Continuous quality improvement in small general medical practices: the attitudes of general practitioners and other practice staff.

OBJECTIVES: Continuous quality improvement (CQI) offers opportunities to improve care in small-scale office-based practice. Little is yet known about the implementation of CQI in small primary care practices. We studied the attitudes of physicians and staff in small family practices to a model of CQI tailored to office-based practice setting. PRACTICES AND DESIGN: An exploratory study in 20 family practices in The Netherlands. Practices were stimulated to adopt the model for continuous quality improvement. MAIN OUTCOME MEASURES: The use of the model at the end of the study period, the perception of the physicians and staff of their success with adopting the model, their view of its usefulness, their willingness to continue and personal and practical obstacles. Measurements were made using written questionnaires. RESULTS: The rate of implementation of the model varied between practices. Participants rated their success in performing improvement projects, holding regular quality meetings and setting targets and priorities. They were positive about the usefulness of the model and they were generally willing to continue to use it. Barriers included the size of workload and the tendency to postpone actions until external support by an outreach visitor was provided. Physician and staff attitudes were homogeneous at a practice level. CONCLUSION: Our findings stress the importance of starting CQI with small, easy-to-handle projects. Workload reduction might be an important issue to focus on. Personal obstacles should be addressed throughout the introduction. We found attitudes in small-scale practices to be homogeneous, so that it was important to pay explicit attention to commitment to CQI from the start of the introduction.

Setting up improvement projects in small scale primary care practices: feasibility of a model for continuous quality improvement.

OBJECTIVES: To evaluate the feasibility of a model for continuous quality improvement in small scale general practice and the improvement projects that practices ran after the introduction of continuous quality improvement. DESIGN: A descriptive study. SETTING: Twenty general practices in the Netherlands tested the model in an intervention period of 18 months. INTERVENTION: A model for continuous quality improvement adapted for general practice was introduced into the practices using a structured strategy. Practices were supported by trained facilitators. MAIN OUTCOME MEASURES: Acceptance at introduction and continued application of the model; the topics of improvement projects that were set up in the practices; whether the improvement projects had been completed; whether they had met the criteria (the use of the "quality cycle" and the Oxford audit score); and whether the self set objectives had been met. RESULTS: The model was introduced and accepted in all participating practices. Practices started 51 improvement projects. At the end of the study period 33 improvement projects had been completed. Practices chose a wide variety of objectives for these projects; most of them concerned medical or organisational topics. Practices started projects mainly because the topic was felt to be a problem or was causing a bottleneck in the organisation. The quality cycle was used in all projects, but practices did not always collect data and evaluate the outcomes. Fourteen projects could be discerned as "full audit". No differences existed in the quality of improvement projects among the various types of practice or between the topics addressed. At the end of the study period half of the practices continued applying the model. CONCLUSION: This study showed that the model was feasible for small scale general practice. However, application of the model tended to disintegrate after the facilitator had left the practice. Practices succeeded reasonably well in running improvement projects. Introduction of continuous quality improvement should particularly focus on this. It is suggested that intensive support is necessary to implement and maintain continuous quality improvement in small scale practices.