Quality in Family Practice: The Tool Lisa Dolovich, PharmD David Price, MD Friday, March 6, 2009 Toronto Metropolitan Hotel
Overview � Quality program milestones � Historic perspective � Guiding principles � Documents developed to guide practices � Pilot projects � Delphi process & categorization � Updated tool � Next steps
Quality Program: Milestones to Date � Recommendation of a provincial assessment program � Developed the Quality Assessment Tool � Trained Advisors & Assessors � Pilot-tested in 3 practices � Field-tested in 7 practices Delphi process to update tool � E-learning Tool �
HISTORIC PERSPECTIVE & GUIDING PRINCIPLES
The Quality in Family Practice Program - Guiding Principles � Voluntary � Consumer involvement � Interdisciplinary teams � CQI and PDSA cycles � Self-reflection
Quality Tartan
Quality Interactive Circles
Recommendations Major recommendation 2004 T he Ministry of Health should establish a Quality in Family Practice program in Ontario. Other recommendations • Governance • Tool • Process • Costs • Terminology • Assessor training
The Quality Assessment in Family Practice Tool � Developed in Phase 1 (2003-2005) � Based on NZ Tool (Cornerstone) & was adjusted for Canadian setting � Incorporated elements of Hamilton Tool (key features of care in Ontario) � Extensive review of similar tools in Australia, and the UK (QTD and QPA) � IncludedUS P4P (California) � Included indicators being developed in Canada through the PHCTF (Jan Barnsley (Ontario), Alan Katz (Manitoba)
The Quality Assessment in Family Practice Tool � 5 broad areas: A.Factors affecting patients B.Physical factors affecting the practice C.Clinical practice systems D.Practice and patient information management E.Continuous quality improvement and continuing professional development and quality of work life � 80 indicators (with 335 associated criteria)
Documents Developed to Guide Practices � Assessment Tool for Practices � Assessment Tool for Assessors � Assessment Grid � E-tool set up to complete grids � Practice Summary –based on grid � Feedback re: assessment from Advisor � Quality Tool Questionnaires – link back to criteria � Website
TESTING OF THE TOOL IN FAMILY PRACTICE
Pilot Test (Phase 2) To test the feasibility and acceptability of the Quality program and tool – Large rural practice – Mt. Forest – Large Urban Practice – K-W – Solo practice - Hamilton
Pilot Test (Phase 2) - Key Findings � All 80 indictors & 335 criteria tested in the 3 practices � Standards were met for 83% of the legal criteria completed, 74% of the essential criteria completed and 64% of the desirable criteria completed � Commendable practice changes and improvements included: – team behavior and morale; – regular practice meetings; – implementation of Bill 31; – physical facility improvements; – patient surveys; – patient access to telephone and appointments; – practice audits; – infection control; and – medication management and record keeping.
Field Test (Phase 3) To develop capacity within practices to support quality initiatives – Subset of indicators chosen – 7 practices: Marathon, Barrie, Mount Forest, Kitchener, Hamilton, Stratford, Ottawa – Chart audit training program developed – Patient satisfaction assessments – Staff quality of work life assessments – Comparative, anonymous practice profiles reports generated
Field Test - Key Findings � Further refinement of the Quality assessment process, Assessment Tool, and website � Identification of skills and competencies required for Advisor and Assessors � Identification of processes needed to ensure that a practice assessment incorporates team commitment, self-assessment, and CQI principles � Establishment of a network between FHTs to share experiences and best practices
DELPHI PROCESS & CATEGORIZATION
Delphi Study: Funding & Team � Funding from MOHLTC Team: � Lisa Dolovich: Co-Principal Investigator � Cheryl Levitt: Co-Principal Investigator � David Price: Co-Principal Investigator � Kalpana Nair: Research Coordinator � Carol Lane: Administrative Assistant
Delphi Process � Comparison of Quality Tool with: � Quality & Outcomes Framework (UK) � EPA Tool � CIHI (Pan-Canadian Indicators for Primary Care) � Quality Tool had already incorporated key features from Australia and NZ Tools __________________________ ► 63 indicators (36/80 from Quality and 27 from other tools) brought to Delphi Panel
Delphi Panel Participants 1. Alan Abelsohn 13. Michelle Martin 2. Gina Agarwal 14. Jennifer McGregor 3. Anne Barber 15. Heather McLean 4. Gary Bloch 16. Val Rachlis 5. Angela Carol 17. Gordon Riddle 6. Mel Cescon 18. Carol Ridge 7. Peter Deimling 19. David Smith 8. Anne DuVall 20. Les Solomon 9. Mike Green 21. Suzanne Trivers 10. Linda Hilts 22. Jennifer Willsie 11. Bill Hogg 23. Steve Wetmore 12. Natalie Kennie-Kaulbach
Delphi Panel � Panel of 23 experts from Ontario; some had familiarity with the Quality program � 2 rounds: Online survey using Survey Monkey, followed by teleconference call � Decision Rules: – Include indicator if more than 80% agreed it should be included – Exclude indicator if 50% or more agree it should be excluded – Remaining indicators were included in next survey
Delphi Panel - Survey � Rated each indicator based on 4 principles: 1. Value-added 2. Measurable 3. Standard 4. Important � Also rated whether indicator should be included in the revised tool
Delphi Panel – Summary (Overall) Round 1 (63 indicators) � 30 included; 5 excluded � 28 for discussion (7/63 of these became criteria for already included indicators, therefore 21 for discussion) Round 2 (21 indicators) � 4/21 more excluded (total excluded 4+5= 9/56) � 17/21 for discussion (total ex and dis 9+17=26/56) � 30/56 included
Categorization of Indicators • Asked Delphi panel for input • Re-organized tool based on new categorization • Recognize that there is still overlap between categories • Ultimate goal is to categorize tool into key ideas “buckets” so as to make tool easier to use
Updated Tool - Categories 1. Rights and Responsibilities 2. Access and Availability 3. Physical Facilities 4. Protection and Safety 5. Clinical 6. Medical Record Keeping 7. Continuity of Care 8. Human Resource Management 9. Continuous Professional Development 10. Education
Next Steps • Today – final consensus re: indicators • Tool categorization finalization • Wording revisions to Quality Tool based on Delphi panel feedback • Ensuring links to original background/ rationale are in place for each indicator
E-TOOL PROJECT
QUESTIONS
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