Quality improvement in Primary Care: The New Frontier? A framework for discussion Simon de Lusignan Primary Care Informatics St. George’s Hospital Medical School

St George’s:

Primary Care Informatics 1.Information in the consulting room 2.Data Quality 3.Telemonitoring

Overview Introduction Lessons from: –the literature –general practice –quality improvement programmes NeLH-PC PCDQ Conclusions –Four processes, and –Three enablers of quality improvement

Introduction:

Introduction: There are readily identifiable: – processes, and –enablers to promote quality improvement Learn the lessons from: –the literature –general practice –quality improvement programmes

Lessons from the literature

Shift towards learner-centred education Old think –Passively listening to lectures –Educator decides topic –Read a journal or text book –Errors should be forgotten / denied New think –Actively participate in learning –You decide the topic –Problem solving, simulated cases –Errors are a learning experience Wyatt JC. Clinical Knowledge… in the Information Age London: RSM, 2001

Reviews of the evidence point towards certain themes: “Our data show some evidence that interactive CME sessions that that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and, on occasion,health care outcomes. Based on a small number of well-conducted trials, didactic sessions do not appear to be effective in changing physician performance.” Davis D et al. Impact of formal continuing medical education: do… continuing education activities change physician behavior or health care outcomes? JAMA 1999 Sep 1;282(9):867-74

Emerging evidence supports complex interventions …the complex educational intervention exemplified the best form of knowledge translation (the integration of knowledge into practice), moving the practitioner from –awareness of new guidelines –to agreement with the guidelines and –finally to adoption and adherence, following well-defined patterns of adoption and based on principles of adult learning applied to CME. Davis D. Clinical practice guidelines and the translation of knowledge: the science of continuing medical education. CMAJ 2000; 163 (10 ):1278-9

Lessons from General Practice

The biopsychosocial model: "The dominant model of disease today is biomedical, and it leaves no room within its framework for the social, psychological, and behavioural dimensions of illness." Engel GL. (1977) The need for a new medical model: a challenge for biomedicine. Science;196(4286):129-36

The unique nature of primary care: "Doctors in other parts of medicine are devoted to a particular organ or a technology. They practice according to what the Germans call "Das Schemata"…. …"Das Schemata" is not workable within general practice.“ Fugelli P. (2001) Trust — in general practice. BJGP;51:

The primary care consultation: ‘In general practice, the consultation is a journey, not a destination.’ Neighbour misquoting Milton Erickson Neighbour R. The Inner Consultation. How to develop an effective and intuitive consulting style. Manchester: MTP Press, 1987.

Lessons from two quality improvement programmes…

Primary Care National electronic Library for health NeLH-PC Lots of use up to hits per month No evidence systematically changes practice

Primary Care Data Quality PCDQ Single clinical focus Incremental change Feedback of own data Summary data presented to whole PCO

Conclusions:

Four key processes for quality improvement in Primary Care: 1.Access to the evidence 2.Feedback about your quality of care 3.Opportunities to share dilemmas 4.Mentorship

Three enablers: 1.Informatics 2.Effective professional and educational structures 3.Health service with a vision and appropriate targets

Thanks for listening… Simon de LUSIGNAN