Family Practice, Vol 15, 354-362, Copyright © 1998 by World Organization of Family Doctors
P Ram, R Grol, P van den Hombergh, JJ Rethans, C van der Vleuten and K Aretz
OBJECTIVES: The precise relationship between practice management
(structure) and the doctor's actual performance (process) in general
practice is tenuous. Analysis of their mutual relationship may yield
insight into the way they contribute to outcome and into corresponding
assessment procedures. METHOD: In a cross-sectional study, consultations of
93 GPs were videotaped in their own practice and assessed by peer-observers
on medical performance and on communication with patients, followed by a
practice visit by a non-physician observer using a validated Visitation
Instrument to assess Practice management and organization (VIP). Pearson
correlations (observed and disattenuated for unreliability of the
instruments) between scores on 22 practice management dimensions and scores
of 16 selected cases on medical performance and communication were
calculated. The predictive value of specific practice management aspects
for actual performance was determined by multiple regression analysis, with
performance scores as dependent variables and scores on the 22 management
dimensions and GPs' professional characteristics as independent variables.
RESULTS: Nine practice management dimensions correlated significantly with
medical performance and so did five dimensions with actual communication.
Overall, most associations were weak. Combined with demographic variables
(age for medical performance and working single- handedly for
communication), 26% of variance in medical performance scores could be
explained by only three practice management dimensions. One practice
dimension (delegation of medical tasks to the practice assistant) explained
11% of variance in communication with patients. Organization of quality
assessment activities explained most of the variation in medical
performance. CONCLUSIONS: Practice management (structure) and actual
performance (process) seem to be largely autonomous constructs. Quality
improvement and assessment activities should emphasize that practice
management is different from actual performance. Structure and process may
contribute to patient outcome independently of each other.
ORIGINAL CLINICAL RESEARCH
Structure and process: the relationship between practice management and actual clinical performance in general practice
Centre for Quality of Care Research, University of Maastricht, The Netherlands.
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