|Year : 2018 | Volume
| Issue : 1 | Page : 5-10
The use of quality circles as a support tool in the taking over of practices by young general practitioners
Norbert Král, Bohumil Seifert, Jan Kovář, Cyril Mucha, Jana Vojtíšková, Jáchym Bednár, Seifert Martin
First Faculty of Medicine, Charles University, Institute of General Practice, Prague, Czech Republic
|Date of Web Publication||30-Apr-2018|
Dr. Norbert Král
First Faculty of Medicine, Charles University, Institute of General Practice, Albertov 7, 120 00 Prague 2
Source of Support: None, Conflict of Interest: None
Introduction: Although informal meetings of healthcare professionals in smaller groups are common in the area of primary care in the Czech Republic, the method of quality circles is not in wide use. The aim of our project is to use this method to help new general practitioners (GPs) when they take over a medical practice and to suggest measures to improve the organization and overall attractiveness of new practices, as well as patient satisfaction. Materials and Methods: For the purposes of this observation, an already existing informal group formed by healthcare professionals and their trainees was used. The group met a total of four times in a 6-month period. In the first meeting, problematic areas were identified. In the second, specific issues of newly starting to practice were discussed, with time to consider suggestions for improvements. The third meeting consisted of an analysis of the suggested measures and their implementation, and in the fourth, these measures and their effects were evaluated. Results: On the basis of the discussion in the first and second meetings, suggestions were made, and then, during the third meeting, structured into three dimensions: (1) The organization of work, including clinical activities, (2) the attractiveness of the practice and the satisfaction levels of the patients, (3) the satisfaction levels of the employees. In each area, specific measures were proposed. The new doctors' feedback in the fourth phase of the project was positive. The main problems the new doctors faced were related to their lack of knowledge and experience with buying or starting their own practice, as well as being an effective team leader. Conclusion: Despite the application of small groups being significantly larger, it was demonstrated that if GPs are given direction and clear goals in their meetings, these meetings can be very constructive. Small groups thus offer a good platform for young GPs in starting their own practice, giving them the capacity to do so.
Keywords: Education, general practice, primary care, quality circle
|How to cite this article:|
Král N, Seifert B, Kovář J, Mucha C, Vojtíšková J, Bednár J, Martin S. The use of quality circles as a support tool in the taking over of practices by young general practitioners. J Family Med Prim Care 2018;7:5-10
|How to cite this URL:|
Král N, Seifert B, Kovář J, Mucha C, Vojtíšková J, Bednár J, Martin S. The use of quality circles as a support tool in the taking over of practices by young general practitioners. J Family Med Prim Care [serial online] 2018 [cited 2019 Jul 24];7:5-10. Available from: http://www.jfmpc.com/text.asp?2018/7/1/5/231550
| Introduction|| |
Definition and background information
The basic attribute of “Small groups” (also known as “Peer Review Groups,” or “Quality Circles”) is the regular voluntary meeting of between 6 and 12 healthcare professionals with a similar professional background. The aim of the small groups is to increase the education and competence of general practitioners (GPs) and to provide for the exchange of experience and opinions on various matters from common practice but also the area of management. Many studies have convincingly shown that small groups may improve the performance of the individual and the group alike in care costs, indicative diagnostic tests, common practice in prescription, adherence to standard recommended practice, and this collectively represents an improvement in the measurable outcomes as perceived by patients and the improvement in the indicators of the performance of practice.,,, Small groups also have a positive impact on the behavior and psyche of participants, as they lead to the reduction of stress, anxiety, depression, sleep deprivation, and on the other hand, increase resilience, self-esteem, and the decision-making abilities of individuals.
The groups discuss topics that they agreed on ahead of time, and that is based on the current needs of their practice (e.g., a clinical problem, the implementation of a recommended standard procedure, new methods from pharmacotherapy, diagnostics, or mistakes), and spontaneously create projects that promote quality, compare the results of audits, discuss joint research, or deal with the organizational and clinical aspects of their work, including the satisfaction of patients and employees. The cooperation of participants is not only typical but also necessary for small groups to work, and apart from the usual discussion and finding consensus, small groups also use brainstorming or role play (i.e., the dramatization of problematic scenarios) and reflective thinking (the finding of connections between new information and existing knowledge). Resources used in small groups include educational strategies such as auditing, feedback, workshops, and the contributions of head physicians on the issues at hand. The presence of these head physicians as facilitators significantly increase the performance of small groups, as they engage and activate individuals as well as the entire group, support the autonomy of the group in their choice of topics, and provide current information on the problem, or offer alternative views for discussion.
The use of small groups started in Netherlands at the end of the 1970s, and the form quickly found its place among the methods of improving the quality of primary care. Small groups then spread to many European countries and are now a standard component of the continuing education of healthcare professionals in Ireland, Germany, Austria, Switzerland, Denmark, Norway, Sweden, Belgium, France, as well as Croatia, for example, where they go as far as making these meetings mandatory, directed by detailed methodology. These activities are generally coordinated by national GP societies or medical school departments, which take care of the organizational structure.,
Small groups in the context of the Czech Republic
Currently, the Czech Republic does not have a systemized platform for education in the form of small groups. The atomization of the practice on the one hand and the development of organized education on the other hand suppressed these activities to a certain extent, but a natural need for meetings in the environment of independently operating surgeries of general practice remains. Doctors and nurses thus get together in informal contexts only to share their experiences, whether clinical or organizational, but also to discuss their successes or mistakes in diagnostics or therapy, offer each other encouragement or motivation, and learn from one another. These meetings can, however, go beyond fulfilling a social function and have an educational impact, thus consequently contributing to improving the quality of care provided. The current situation and experience based on results from abroad as well as the current needs of GPs suggest that education in the form of small groups should be formalized and systematically developed. Formalized small groups would thus become another in the wide spectrum of educational activities on offer in the Czech Republic promoting the life-long learning and professional improvement of GPs, alongside conferences, seminars, workshops, scientific articles, and e-learning courses.
The implementation of a formalized system of small groups could be especially useful for beginning GPs starting their own practice. Since 2009, the residential program in the Czech Republic brought more than 670 young doctors into the field of practical medicine. Although some of those who attested in this field remained as employees in training or other practice, others decided to start their own private practice, whether it was bought, inherited, or newly established. The starting of one's own practice poses a major challenge for any young doctor. In addition to demands of independently managing clinical situations with only a limited range of experience, doctors are exposed to stress from the management of the practice and its organization, as well as financial demands. Whereas specialized training normally takes place in thriving practices with a higher level of organizational of work and development of information technologies with good equipment and well-trained nurses, practices that are taken over usually do not reach this standard. Novice private GPs are not provided with sufficient systematic support in this regard.
The objective of the project described is a contribution to the solution to the issues young GPs face when starting their own practice, as described above, using the methodology of small groups, absent in the Czech Republic. As part of our project, we have been observing an informal small group (made out of GPs, residents, and nurses, 12 people in total), formed between professionals from three accredited GP offices in Prague (where the head physicians also teach at the Institute of General Medicine of the First Faculty of Medicine at Charles University) dedicated to the teaching of medical students and resident physicians in programs for preattestation preparation. We gave the meetings a set form and recorded their outcomes.
This small group has already been meeting at least 4 times a year. The specific topic of the meetings is the quality and organization of the pre- and post-gradual teaching in the offices of GPs, preparation for attestation, and also improving the quality and safety of healthcare. The head physicians of the institution in which the meeting takes place take turns in the providing of specialized content.
| The Aims and Methodology of the Project|| |
The aim of the project is to help attested GPs (former residents in one of the institutions) to take over their own medical practice and thus take advantage of an existing group formed by healthcare professionals of three general practices (from hereinafter, “Group”) to increase the organizational level of the new practice, its effectiveness and attractiveness, and the satisfaction of its patients and employees. A facilitator was selected for the Group, and its members and the members and alumni of the residential program were given formal rules for meeting, schedules, and expected outcomes. We wanted to find out if formalizing its activities and recording its outcomes would make a difference in the education of young GPs, and whether small groups have the potential of filling in the void that currently exists in the Czech Republic in providing support to young doctors starting their own practices.
The meetings of the small group were thus given a set form, as follows:
- The first meeting of the Group features an introduction of the issues at hand. Possible difficulties are identified, and head physicians offer their experiences regarding the takeover of practices. Residents suggest possible changes in the current training practice, and the organizational aspects of each are discussed
- The second meeting of the Group aims to identify critical issues concerning general practice and find areas and suggestions for improvement. The meeting is followed by the electronic submission of suggestions and ideas for the development of practice, based on their experience
- In the third meeting of the Group, critical analysis of the suggested ideas is performed, and recommendations are selected for implementation
- The fourth meeting of the Group with doctors from new practice is intended to evaluate the continuity of the proposed measures and their effect.
The time period between the first and fourth meeting was 6 months. The length of each individual meeting was between 90 and 120 min. The topic of the meeting was announced to the Group ahead of time so that all the participants could prepare themselves and think about their contribution to the discussion. The head physician of one of the institutions took care of the formal organizational aspects and facilitated the discussion.
The aim of the first meeting was the naming of the attributes related to the taking over of a practice and determining possible areas for discussion. The discussion then focused on the characteristics of the individual practices of the participants. The leading physicians, who have already either established or taken over their own practice, shared their experience and compared notes about other methods or standard practice among each other. Residents also had comments about the organization of the practices in which they were being trained and suggested changes.
The Group's second meeting took place in the location of a new practice. This practice, situated in a small health center in Prague, where there are 6 other GPs, as well as several specialists, was taken over from a retiring physician. The building is approximately 30 years old. Waiting rooms and public facilities are shared among the practices; each practice then has two rooms – the physician's office and the nurse's preparation room. In many ways, the practice still carries the characteristics of the past era, lacking IT, Point of Care Testing (POCT) methods (such as CPR or INR, among others), and other diagnostic tools. The care for patients in the practice is then shared among two physicians who recently ended their residency. The practice is keeping the nurse who had worked there previously. The facilities of the healthcare center are illustrated by contractual or educational materials without the option for these to be changed.
| Outcomes and Discussion|| |
On the basis of previous meetings, the Group had various suggestions, as well as critical comments, that were further discussed and subjected to critical analysis.
These suggestions were structured into three dimensions:
- The organization of work, including clinical activities
- The attractiveness of the practice/the satisfaction levels of the patients
- The satisfaction levels of the employees.
Most of the recommendations of the first type were linked to how the practice was equipped (software, POCT, electronic communication, the appointment making system). Great emphasis was placed on proper record keeping and compliance with applicable laws (the distribution of responsibilities, compliance with standard procedures, informed consent, access to documentation) and also the management of patient care (active registration, the appointment making system, the system of the dispensation of chronic patient, and cooperation with specialists). An overview of all 21 of the recommendations suggested for implementation is presented in [Table 1].
The second type of recommendations was oriented toward patient satisfaction. The recommendations could be divided into two subareas. The first is mostly concerned with providing patients with necessary information (options for making appointments and receiving consultation, web pages, social networking, an electronic bulletin boards, informational leaflets as complements for oral communication). The second involves the ensuring of the comfort and privacy of patient. An overview of all 8 of the recommendations suggested for implementation is presented in [Table 2].
As for the third type of recommendation, there were 7 different suggestions made for the improvement of the employee satisfaction. In addition to providing a comfortable environment for the employees, emphasis was placed on furthering the education and the mental health of the employees (get-togethers with colleagues outside the practice, cooperating with partner practices, setting up Balint group More Detailss). An overview of the recommendations suggested for implementation in a new practice is presented in [Table 3].
A benefit of small groups is their flexibility, which allows for the discussion of any issue relevant to general practice.,, Literature about the utilization of small groups for the implementation of a standard recommended procedure in the treatment of bronchial asthma, diabetes mellitus, the performance of clinical audits in the administering of antibiotics or PPI, or projects aimed at increasing the organizational level of the practices or preparation for accreditation, thus exists. These projects present a unique way to utilize small groups.,,,
During their specialization preparation, residents acquire some basic knowledge about the management of their own practices and the organization of activities. The level of this knowledge is almost always related with the organizational level of the practice in which they are being trained and the willingness of the training physician to supply this information. Newly qualified GPs looking to start their own practices must rely on relevant legal norms, can use the textbook “General Practice Medicine” (Vseobecne prakticke lekarstvi) for general observations, read materials published by the Association of GPs, or journals published by other publishers. All of this information, however, is very generalized and may be of limited use, as all GPs start their practices with a unique set of equipment, in different environments, and under various conditions., GPs may ask their training physicians for advice if they are in the same location. The suggested project, however, is the formalized process of support for a resident using the methodology of small groups, formed by physicians and nurses who know the specifics of each practice.
The project put emphasis on the development of the organization of activities, be they managerial or clinical. The organizational level of a practice directly affects the quality of care and the safety of patients, the satisfaction levels of both patients and practice employees, as well as the economic efficiency of the practice.,, The presented suggestions constitute of a disparate set according to the priorities and contributions of individual groups, appropriately adjusted for the possibilities of each specific practice. Only some of the recommendations can be generalized.
The GPs' feedback on the levels of support they received in the small groups was positive. They stated that they truly felt that they lacked knowledge and experience when buying, establishing, and managing a new practice., They were running into problems when equipping their practice and implementing methods, that worked in the practice of their training physicians without any issues and which they never had to worry about. It was not possible to implement all suggested recommendations; some were implemented only partially or remain in the process of being planned. Everyday practice always brings new issues, which seem more important, and the organizational measures for improving the quality of healthcare thus receive lower priority. That is why, from the point of view of efficiency, we are missing continuity and discussion, which would contribute to a higher level of realization. It is also clear, that with time, it will be possible to conjoin some items, and others will disintegrate into separate parts. On the other hand, we believe that the importance and efficiency of small groups is not only in the fulfilling of the points discussed but also we feel that small groups have helped us mainly to improve our professional self-esteem.
The participants stressed the significance of small groups in preventing burnout syndrome. There was general consensus that small groups should be introduced within healthcare centers, open to GPs and cooperating specialists alike.
Apart from those previously discussed benefits of the small groups (local educational possibilities and exchange programs – CME lessons, congresses), the GP trainees have the increasingly inspiring and enhancing possibilities that come from international projects and programs. Some published documents prove very easy and meaningful worldwide cooperation setup. They work due to similar needs and feelings of the GPs across the world. At the moment, many professional development opportunities are in place, for example, Young Doctors Movement (YDM) under World Organization of family Doctors. YDM has been working for over a decade now, and its popularity has come from its variety of educational and scientific projects. YDM organizes exchange programs and these are great chance for the international cooperation and for the young GPs' personal and professional skills development. By participating in an exchange program, future GPs/FPs are given the chance to experience intercultural communication and peer collaboration. All the above contribute to the growth and development of primary care all over the word.
| Conclusion|| |
Although the significance of small groups is much wider, it turns out that if regular meetings of GPs receive a clear goal and direction, the meetings can be very constructive and in this specific case can also partially fulfill the mission and meaning of “true” small groups. Small groups offer a good platform in their capacity to support young GPs when they are starting their own practice, as demonstrated on the following outcomes of our project:
- Our small group managed to come up with a list of suggestions and recommendations, which is possible to implement when setting up or establishing a new practice
- As part of the meetings of the small groups, beginning doctors got answers to a whole range of questions arising from the current issues
- Young practitioners greatly appreciated this form of preparation for starting out in their own independent activities as GPs.
In terms of the methodology of small groups, ours was the first project of its kind in the field of general practice in the Czech Republic. We are aware that the purpose of small groups in medicine is associated more with the technical aspects of the profession rather than the organizational aspects. We consider our project to be the beginning of our efforts in the development of education in the form of small groups and its eventual inclusion in the system of education of GPs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
O'Riordan M. Continuing medical education in Irish general practice. Scan J Prim Health Care 2000;18:137-8.
Rohrbasser A, Mickan S, Harris J. Exploring why quality circles work in primary health care: A realist review protocol. Syst Rev 2013;2:110.
Eliasson G, Mattsson B. From teaching to learning, experiences of small CME group work in general practice in Sweden. Scan J Prim Health Care 1999;17:196-200.
Wensing M, Broge B, Riens B, Kaufmann-Kolle P, Akkermans R, Grol R, et al.
Quality circles to improve prescribing of primary care physicians. Three comparative studies. Pharmacoepidemiol Drug Saf 2009;18:763-9.
de Villiers M, Bresick G, Mash B. The value of small group learning: An evaluation of an innovative CPD programme for primary care medical practitioners. Med Educ 2003;37:815-21.
Peterson U, Bergström G, Samuelsson M, Asberg M, Nygren A. Reflecting peer-support groups in the prevention of stress and burnout: Randomized controlled trial. J Adv Nurs 2008;63:506-16.
Gerlach FM, Beyer M. New concept for continuous documentation of development of quality circles in ambulatory care: Initial results from an information system in Germany. Qual Health Care 1998;7:55-61.
Zaher E, Ratnapalan S. Practice-based small group learning programs: Systematic review. Can Fam Physician 2012;58:637-42, e310-6.
Beyer M, Gerlach FM, Flies U, Grol R, Król Z, Munck A, et al.
The development of quality circles/peer review groups as a method of quality improvement in Europe. Results of a survey in 26 European countries. Fam Pract 2003;20:443-51.
Býma S, Seifert B, Šmatlák V, Štolfa J. Concept of general practice and WHO. Acta Med 2014;3:10-2.
Munck A, Gahrn-Hansen B, Sogaard P, Soggard J. Long-lasting improvement in general practitioners' prescribing of antibiotics by means of medical audit. Scand J Prim Health Care 1999;17:185-90.
Schubert I, Heymans L, Fessler J. General practitioners' guideline for palliative care. A survey of guideline acceptance in quality circles of primary medical care. Med Klin (Munich) 2010;105:135-41.
Hartmann P, Grüsser M, Jörgens V. Structured public health quality circle on the topic of diabetes management in general practice. Z Arztl Fortbild (Jena) 1995;89:415-8.
Svab I, Pavlic DR, Radić S, Vainiomäki P. General practice east of Eden: An overview of general practice in Eastern Europe. Croat Med J 2004;45:537-42.
Oleszczyk M, Svab I, Seifert B, Krztoń-Królewiecka A, Windak A. Family medicine in post-communist Europe needs a boost. Exploring the position of family medicine in healthcare systems of Central and Eastern Europe and Russia. BMC Fam Pract 2012;13:15.
Grol R, Wensing M. Implementation of quality assurance and medical audit: General practitioners' perceived obstacles and requirements. Br J Gen Pract 1995;45:548-52.
Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 2012;10:63-74.
Contencin P, Falcoff H, Doumenc M. Review of performance assessment and improvement in ambulatory medical care. Health Policy 2006;77:64-75.
Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, et al.
Audit and feedback: Effects on professional practice and healthcare out-comes. Cochrane Database Syst Rev 2012;(6):CD000259.
Vollmar HC, Rieger MA, Butzlaff ME, Ostermann T. General practitioners' preferences and use of educational media: A German perspective. BMC Health Serv Res 2009;9:31.
Tausch BD, Härter MC. Perceived effectiveness of diagnostic and therapeutic guidelines in primary care quality circles. Int J Qual Health Care 2001;13:239-46.
Hoedebecke K, Scott-Jones J, Pinho-Costa L. New Zealand among global social media initiative leaders for primary care advocacy. J Prim Health Care 2016;8:94-8.
Yakubu K, Hoedebecke K, Nashat N. Young doctor movements: Motives for membership among aspiring and young family physicians. J Family Med Prim Care 2015;4:177-81.
] [Full text]
Barata AN, Rigon S. Family medicine 360°: Global exchanges in family medicine. J Family Med Prim Care 2015;4:305-9.
] [Full text]
[Table 1], [Table 2], [Table 3]