Family Practice Vol. 18, No. 1, 21-26
© Oxford University Press 2001
Research in Practice |
Features of primary health care teams associated with successful quality improvement of diabetes care: a qualitative study
Clinical Governance Research and Development Unit, Department of General Practice and Primary Health Care, University of Leicester and
a Leicestershire Primary Care Audit Group, Leicester General Hospital, Leicester, UK.
Correspondence to Keith Stevenson, Clinical Governance Research and Development Unit, Department of General Practice and Primary Health Care, University of Leicester, Gwendolen Road, Leicester LE5 4PW, UK.
Stevenson K, Baker R, Farooqi A, Sorrie R and Khunti K. Features of primary health care teams associated with successful quality improvement of diabetes care: a qualitative study. Family Practice 2001; 18: 21–26.
Received 5 November 1999; Revised 12 May 2000; Accepted 5 September 2000.
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Abstract |
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Background. In quality improvement activities such as audit, some general practices succeed in improving care and some do not. With audit of care likely to be one of the major tools in clinical governance, it would be helpful to establish what features of primary health care teams are associated with successful audit in general practice.
Objective. The aim of the present study was to identify those features of primary health care teams that were associated with successful quality improvement during systematic audit of diabetes care.
Method. Semi-structured tape-recorded interviews were carried out with lead GPs and practice nurses in 18 general practices in Leicestershire that had the opportunity to improve their care and had completed two data collections in a multipractice audit of diabetes care. The interviewees were asked to describe their practice's approach to audit and the transcripts were coded for common features and judged for strength of feeling by blinded independent raters. Features common to practices that had, and those that had not, managed to improve diabetes care were identified.
Results. Six features were identified reliably in the transcripts by blinded independent raters. Four were significantly associated with the successful improvement of care. Success was more likely in teams in which: the GP or nurse felt personally involved in the audit; they perceived their teamwork as good; they had recognized the need for systematic plans to address obstacles to quality improvement; and their teams had a positive attitude to continued monitoring of care. A positive attitude to audit and a personal interest in the disease were not associated with improvement in care.
Conclusions. Success in improving diabetes care is associated with certain organizational features of primary health care teams. Experimental studies are required to determine whether the development of teamwork enables practice teams to identify and overcome systematically the obstacles to improved quality of patient care that face them.
Keywords. Audit, clinical governance, diabetes care, quality improvement, teams.
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Introduction |
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From 1990, clinical audit became the principal method of quality improvement in primary care in England and Wales, and many teams have taken part in audits.1 From April 1999, clinical audit was incorporated into clinical governance, a new quality improvement system that will include additional methods of improving care such as continuing professional development and risk management.2 If clinical governance is to be an effective quality system, it needs to take note of the lessons from audit about improving quality.
To promote audit in general practice, audit groups were formed and included representative local health professionals and staff employed to provide advice and support. One strategy adopted by audit groups has been to invite local teams to take part in multipractice audits in which the performance of each participating team can be assessed against established evidence-based criteria. Support is provided through the audit, with each team receiving anonymized comparative feedback.3
However, even if deficiencies in care are identified during audit, improvements may not take place. One explanation for the variable success of efforts to implement change is that obstacles or barriers to change may be present.4,5 Different primary health care teams may face different obstacles at different times.6,7 For example, some teams may have problems in setting and achieving objectives,8–10 and these might influence the quality of care provided by these teams to people with diabetes. In a recent study of primary health care teams, obstacles were identified that might hinder the delivery of high quality care for people with diabetes,11 but the impact of obstacles on quality improvement was not investigated. As yet, no study in primary care has investigated the association between identified obstacles and success in quality improvement of diabetes care.
Therefore, the aim of this study was to identify features of primary health care teams that were associated with improvements in care during an audit of diabetes care.
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Method |
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Leicestershire primary care audit group co-ordinated a multipractice audit of diabetes during 1994–1997. The audit group provided support in carrying out the audit, undertook data analysis and feedback, and encouraged teams to develop action plans to address aspects of care identified as needing improvement in the first data collection. The primary health care teams taking part in the audit collected data from patient notes to assess how successful they had been in complying with six evidence-based criteria of care.12 The criteria required assessment of the following in the previous 12 months: blood pressure; glycated haemoglobin; urine for protein; smoking status; fundi; and feet.
The findings of the first data collection were fed back to the participating teams to enable them to compare their own performance anonymously with the other teams taking part. Each team was asked to call a team meeting to discuss their results and agree an action plan to improve performance, to submit its action plan to the audit group and to repeat the data collection after 12 months. The audit group calculated the improvement in compliance with the criteria for each team taking part between the first and second data collections. For each team, the mean of the improvement for the six criteria was also calculated.
Improvement was calculated as the difference between the mean achieved in the second data collection minus the mean achieved in the first. At the time of the study, 43 teams had completed two data collections of the audit. The mean improvements ranged between practices from an improvement of performance of +44.0% in one practice to a decline of –12.7% in the least successful practice. Practices that were already high performing at baseline would have little opportunity to improve, consequently those in the top quartile at baseline (those with >90% of patients sampled achieving the criterion of good quality care) were not included in the study. This reflects our interest in improvement in care rather than simply level of performance. The remaining 75% of teams were placed in three groups according to their level of performance at the first data collection. The three teams that had improved the most and the three that improved the least or deteriorated in each group were selected for interview. Thus, the study sample included one group of nine teams that had achieved reasonable improvements in care and another group of nine teams, matched in terms of initial level of performance, that had achieved little or no improvement.
The GP and nurse identified by each team as responsible for leading the audit were asked to take part in separately conducted interviews. They were told that they would be asked to discuss what they perceived to be the factors that promoted or impeded improvement in their team's care during the audit. The interview questions concerned general management of the audit, specific aspects of diabetes care management, perceived obstacles to achieving successful diabetes care and finally the interviewee's attitude to audit and the need to re-audit. All the interviews were carried out by one researcher (KS), during February–April 1998. The interviewer used a semi-structured explorative technique, with every participant being asked the same stem question but unique follow-up questions could be used to clarify the participant's feelings.13 Each interview lasted ~45 minutes, and was tape-recorded and transcribed. Although all 18 GPs were interviewed, two nurses were no longer working in their teams and were lost to the study.
The analysis of the interviews took place in two stages. In the first stage, each transcript was reviewed independently by two pairs from the research team (KK/RB and AF/RS), blind to the degree of quality improvement achieved by teams. Each transcript was given a project code and any identifying clues were removed to preserve annonymity of the practice. The reviewers marked on the transcript where they felt views were expressed by respondents about audit or teamwork, or that suggested obstacles to change. All these statements were grouped under draft theme headings. The transcripts were reviewed several times until the underlying themes emerged and could be identified reliably by two independent raters.
In the second stage of the analysis, each transcript was reviewed independently for a second time by two pairs of researchers (RB/KK and AF/RS), again blind to the identity of the practices and the extent of improvement in care. They were asked to classify the responses as negative (–), neutral to mildly positive (+) or strongly positive (++), in relation to the particular theme concerned. Differences between the independent reviewers were resolved in discussion. The relationships between the response grading and the degree of improvement achieved by teams were then explored by relating responses and improvement in descriptive tables.
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Results |
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Six themes featured regularly in the transcripts, and examples of comments in each theme are given in Table 1
. A description and interpretation of the ratings given to comments follows.
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Theme 1: team attitude to audit
GPs and nurses identified similar issues. Attitudes to audit were linked to past experience of audit and its role in managing care. All 18 GP interviewees were rated as mildly positively disposed, or strongly positively disposed, to audit. A typical mildly positive response from responders in teams that had limited past experience of audit was a wish to try it to see if it works. Other responders felt more confident about their audit experience and accepted it as a quality improvement mechanism. The most positive responses indicated that audit was thought of as part of team culture and a routine activity. The nurses were generally mildly positive but two gave responses rated as negative.
Theme 2: personal interest in the disease
All the GPs and most of the nurses reported having a special interest in, or responsibility for, diabetes care. Those who had a special interest in diabetes had often taken the lead organizing diabetes care for the team. These responses were coded as strongly positive. However, others who did not have a particular interest, but had been given responsibility by their teams for overseeing diabetes care and still saw it as an important activity, were coded as mildly positive. Some nurses reported no particular interest in the disease and gave the impression that they felt obliged to carry out audit, and these were graded as negative.
Theme 3: degree of teamwork in the practice
There were clear differences between practices in the way that they described the degree of teamwork that operated in the practice. Some GPs and nurses commented enthusiastically about team climate or commented about the value of team activity, and their statements were graded as strongly or mildly positive. There was evidence, however, of disharmony in some teams, and these comments received negative gradings.
Theme 4: degree of personal involvement in the audit
From comments in the transcripts, it was evident that GPs and nurses were involved in the audit to different extents. In two teams, the GPs seemed to have little involvement and delegated responsibility for carrying out the audit to other team members. In other teams, the lead GPs reported carrying out the audit independently without any help from any other team member.
Theme 5: recognizing the need to overcome obstacles
The interviewer sought to discover how respondents dealt with the need to improve diabetes care. Rationalization was sometimes evident, with team members justifying poor audit results by citing the failure of other agencies to provide accurate data. These comments were rated as negative (i.e. not recognizing the need to overcome obstacles). The contrast with other comments is marked, with some teams clearly regarding audit as a mechanism to help identify what needed to be changed, and to be followed by the development of systematic plans to implement change.
Theme 6: willingness to audit diabetes care again
GPs' comments generally fell into one of three groups. First, there was a group of negative responses, accompanied by expressions of disappointment in audit or difficulty in finding time for audit. A second group of mildly positive responses indicated some recognition of the need to audit again. A third group indicated strong commitment to further audit. The nurses' responses generally fell into the same categories, although it was clear that decisions to carry out an audit were not usually made by some nurses.
Association between features of teams and quality improvement
Table 2 shows the relationship between the ratings given to responses from GPs and the mean percentage practice improvement in the audit, and Table 3 shows the same relationship for the nurses. Taking the combined scores of GPs and nurses to represent the practice team score, a Spearman rank correlation indicated that a positive team attitude to audit on its own was not associated with successful quality improvement and neither was having a strong personal interest in diabetes. However, positive perceptions of teamwork, feelings of involvement in the audit, recognition of the need to overcome obstacles and a willingness to audit again were all significantly associated with successful quality improvement (Table 4).
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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In this study, the GPs and nurses leading diabetes audit were interviewed, and their responses were associated with the extent to which their teams had succeeded in improving quality of care for people with diabetes. Four themes emerged as associated with quality improvement. Success was related to: degree of personal involvement in the audit; the degree of teamwork in the practice; the development by the team of systematic plans to implement change; and having a positive attitude to the need to re-audit. Neither a positive attitude towards audit nor having a personal interest in the disease discriminated successful from unsuccessful teams. These results indicate that teamwork is associated with the effectiveness of quality improvement. GPs and nurses from the same teams expressed similar views about their teamwork (Tables 2 and 3
), a finding that emphasizes the importance of teamwork and gives some support to our analysis of the interview responses. However, some qualifications should be made. Representatives of only 18 practice teams were included, all of whom had volunteered to take part in a multipractice audit and had completed two data collections. It would be inappropriate, without additional evidence, to assume that the findings apply to teams that do not take part in, or do not complete, audit. Furthermore, although an association between features of teams and success in quality improvement has been demonstrated, the relationship may not be causative. Further studies are required to determine which features are causative, and which interventions would be most likely to resolve them and enable teams to undertake successful quality improvement. Nevertheless, there was a high level of inter-rater agreement about the themes by independent, and blinded, raters, and the themes were similar to the barriers to implementing diabetes care identified in another recent study.10
The method used to gather the data and analyse them should also be considered. The interviewer was aware of the improvement scores of the practices, but it was agreed that he needed to be if he was to ask the lead practitioner or nurse why particular aspects of care had improved and which others had not. Particular care was taken to blind the raters of the transcripts to the identity and actual degree of improvement achieved by the practices. It was possible, however, to detect from the transcripts where improvement or lack of improvement was being discussed. The raters, however, were instructed specifically to search for and identify interpersonal and organizational comments that reflected team climate or efficiency.
The finding of an association between good practice organization and ability to improve care through audit are supported elsewhere.14,15 There is a strengthening belief that the culture of a practice, those shared attitudes and beliefs that underpin the way the practice team goes about its business, is important to effective implementation of quality improvement activities.16,17 Linked to this are the resource issues that affect the ability of a team to function effectively and give audit a high priority.18–20
If clinical governance in primary care groups is to achieve quality improvements through mechanisms such as multipractice audit, then we need more research to find out which features in which types of teams are directly linked to improvements in care. Clinical governance leads could then identify practice teams that have features that might limit their success in quality improvement and offer appropriate help.
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References |
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1 Hearnshaw H, Baker R, Cooper A. A survey of audit in general practice. Br J Gen Pract 1998; 48: 979–981.[Medline]
2
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Baker R, Robertson N, Farooqi A. Audit in general practice: factors affecting participation. Br Med J 1995; 311: 31–33.
15 Lervy B, Wareham K, Cheung W. Practice characteristics associated with audit activity: a medical audit advisory group survey. Br J Ged Pract 1994; 44: 311–314.
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17 Greenhalgh T. Change and the organisation: culture and context. Br J Gen Pract 2000; 50: 340–341.
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