Family Practice Vol. 17, No. 6, 455-461
© Oxford University Press 2000
Developing a ‘consultation quality index’ (CQI) for use in general practice
University of Edinburgh, Department of Community Health Sciences–General Practice, 20 West Richmond Street, Edinburgh EH8 9DX and
a Imperial College School of Medicine, Department of Primary Health Care and General Practice, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.
Howie JGR, Heaney DJ, Maxwell M, Walker JJ and Freeman GK. Developing a ‘consultation quality index’ (CQI) for use in general practice. Family Practice 2000; 17: 455–461.
Received 4 May 2000; Accepted 17 July 2000.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Background. The core values of general practice include holism and patient-centredness. None of the measures of quality of care in general practice presently capture the expression of these values at routine consultations.
Objectives. The aim of the present study was to construct a ‘consultation quality index’ (CQI) which reflects the core values of general practice, using as proxies ‘consultation length’ and how well patients ‘know the doctor’ as process measures and ‘patient enablement’ as an outcome measure.
Methods. The CQI was constructed from data collected from 23 799 adult English-speaking patients consulting 221 doctors in four demographically contrasting areas of the UK during 2 weeks of March/April 1998. A total of 171 doctors who entered 50 qualifying consultations were allocated scores for the three component variables, and a total CQI was calculated.
Results. CQI scores were in the range 4–18. Validity was examined by looking at high and low scorers in greater detail and by searching for correlates with case mix, patient age and gender, and the deprivation scores of the practices concerned. Particular attention was paid to how registrars and doctors new to their practices scored. The scores of different doctors in the same practice were also noted. The results had strong face validity and were independent of case mix and deprivation. Reliability was gauged by examining similar work from a previous study which had collected information on consultation length and enablement over three time periods. High CQI scores were associated with smaller overall practice list sizes.
Conclusions. We have outlined possible uses for the CQI as part of the packages assessing quality of care by doctors and practices. The measure may also have a part to play in recognizing poorly performing doctors. We suggest how CQI scores could contribute to an incentive scheme to reward good consulting practice. Further work is in hand to compare doctors' CQI scores with scores based on performance indicators constructed from routine NHS data on prescribing and preventive medicine.
Keywords. Consultation quality index, general practice, quality of care.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Disciplines achieve their identity through having their own case mix and the skills appropriate to that, by being able to support their own research and post-graduate training programmes, and by having a discernible philosophy.1,2 In general practice, the territory, research and training are embodied in the profession's policy statements that define targets for GPs to aspire to. 3–5 These statements also include implicit and explicit statements about values and attitudes which together reflect the philosophy of the discipline. This has proved the hardest component of general practice to define in a way which can be measured.
These values and attitudes include holism and patient-centredness. Holism—the integration of physical, psychological and social components of health problems in making diagnoses and planning management—is well established as a central issue of good consulting practice,6,7 and there is good evidence that this is promoted by longer consultations8–10 and by greater continuity of care.11–13 ‘Patient-centredness’ is harder to define, but again supports a considerable literature, much of it of a descriptive or qualitative nature.14–17 If we accept that it indicates a commitment by doctors to value the contribution of patients to deciding what is wrong with them and how their care should be managed, Wensing's review of the literature on patients' views of their care assumes great significance.18 This review suggests that, among other things, patients place great emphasis on being helped to understand the nature of their problems and made able to manage their own illnesses. In recent work, we have attempted to develop an outcome measure [‘enablement’, measured by the Patient Enablement Instrument (PEI)] which captures these issues.19,20
Finding a way of assessing whether the goals of holism and patient-centredness are achieved at consultations by doctors has proved difficult, but it is a necessary part of assessing quality of general practice care across its full breadth. In order to take this process forward, we attempt in this study to construct a ‘consultation quality index’ (CQI) by amalgamating information on doctors' mean consultation length, how well their patients know them (a proxy for personal continuity of care) and the extent to which they ‘enable’ their patients.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The CQI was constructed from data collected during March/April 1998 from a randomly selected group of practices in four participating regions (Lothian, Coventry, Oxfordshire and west London). The aim was to involve 10 practices/50 doctors in each region. Approximately twice this number were approached to take part, one condition being the agreement of all partners in small practices and of all except one or two in practices of five or more partners; 38% of practices approached agreed to take part, including 221 doctors. Locums, assistants and registrars were included if they wished to participate.
All patients consulting these doctors during any two consecutive weeks during the survey period were invited to complete a pre-consultation questionnaire exploring a variety of issues relating to health needs (including the GHQ 12 and a set of social questions). A number of questions about the doctor being consulted were included, one of which asked how well the patient knew the doctor they were about to see. Responses were recorded on a 5-point Likert scale, two points of which indicated ‘well’ or ‘very well’. Wishes regarding prescriptions were noted. A question about languages spoken at home was included. After the consultation, patients were asked to complete the ‘enablement’ outcome questionnaire (PEI20; see Fig. 1
) and answer a few questions about prescriptions received and interruptions experienced. The doctor recorded the start and finish time of the consultation and whether the patient was a temporary resident or an ‘extra’ to planned bookings. All data were recorded on one form. Pre- and post-consultation information was kept blind by a system of seals. Biographical data on doctors (including languages spoken at home) and organizational data about practices (including enumeration district level deprivation scores) were collected. The methods have been described more fully elsewhere.21 Information was collected from 23 799 patients where the only language spoken at home was English, and from 2195 ‘other language’ patients. A total of 7338 eligible patients (22%) were not given or did not complete the questionnaire, but consultation length data were collected for them.
|
Case mix variables included age and gender of patients. At the level of clinical needs, patients were identified as having acute problems (45.2%), chronic problems (42.1%), social problems (41.4%), psychological problems (29.7%) or administrative needs—including wishing a prescription without having referred to another clinical need—(8.4%). According to our classification, 50.8% of patients had more than one health need; 19.6% of patients indicated in their pre-consultation questionnaire that they wanted to discuss more than one problem at their consultation.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Preliminary analyses
Data were analysed using SAS. ‘Other language’ patients had significantly shorter consultations and higher enablement scores (irrespective of whether seeing an ‘English language’ or ‘other language’ doctor)21, and these were analysed separately from the English language patient consultations. In order to assess minimal sample sizes from which stable doctor mean scores for enablement, consultation length and ‘knowing the doctor well’ could be calculated, we compared rank correlations between doctors for a series of 10 samples of 50, 100 and 150 consultations for each variable. Samples of 50 consultations gave high inter-sample correlations for mean consultation length (typically r = 0.95), mean enablement (typically r = 0.88) and mean scores for ‘knowing the doctor well’ (typically 0.97). Overall, 221 doctors took part in the study. All 171 doctors (77%) who had 50 or more consultations with English language patients, for whom completed PEI scores were available, were included in the calculations of the CQI. Those lost to this part of the study because of small numbers of returns were mainly locums, part-time partners and doctors seeing large numbers of other language patients.
Developing the CQI
All doctors with at least 50 qualifying consultations were ranked in descending order separately for their mean enablement score, mean consultation length and the percentage of patients consulting who knew them well or very well using all data available. The ranks were divided into sextiles. Doctors in the top sextile for any variable were allocated a score of 6 points, down to a score of 1 point for a place in the sixth (lowest) sextile. A total CQI score was then calculated for each doctor by adding their scores for all three variables. The scores thus ranged from 3 to 18.
The boundary values for each sextile of each variable are shown in Table 1. The CQI score was separated into six bands, four of three points each and two (in the middle range) of two points each. The distribution of the 171 doctors within these six bands is also shown in Table 1, as is the mean total patient list of the practices they were working in. (Doctors' CQI score position on a continuous rank correlated highly with their position within the six CQI bands of Table 1; r = 0.98.)
|
Influence of demographic and case mix variables
In the principal analyses of the determinants of enablement and consultation length which we reported on previously,21 we identified age, gender, wish for a prescription and aspects of clinical case mix as being important. At that time, we did not have sufficient information to comment on the possible relationship with practice deprivation scores. Thus we needed to explore the extent to which these variables might influence a doctor's position on the CQI.
There was no correlation between doctors' rank order on the CQI or on any of its components and the proportion of female patients seen (r = 0.01). There were modest correlations between doctors' ranks on the CQI and the proportion of patients they saw aged over 65 (r = 0.35), the number of patients who said they had been asked to come back (r = 0.29) and the ratio of chronic to acute patients they saw (r = 0.33), all of which reflected correlations with knowing the doctor well. Not surprisingly, the doctors' rank for the ratio of chronic to acute consultations was itself correlated with the doctors' rank for patients aged over 65 (r = 0.42) and for the rank of patients asked to return (r = 0.58). In practical terms, the difference between the average doctor in CQI band 6 against band 1 was 22.5% versus 13.5% for patients seen age over 65, 30.2% versus 21.1% of patients who said they had been recalled, and in range of ratios of chronic to acute patients of 46.2:40.8% to 39.0:49.3%. This effectively means that at an average surgery doctors in the top CQI band had one more patient over 65 asked to return for a chronic complaint than did a doctor in the lowest CQI band. There was no correlation between doctors' pattern of not prescribing to patients who wanted prescriptions and their position on the CQI (r = 0.19).
Correlations between doctors' positions on a deprivation rank (calculated using enumeration district level UPA scores) and their CQI rank were low and not significant (r = 0.06); similarly, correlations between the deprivation rank and ranks for the component parts of the CQI were also low and not significant (enablement r = 0.14; consultation length r = –0.14; knowing the doctor r = 0.16).
In our previous analyses, consultation length had been shown to vary by clinical need; for example, mean consultation length for biomedical problems (acute and chronic presentations only) was 7.6 minutes [95% confidence interval (CI) 7.5–7.7] as against 8.9 minutes (95% CI 8.7–9.1) for patients with psychological problems (any consultations where the patient's GHQ 12 score was 5 or more). We created ranks of doctors according to the proportion of patients they saw with social and psychological problems (irrespective of whether patients also had biomedical problems) and with acute or chronic problems (irrespective of whether they also had psychological or social problems). There were no significant correlations between these case mix measures and the complete CQI or any of its three component parts.
Although we have excluded consultations with other language patients from the construction of our CQI, we attempted to compare doctors' relative ranks in the components of the CQI for English language patients, with a second index calculated from consultations with ‘other language’ patients. No doctors had 50 qualifying consultations for both language options, but 10 had 25 each for enablement, 19 had 25 each for consultation length, and 10 had 25 each for knowing the doctor well. The correlations between their rank placings for the ‘English language’ and ‘other language’ indexes for the three measures were 0.72, 0.87 and 0.70, respectively.
Reliability
As described above, we checked the internal consistency of doctors' scores for the three components of the index by comparing series of subsamples from the total pool of consultations available. In a single cross-sectional survey, it is not possible to do more to assess the reliability of measures being tested. However, we did have access to previous comparable data on mean enablement and mean consultation length from work with a sample of 42 Grampian doctors who had contributed data on three different periods over 18 months in 1992 and 1993.19 We re-analysed that data putting scores within the boundary values for the present study and collapsing our six CQI bands into three because of the smaller sample of doctors. Twenty-six of 42 Grampian doctors had identical enablement bands for all three periods of data collection, and 22 of 42 had three identical consultation length bands. For only three of 42 doctors were scores found which ranged from the top to the bottom of the three bands for either measure. (It was, of course, not possible to undertake test–retest studies as different patients attended during different data collection periods.)
Validity
We have shown in the previous section that scores for the measures we have constructed are largely independent of variations in the demographic features and health needs of patients seen between different doctors, and that where there were relationships (proportion of elderly patients seen; proportion of patients recalled; ratio of acute: chronic patients seen) they did not seem significant in terms of clinical practice (the scoring system could, however, be subjected to a simple weighing process if felt appropriate).
We were aware of a number of possible anomalies relating in particular to registrars and less experienced doctors who might have fewer patients who knew them well. We also wanted to look for potential confounding issues by studying the top and bottom scorers in the CQI. We thus examined a number of atypical situations in greater depth.
- (i) Least good CQI band (band 1): five doctors scored 4 points and eight doctors scored 5 points. Five doctors were in the lowest sextile for both enablement and consultation length scores, and another five scored in the lower two sextiles for both these components. It was not arithmetically possible for these doctors to score above average for any of the three components of the CQI. Excluding two locums, only one of the remaining 11 doctors had been in their current practice for less than 3 years.
- (ii) Best CQI band (band 6): 17 doctors scored between 16 and 18 points. Seven scored in the top and a further eight in the top two sextiles for both enablement and consultation length scores. It was not arithmetically possible to score below 4 points (that is to be below average) on any of the three components of the CQI. All 17 doctors had been in their current practices for more than 3 years.
- (iii) Lowest sextile for ‘knowing the doctor well’: of the 27 doctors who had fewer than 21% of patients who knew them well, seven eventually scored between 9 and 12 points for the CQI and another two scored 13 points or above. Eight of the 27 doctors were registrars and four were either locums or assistants. A further 10 were new principals and had been in their current practice less than 3 years. It was noticeable that the registrars had longer consultations (mean band 5) than the new principals in the group (mean band 4), and achieved higher enablement bands (mean band 4 against 2.5). These differences were not explained by case mix.
- (iv) Registrars/locums/assistants/new to practice doctors: eight doctors were registrars, four were locums and 15 were principals with less than 3 years experience in their current practice. The mean CQI scores for these groups were 10, 7 and 8, respectively; one of the eight registrars, none of the four locums and two of the 15 young principals scored 13 points or more; and five of the registrars, one of the locums and three of the young principals scored 9–12 points.
- (ii) Best CQI band (band 6): 17 doctors scored between 16 and 18 points. Seven scored in the top and a further eight in the top two sextiles for both enablement and consultation length scores. It was not arithmetically possible to score below 4 points (that is to be below average) on any of the three components of the CQI. All 17 doctors had been in their current practices for more than 3 years.
Finally, we looked at the scores of different doctors in complete partnerships to explore the face validity of our findings. Because of our commitment to confidentiality, we are only able to comment on figures where the doctors declared themselves to us either on receipt of results or at the feedback meetings arranged after the main results had been analysed. Table 2 shows a selection of combinations of doctors' scores in eight of our participating practices. One of the two doctors scoring 4 was receiving treatment for depression and the other professed to disillusionment with his clinical work. The doctor scoring 5 in practice 5 was a locum. One of the doctors in the two-doctor partnership scoring 17:7 was a very experienced doctor and the other a new and part-time partner; the doctor who scored 16 in practice 7 has resigned to work single-handedly elsewhere. The two doctors who scored 15 are a husband and wife team.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Consultation audit
The principal application of the CQI is likely to be as a component of packages attempting to audit quality of care at practice and doctor level, of which the RCGP Quality Practice Award is the present leader in the field. To date, most credible current measures of quality have been in the areas of chronic disease management or the achievement of health promotion targets. These assess care over time, and care by teams rather than care given by individual clinicians at individual consultations. The CQI thus appears capable of filling an important gap in the market. Current thinking categorizes quality as relating to access and effectiveness, with effectiveness divided into technical and non-technical/interpersonal effectiveness.22 Initially, we saw our measure relating to the area of non-technical or interpersonal effectiveness, but in reality its components also relate to aspects of access (Can you see a doctor you know? How long do you have at your consultation when you get it?) and to technical effectiveness (improved likelihood of making a holistic diagnosis when one is appropriate).
In this study, our measure has highlighted two doctors with motivation or health problems, a small number whose pattern of care seems destined to be of suboptimal effectiveness unless changes in consultation length and continuity are put in place, one doctor who has indicated he is now reviewing his personal consulting style, two practices we know of who are reviewing their booking arrangements, and another which is thinking of taking on a further partner to allow a change to 10 minute appointments in the hope of improving disappointing enablement scores.
Development
A number of further developments are in hand or being planned. We currently are comparing the CQI scores of the doctors and practices in our study with their achievement of routine NHS data-based performance indicators. We also wish to encourage debate about where boundary values between the bands in our quality categories should be drawn; Table 1
at present distributes our present cadre of volunteer doctors in a mechanistic way and it may well be that the top groups should be widened and the lower ones narrowed. Case mix seems less critical than might have been expected, but there may be an argument to include a small weighting in relation to the proportion of elderly patients seen. The problem of handling ‘other language’ patient consultations needs further thought, and will be of importance in areas with large ethnic minority groups. The fact that quality scores for ‘other language’ patients may balance out through having higher enablement despite shorter consultations is not a sound way of making progress—although this is an issue which has also not been addressed in considering other indicators or reward systems generally. If the CQI is to become part of a reward system, we need to demonstrate that change through education or administrative change is possible (there is already evidence that it is23).
Finally, we need to reflect on three criticisms that have been made: (i) that our system could still reward gross inefficiency through doctors simply spending ages with the same chronic patients; (ii) that doctors would ‘game the system’ by recording inaccurate consultation lengths; and (iii) that our measure does not cover the problem of ‘nice doctors' who miss appendicitis, meningitis and treatable malignancy. We can only say that we recognize these issues, which we believe apply to all other present or proposed measures to a greater or lesser extent, and is why we again point out that our measure should be used as a component of a wider set of measures and not as a single solution to a complex problem.
Research
The CQI has a part to play in the continuing debate on how to conceptualize, measure and deliver quality of care generally. At the level of 50 consultations per doctor used in this study, consultation length and knowing the doctor well explain 24% of the variation between mean enablement scores achieved by different doctors (the percentage explained rises to 35, 53 and 69% for sample sizes of 100, 125 and 150 consultations, but the number of qualifying doctors falls in parallel). However, other interpersonal skills or attributes must be at work as well, and work will continue to try to find out what these are. We hope that discovering new ways of capturing the concepts of empathy and communication skills in a measurable way may improve the comprehensiveness of our index. We are still trying to find a way of defining doctors' attitudes or interpersonal style.
It is of interest, however, that CQI scores at doctor level seem to rise as the combined list size of doctors' practices falls (Table 1). This appears to be a correlate with our index rather than an independent predictor, but gives further support to the argument that there may be a size of partnership beyond which quality (as measured by our index) is at risk of being compromised.24,25
Rewards/incentives
Given that rewards for doing ‘good things’ and incentives to encourage their provision are already an integral part of GP remuneration, there is a strong case for introducing a payment to reward or encourage consulting patterns which reflect core values (holism and patient-centredness in this case) of the discipline. Subject to some further development work (discussed below), we believe an incentive system could be developed to reward high scores on our composite index (e.g. doctors in CQI bands 5 and 6) and to encourage doctors in the lower groups (e.g. bands 1 and 2) to alter their administrative and clinical practices in the hope of achieving better outcomes. For the sake of argument, we suggest awarding two ‘incentive’ units for a score in either band 5 or 6 of the CQI, one unit for a score in bands 3 and 4, and no units for a score in bands 1 and 2. Were £60m again available to the Doctors and Dentists Review Body to promote quality in primary care (£2000/principal in the UK), this would equate to £4000/annum per doctor in the top level and £2000/annum in the second level—sums similar to those which recently have or currently are used to promote or reward achievement of public health targets for screening and immunization, to promote better management of chronic health problems or to reward doctors who undertake regular post-graduate education.
Conclusion
An essential part of a discipline is the philosophy it espouses. For general practice, this embraces holism and patient-centredness. Measuring the extent to which these are achieved at routine consultations is a considerable challenge, and present packages for assessing quality lack a component in this area. To try to fill this gap, we have created a ‘consultation quality index’ by bringing together bodies of work on enablement (as an outcome measure), consultation length and ‘knowing the doctor well’ (as process measures), all of which reflect issues of importance to patients. An important strength of our work is that definition of need and assessment of outcome have both been determined exclusively by patient responses.
This paper looks at how such a composite measure could be scored and examines a variety of issues relating to reliability and validity. We feel this measure (the CQI) is now at least as well researched and conceptually based as those currently available or under development, and that it could now be added to the range of quality measures being considered for use by doctors and practices.
|
Acknowledgments |
|---|
We thank the following, all of whom have contributed to regular discussions about the planning and implementation of this project: Dr T Jones (Oxfordshire Health Authority); Dr M Stern (Coventry Health Authority); Dr P Berrey (Lothian Health Board); Dr R Elton (University of Edinburgh); Ms H Rai and Dr M Pierce (Imperial College School of Medicine); and Mr S Campbell (National Primary Care Research and Development Centre). We also wish to acknowledge our indebtedness to the 221 doctors and 53 practices who participated, together with their managers and reception staff. Without their tolerance, commitment and goodwill, this work could not have been undertaken. JH, DH and MM initiated the study and wrote the protocol, along with GF. All authors contributed to the design of research instruments and the recruitment and briefing of practices. JH, DH and MM led the design of the analyses, which was carried out by JW. All authors contributed to the interpretation of the results. JH, DH, MM and JW wrote the paper, which GF helped to edit and develop. JH is the guarantor. The work was supported by grants from: the Chief Scientist's Office at the Scottish Office Home and Health Department; Anglia and Oxford NHS R & D Directorate; West Midlands NHS R & D Directorate; and North Thames NHS R & D Directorate.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
1 Richardson IM. The value of a university department of general practice. Br Med J 1975; iv: 740–742.
2 McWhinney IR. General practice as an academic discipline. Lancet 1966; i: 419–423.
3 Royal College of General Practitioners. The Nature of General Medical Practice. Report of a working party. (Report from General Practice No. 27) Exeter: RCGP, 1996.
4 The Joint Committee on Postgraduate Training for General Practice. Recommendations to Deaneries on the Selection and Re-Selection of General Practice Trainers. 1998.
5 Royal College of General Practitioneers and General Practitioners Committee. Good Medical Practice for General Practitioners. Draft document for consultation. 1999.
6 Stott NCH, Davis RH. The exceptional potential in each primary care consultation. J R Coll Gen Pract 1979; 29: 201–205.[Medline]
7 Greenhalgh T, Eversley J. Quality in General Practice: Towards a Holistic Approach. London: King's Fund, 1999.
8 Wilson A (1991) Consultation length in general practice: a review. Br J Gen Pract 41: 119–122.[ISI][Medline]
9 Howie JGR, Porter AMD, Heaney DJ, Hopton JL. Long to short consultation ratio: a proxy measure of quality of care for general practice. Br J Gen Pract 1991; 41: 48–54.[ISI][Medline]
10 Wilson A, McDonald P, Hayes L, Cooney J. Health promotion in general practice: a minute makes a difference. Br Med J 1992; 304: 227–230.
11
Hjortdahl P. General practice and continuity of care: organisational aspects. Fam Pract 1989; 6: 292–298.
12 Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient satisfaction. Br Med J 1992; 304: 1287–1290.
13
Freeman G, Hjortdahl P. What future for continuity of care in general practice? Br Med J 1997; 314: 1870–1873.
14 Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-centered Medicine: Transforming the Clinical Method. Thousand Oaks, CA: Sage, 1995.
15 McWhinney IR. The need for a transformed clinical method. In Stewart M, Roter D (eds). Communicating with Medical Patients. Newbury Park, CA: Sage, 1989: 25–40.
16 Toon PD. What is Good General Practice? Occasional Paper 65. London: Royal College of General Practitioners, 1994.
17 Neighbour, R. The Inner Consultation. Lancaster: MTP, 1987.
18 Wensing M, Jung HP, Mainz J, Olesen F, Grol R. A systematic review of the literature on patient priorities for general practice care. Part 1: description of the research domain. Soc Sci Med 1998; 47: 1573–1588.
19 Howie JGR, Heaney DJ, Maxwell M. Measuring Quality in General Practice. Occasional Paper 75. London: Royal College of General Practitioners, 1997.
20
Howie JGR, Heaney DJ, Maxwell M, Walker JJ. A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Fam Pract 1998; 15: 165–171.
21
Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK, Rai H. Quality at general practice consultations: cross sectional survey. Br Med J 1999; 319: 738–743.
22 Roland M, Holden J, Campbell S. Quality Assessment for General Practice: Supporting Clinical Governance in Primary Care Groups. Manchester: University of Manchester, National Primary Care Research and Development Centre, 1998.
23 Williams M, Neal RD. Time for a change? The process of lengthening booking intervals in general practice. Br J Gen Pract 1998; 48: 1783–1786.[ISI][Medline]
24 Baker R, Streatfield J. What types of general practice do patients prefer? Exploration of practice characteristics influencing satisfaction. Br J Gen Pract 1995; 45: 654–659.[ISI][Medline]
25 Howie JGR. The John Fry Fellowship 1999. Patient-centredness and the Politics of Change. A Day in the Life of Academic Practice. London: The Nuffield Trust, 1999.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  G. Ahlen, B Mattsson, and R. Gunnarsson Physician patient questionnaire to assess physician patient agreement at the consultation Fam. Pract., October 1, 2007; 24(5): 498 - 503. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Haggerty, F. Burge, J.-F. Levesque, D. Gass, R. Pineault, M.-D. Beaulieu, and D. Santor Operational Definitions of Attributes of Primary Health Care: Consensus Among Canadian Experts Ann. Fam. Med, July 1, 2007; 5(4): 336 - 344. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. G Evans, A. Edwards, S. Evans, B. Elwyn, and G. Elwyn Assessing the practising physician using patient surveys: a systematic review of instruments and feedback methods Fam. Pract., April 1, 2007; 24(2): 117 - 127. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Y. Zhang, J. Rohrer, T. Borders, and T. Farrell Patient Satisfaction, Self-Rated Health Status, and Health Confidence: An Assessment of the Utility of Single-Item Questions American Journal of Medical Quality, January 1, 2007; 22(1): 42 - 49. [Abstract] [PDF]
|
|
|
|
|
|
B. McKinstry, I. Colthart, and J. Walker Can doctors predict patients' satisfaction and enablement? A cross-sectional observational study Fam. Pract., April 1, 2006; 23(2): 240 - 245. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Howie, D Heaney, and M Maxwell Quality, core values and the general practice consultation: issues of definition, measurement and delivery Fam. Pract., August 1, 2004; 21(4): 458 - 468. [Full Text] [PDF]
|
|
|
|
|
|
B. McKinstry, J. Walker, D. Blaney, D. Heaney, and D. Begg Do patients and expert doctors agree on the assessment of consultation skills?: A comparison of two patient consultation assessment scales with the video component of the MRCGP Fam. Pract., February 1, 2004; 21(1): 75 - 80. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P Bower, S Campbell, C Bojke, and B Sibbald Team structure, team climate and the quality of care in primary care: an observational study Qual. Saf. Health Care, August 1, 2003; 12(4): 273 - 279. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Pollock and J. Grime GPs' perspectives on managing time in consultations with patients suffering from depression: a qualitative study Fam. Pract., June 1, 2003; 20(3): 262 - 269. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Roland, D. J Heaney, M. Maxwell, J. Howie, H. A Lee, S. W Mercer, H. Hasegawa, D. Reilly, and A. P Bikker Length of consultations BMJ, November 23, 2002; 325(7374): 1241 - 1241. [Full Text] [PDF]
|
|
|
|
|
|
D. J Heaney, J. J Walker, J. G. Howie, M. Maxwell, G. K Freeman, P. N. Berrey, T. G Jones, M. C Stern, and S. M Campbell The development of a routine NHS data-based index of performance in general practice (NHSPPI) Fam. Pract., February 1, 2002; 19(1): 77 - 84. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S M Campbell, M Hann, J Hacker, C Burns, D Oliver, A Thapar, N Mead, D G. Safran, and M O Roland Identifying predictors of high quality care in English general practice: observational study BMJ, October 6, 2001; 323(7316): 784 - 784. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||