudes towards a mandatory accreditation programme.

INTRODUCTION: The objective of this study was to analyse Danish general practitioners' (GPs) a priori attitudes and expectations towards a nationwide mandatory accreditation programme. METHODS: This study is based on a nationwide electronic survey comprising all Danish GPs (n = 3,403). RESULTS: A total of 1,906 (56%) GPs completed the questionnaire. In all, 861 (45%) had a negative attitude towards accreditation, whereas 429 (21%) were very positive or posi-tive. The negative attitudes towards accreditation were associated with being older, male and with working in a singlehanded practice. A regional difference was observed as well. GPs with negative expectations were more likely to agree that accreditation was a tool meant for external control (odds ratio (OR) = 1.87 (95% confidence interval (CI): 1.18-2.95)), less likely to agree that accreditation was a tool for quality improvement (OR = 0.018 (95% CI: 0.013-0.025)), more likely to agree that it would affect job satisfaction negatively (OR = 21.88 (95% CI: 16.10-29.72)), and they were generally less satisfied with their present job situation (OR = 2.51 (95% CI: 1.85-3.41)). CONCLUSION: Almost half of the GPs had negative attitudes towards accreditation. FUNDING: The three Research Units for General Practice in Odense, Aarhus and Copenhagen initiated and funded this study. TRIAL REGISTRATION: The survey was recommended by the Danish Multipractice Committee (MPU 02-2015) and evaluated by the Danish Data Agency (2015-41-3684).

Preparing general practitioners to receive cancer patients following treatment in secondary care: a qualitative study.

BACKGROUND: Many patients consider the interface between secondary and primary care difficult, and in particular, the transition of care between these different parts of the healthcare system presents problems. This interface has long been recognized as a critical point for quality of care. The purpose of our study is to formulate solutions to problems identified by cancer patients and healthcare professionals during the transition from hospital back to general practice on completion of primary treatment for cancer. METHODS: A qualitative study based on focus groups at a seminar for professionals in both primary and secondary healthcare. Participants discussed solutions to problems which had previously been identified in patient interviews and in focus groups with general practitioners (GPs), hospital doctors, and nursing staff. The data were analyzed using framework analysis. RESULTS: Solutions, endorsed by all groups at the seminar to improve transition back to general practice after primary treatment for cancer, were: 1) To add nurses' discharge letters addressing psychosocial matters to medical discharge letters; 2) To send medical discharge letters earlier from some hospital departments to GPs; 3) To provide plans and future affiliations for patients when they leave a department, and 4) To arrange a return visit to general practice dedicated to discussion of the patients' cancer disease and the treatment experience. CONCLUSIONS: The transition of care of cancer patients appears too complex to be coordinated by administrative standards alone. We recommend that healthcare professionals are more engaged and present in the coordination of care across organizational boundaries.

The challenges of boundary spanners in supporting inter-organizational collaboration in primary care--a qualitative study of general practitioners in a new role.

BACKGROUND: The visions of more integrated care have created new roles and accountabilities for organizations and professionals. Thus, professionals are increasingly expected to engage in boundary spanning activities in order to facilitate inter-organizational and inter-sectoral collaboration. However, this task can be difficult for individual actors and it is important to investigate the work and challenges of boundary spanners in various settings. This study explores the challenges related to a new boundary spanning role for general practitioners employed to facilitate collaboration between the municipalities and general practice. METHODS: The study is based on semi-structured interviews with ten general practitioners acting as municipal practice consultants in the Capital Region of Denmark. The transcribed interviews were analyzed in several steps organizing the material into a set of coherent and distinct categories covering the different types of challenges experienced by the informants. RESULTS: The main challenges of the general practitioners acting as boundary spanners were: 1) defining and negotiating the role in terms of tasks and competencies; 2) representing and mobilizing colleagues in general practice; 3) navigating in an unfamiliar organizational context. CONCLUSIONS: The results support previous studies in emphasizing the difficult and multifaceted character of the boundary spanning role. While some of these challenges are not easily dealt with due to their structural causes, organizations employing boundary spanners should take note of these challenges and support their boundary spanners with matching resources and competencies.

[Increasing shortage of general practitioners in social deprived Danish communities].

The increasing shortage of general practitioners (GPs) in Denmark is expected to continue until 2020. This study investigates the development of GP shortage in the communities of Region of Zealand in relation to patients' social deprivation. From 2010 to 2013 the number of GPs in the most affluent communities decreased by 2.7%, whereas the number of GPs in social deprived communities decreased significantly more by 6.3%. This observation can be expected to worsen unless further interventions to promote recruitment of GPs in social deprived areas are initiated.

The effectiveness of a semi-tailored facilitator-based intervention to optimise chronic care management in general practice: a stepped-wedge randomised controlled trial.

BACKGROUND: The Danish health care sector is reorganising based on disease management programmes designed to secure integrated and high quality chronic care across hospitals, general practitioners and municipalities. The disease management programmes assign a central role to general practice; and in the Capital Region of Denmark a facilitator-based intervention was undertaken to support the implementation of the programmes in general practice. The purpose of the study was to assess the effectiveness of this semi-tailored facilitator-based intervention. METHOD: The study was a stepped-wedge, randomised, controlled trial among general practices in the Capital Region of Denmark. The intervention group was offered three one-hour visits by a facilitator. The intervention was semi-tailored to the perceived needs as defined by each general practice, and the practices could choose from a list of possible topics. The control group was a delayed intervention group. The primary outcome was change in the number of annual chronic disease check-ups. Secondary outcomes were: changes in the number of annual check-ups for type 2 diabetes (DM2) and chronic obstructive pulmonary disease (COPD); changes in the number of spirometry tests, changes in the use of ICPC diagnosis coding and patient stratification; sign-up for a software program for patient overview; and reduction in number of practices with few annual chronic disease check-ups. RESULTS: We randomised 189 general practices: 96 practices were allocated to the intervention group and 93 to the delayed intervention group. For the primary outcome, 94 and 89 practices were analysed. Almost every outcome improved from baseline to follow-up in both allocation groups. At follow-up there was no difference between allocation groups for the primary outcome (p = 0.1639). However, some secondary outcomes favoured the intervention: a higher reported use of ICPC diagnosis coding for DM2 and COPD (p = 0.0050, p = 0.0243 respectively), stratification for COPD (p = 0.0185) and a faster initial sign-up rate for the software program. CONCLUSION: The mixed results from this study indicate that a semi-tailored facilitator-based intervention of relatively low intensity is unlikely to add substantially to the implementation of disease management programmes for DM2 and COPD in a context marked by important concurrent initiatives (including financial incentives and mandatory registry participation) aimed at moving all practices towards changes in chronic care. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01297075.

Reasons for not reporting patient safety incidents in general practice: a qualitative study.

OBJECTIVE: To explore the reasons for not reporting patient safety incidents in general practice. DESIGN: Qualitative interviews with general practitioners and members of the project group. SETTING: General practice clinics in the Region of Northern Jutland in Denmark. SUBJECTS: Twelve general practitioners. MAIN OUTCOME MEASURES: The experiences and reflections of the involved professionals with regard to system use and non-use. RESULTS: While most respondents were initially positive towards the idea of reporting and learning from patient safety incidents, they actually reported very few incidents. The major reasons for the low reporting rates are found to be a perceived lack of practical usefulness, issues of time and effort in a busy clinic with competing priorities, and considerations of appropriateness in relation to other professionals. CONCLUSION: The results suggest that the visions of formal, comprehensive, and systematic reporting of (and learning from) patient safety incidents will be quite difficult to realize in general practice. Future studies should investigate how various ways of organizing incident reporting at the regional level influence local activities of reporting and learning in general practice.

Positive experiences with a specialist as facilitator in general practice.

INTRODUCTION: The use of facilitators for quality improvement in general practice has accelerated during the past decade. As general practitioners (GPs) or pharmacists have typically been used as facilitators, there is a lack of knowledge of how other professionals function as facilitators. This article explores the experiences and assessments of GPs and nurses participating in a project in which a medical specialist (endocrinologist) acted as a facilitator for quality improvement. METHODS: This study is based on observations of facilitation sessions and interviews with the health professionals (13 GPs, four nurses, one endocrinologist) participating in a facilitation project in the Capital Region of Denmark. RESULTS: The facilitator sessions primarily focused on pharmacological issues related to diabetes treatment. The respondents described the facilitation sessions as a positive and motivating learning experience, and the majority of them were able to point to specific learning outcomes. CONCLUSION: The results suggest that for selected medical issues, a trained medical specialist can act as a facilitator in general practice to the satisfaction of GPs and staff. Future studies should assess the clinical effects of such facilitation programmes.

Danish general practitioners only play a minor role in the coordination of cancer treatment.

INTRODUCTION: Despite initiatives to integrate treatment and care across organisations, patient trajectories in Danish health-care are not well coordinated. Coordination among many health-care professionals is essential, and it is frequently suggested that a single person should perform the task of coordination. The aim of the article is to discuss whether general practitioners (GPs) may play a coordinating role for individual patients in Danish cancer treatment. MATERIAL AND METHODS: This study is based on individual interviews and focus groups analyzed by meaning condensation. RESULTS: The GP's potential to coordinate patient trajectories was limited by lack of involvement of the GPs by other health-care professionals and lack of needed information. Furthermore, many patients do not regard their GP as a coordinator. Patients who contacted their GP during treatment typically had a close relationship with their GP prior to their cancer diagnosis. In cases with a more distant relationship, patients did not see a need for the GP's involvement. The majority of patients' trajectories were decided within hospitals. The level of information provided to GPs varied much between hospitals and wards. In the majority of cases, GPs had no access to information or were not informed about hospital decisions affecting the patients' trajectories, and they were therefore unable to perform a coordinating role. CONCLUSION: GPs only played a minor or no role at all as coordinators of individual cancer patient trajectories. The findings of the present study question the idea that coordination throughout the entire health-care system may be assigned to a single individual as the involved parties belong to different organizations with different goals, managements and economic resources.

[Implementation barriers--commentaries from organisational sociology]. / Implementeringsbarrierer--en organisationssociologisk nuancering.

During the last two decades numerous technologies for improving the quality of care have been introduced in the healthcare sector. The various problems encountered by such endeavours have given rise to a large number of studies attempting to identify the most effective techniques for implementation and the most important barriers to change. However, the barrier-centred approach to change has not yet fulfilled the expectations of its promoters and has recently come under criticism from research in organisational change. The article explores the contents and implications of this critique.

Screening and brief intervention targeting risky drinkers in Danish general practice--a pragmatic controlled trial.

AIMS: Recommendations for routine alcohol screening and brief counselling intervention in primary health care rest on results from intervention efficacy studies. By conducting a pragmatic controlled trial (PCT), we aimed at evaluating the effectiveness of the WHO recommendations for screening and brief intervention (SBI) in general practice. METHODS: A randomized PCT (brief counselling intervention vs no intervention) involving 39 Danish general practitioners (GPs). Systematic screening of 6897 adults led to inclusion of 906 risky drinkers, and research follow-up on 537 of these after 12-14 months. Outcome measures focused on patients' acceptance of screening and intervention and their self-reported alcohol consumption. RESULTS: Patient acceptance of screening and intervention -10.3% (N = 794) of the target population (N = 7, 691) explicitly refused screening. All intervention group subjects (N = 442) were exposed to an instant brief counselling session while only 17.9% of them (79/442) attended a follow-up consultation that was offered by their GP. Consumption Changes At one-year follow-up, average weekly consumption had increased by 0.7 drinks in both comparison groups. As secondary findings, we observed an indiscriminate absolute risk reduction (ARR = 0.08 (95% CI: -0.02; 0.18)) in male binge drinking, but adverse intervention effects for women on the secondary outcomes (binge drinking ARR = -0.30 (95% CI: -0.47; -0.09)). CONCLUSIONS: The results of brief interventions in everyday general practice performed on the basis of systematic questionnaire screening may fall short of theoretical expectations. When applied to non-selected groups in everyday general practice SBI may have little effect and engender diverse outcome. Women may be more susceptible to defensive reactions than men.

[So dangerous are not measles, mumps and rubella...A qualitative survey of causes of MMR vaccination refusal in the county of Vejle]. / Så alvorlige er maeslinger, fåresyge og røde hunde heller ikke...Kvalitativ undersøgelse om årsager til fravalg af MFR-vaccination i Vejle Amt.

INTRODUCTION: The aim of this study was to investigate why parents in one county of Denmark leave vaccination against measles, mumps and rubella (MMR) undone, with special reference to evaluating the possibilities of increasing the acceptance of the MMR vaccination program. MATERIALS AND METHODS: Data were collected through semi-structured, tape-recorded telephone interviews. The interviewees were 17 strategically chosen parents of children 15 months and 12 years old who had not received the MMR vaccination in 2002. The method of analysis was Systematic Text Condensation. RESULTS: The parents had consulted many sources in their search for information about MMR vaccination. Many referred to their own or others' good experiences with going through the natural illnesses and bad experiences with vaccination. It is a common view that naturally occurring illnesses strengthen the immunity more effectively than vaccination does, and this approach is preferred by some of the parents. The risk of vaccination is viewed as greater than that of going through the natural illnesses. This, however, is not in accordance with scientific knowledge. There was no evidence that leaving vaccination undone was due to the parents' lack of knowledge, forgetfulness or lack of interest in MMR vaccination, and it was rare that only one reason was mentioned. CONCLUSION: The results of the study indicate that doctors can profit by preparing a dialogue with parents who are in doubt about MMR vaccination. Especially it seems that a profound knowledge of the scientific evidence of virus-caused diseases, of their risks and of immunology is necessary to balance parents' most essential misconceptions and their reasons for not choosing vaccination.

Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis.

OBJECTIVE: To determine the effectiveness of programmes of screening in general practice for excessive alcohol use and providing brief interventions. DESIGN: Systematic review and meta-analysis of randomised controlled trials that used screening as a precursor to brief intervention. SETTING: General practice. MAIN OUTCOME MEASURES: Number needed to treat, proportion of patients positive on screening, proportion given brief interventions, and effect of screening. RESULTS: The eight studies included for meta-analysis all used health questionnaires for screening, and the brief interventions included feedback, information, and advice. The studies contained several sources of bias that might lead to overestimates of the effects of intervention. External validity was compromised because typically three out of four people identified by screening as excessive users of alcohol did not qualify for the intervention after a secondary assessment. Overall, in 1000 screened patients, 90 screened positive and required further assessment, after which 25 qualified for brief intervention; after one year 2.6 (95% confidence interval 1.7 to 3.4) reported they drank less than the maximum recommended level. CONCLUSIONS: Although even brief advice can reduce excessive drinking, screening in general practice does not seem to be an effective precursor to brief interventions targeting excessive alcohol use. This meta-analysis raises questions about the feasibility of screening in general practice for excessive use of alcohol.