Background
Setting and intervention: accreditation in Danish general practice
Standard | Standard content |
---|---|
1. The professional quality | Use of diagnosis coding Collection, analysis and use of clinical data for quality improvement |
2. Use of good clinical practice | Detection, course of treatment and division of labour between GP and staff for patients with diabetes or COPD and for vulnerable patients |
3. Adverse events | Reporting, follow-up and process for learning in case of adverse events |
4. Patient evaluations | Completion of a patient evaluation via DAK-E and follow-up on the results |
5. Prevention of confusion of patient’s identity | Identification of patients principally by social security number and labelling of diagnostic material |
6. Prescription of medicine and renewal of prescriptions | Rational and safe medicine ordination and renewal of prescriptions Participation in regional initiatives for correct medicine management Annual assessment of patients’ list of medicine Reporting of side effects |
7. Paraclinical tests | Execution of tests and handling of test materials Quality control of equipment Requisition and follow-up of paraclinical tests Procedures for test results in case of GP’s absence Procedures for missing tests results |
8. Emergency response and cardiac arrest | Handling of acute disease and cardiac arrest in the clinic Participation in cardiopulmonary resuscitation course |
9. The patient health record, data safety and confidentiality | Content of patient health record conforms to current legislation Journal audit performed and follow-up upon if needed Safe storage, handling and destruction of sensitive personal data Discretion and confidentiality in patient contacts |
10. Availability | Accessibility in accordance with collective agreement (e.g. telephone hours, opening hours and waiting time) Physical accessibility Visitation of patients Online practice declaration with relevant information |
11. Referral | Relevant and adequate content and handling of referrals |
12. Coordination of patient care | Coordination and continuity of internal patient trajectories and externally with other health care providers |
13. Acquisition, storage and disposal of clinical utensils and medicine/vaccines | Sufficient stuck of utensils, medicine and vaccines Correct storage of medicine e.g. at the right temperature Control of expiration dates Correct disposal |
14. Hygiene | Cleaning of the clinic and inventory Cleaning and storage of medical equipment Correct hand hygiene Management of infectious patients |
15. Management and operational activities | Ensure clear leadership, resource optimisation and development by having a plan containing plans for quality improvement, division of responsibilities and tasks, quality monitoring of e.g. patient records, equipment and medicine, and development of the clinic and development goals |
16. Hiring, introduction and competency development | Ensure correct competences when hiring Introduction of new GPs, GPs in training and staff Supervision and competency development |
“Basically, the surveyors shall meet the institutions to be accredited with trust: We believe in what we are told, unless there is reason not to, and in return we expect honest answers” (IKAS’ webpage [13]).
Methods
Qualitative interviews
Clinic | Clinic type | GPs and staff | 1. round interview participants | 2. round interview participants | A priori attitude to accreditationb | Survey visit observed |
---|---|---|---|---|---|---|
1 | Partnership | 3 GPs, 1 nurse, 2 secretaries | 2 GPs, 1 nurse, 1 secretary | 1 GP, 1 nurse, 1 secretary | Negative | Yes |
2 | Solo | 1 GP, 2 nurses | 1 GP, 2 nurses | 1 GP, 2 nurses | Positive | Yes |
3 | Partnership | 3 GPs, 2 nurses, 3 secretaries | 3 GPs, 2 nurses, 1 secretary | 3 GPs, 2 nurses, 1 secretary | Negative | Yes |
4 | Solo | 1 GP, 1 biomedical laboratory scientist | 1 GP, 1 biomedical laboratory scientist | 1 GP, 1 biomedical laboratory scientist | Positive | Yes |
5 | Solo | 1 GP, 1 secretary | 1 GP, 1 secretary | 1 GP, 1 secretary | N.A | No |
6 | Partnership | 3 GPs, 3 nurses, 1 secretary | 3 GPs, 2 nurses, 1 secretary | 3 GPs, 2 nurses, 1 secretary | Positive | Yes |
7 | Solo | 1 GP, 1 nurse | 1 GP | 1 GP | Negative | Yes |
8 | Partnership | 2 GPs, 2 nurses | 2 GPs, 2 nurses | 2 GPs, 2 nurses | Negative | Yes |
9a | Partnership | 2 GPs, 1 secretary | 2 GPs | Positive | Yes | |
10 | Solo | 1 GP, 1 nurse | 1 GP, 1 nurse | 1 GP, 1 nurse | Negative | Yes |
11 | Solo | 1 GP, 1 nurse | 1 GP, 1 nurse | 1 GP, 1 nurse | Positive | Yes |
12 | Partnership | 3 GPs, 2 nurses, 2 secretaries | 3 GPs, 2 nurses | 3 GPs, 2 nurses | Negativec Positive | Yes |
Surveyor | Gender | Clinic visited |
---|---|---|
GP-surveyor 1 | M | 1 and 12 |
GP-surveyor 2 | F | 3 and 4 and 10 |
GP-surveyor 3 | M | 5 |
GP-surveyor 4 | M | 7 and 8 and 11 |
GP-surveyor 5 (not interviewed) | M | 2 and 6 |
Staff-surveyor 1 | F | 1 |
Staff-surveyor 2 | F | 2 and 5 and 10 |
Staff-surveyor 3 | F | 6 and 8 |
Staff-surveyor 4 | F | 4 and 7 and 12 |
Staff-surveyor 5 | F | 3 |
Staff-surveyor 6 | F | 11 |
Interview guide for the clinics |
Description of the survey and how it matched their expectations |
Experiences with and reflections on the surveyors’ approach to assess compliance with the standards and ability to obtain an adequate and valid assessment |
The form of communication at the visit |
Descriptions and reflections on what they told and showed the surveyors |
Opinions about the surveyor being a colleague |
Thoughts about potential remarks and the process after the survey (continued adherence or de-implementation) |
Interview guide for the surveyors |
Preparation before the visit |
Their approach and techniques during the survey |
Their reflections on the professionals’ opportunities for not representing an authentic image of their clinic |
Their role as a representative from the accreditation agency while also being a colleague |
The work division between the GP-surveyor and the staff-surveyor |
Specific questions prompted by our observations of survey visits |
Analysis
Results
The surveyors’ approach, experiences, and reflections
De-dramatising the survey visit
Quality of documents influencing the level of scrutiny
“I check whether they meet the requirements present in the standards […] and I skim-read the rest to get a feeling beforehand of what kind of clinic it is, so that when I leave for the clinic, I usually know almost how it will turn out and how it is, you know. It gives me a sense of where I should have a little extra focus, and if they say ‘we do it like this and like this and so on’, and this is also what they have written, I promptly know that that’s how it is” (GP surveyor #2).
Relating the interview to the various space(s) of the clinic
“I always walk around; I don’t sit down that much with the staff because the staff is not used to sit still. They are used to moving around in the clinic […]. And it also makes them more calm that the things we talk about make sense in the room we are in. So, when we talk about laboratory matters, we are in the lab. And then they show me the different procedures they perform. ‘How do you check your autoclave?’ ‘How do you use the dishwasher?’ ‘How do you do these things?’ ‘Have you ensured… how do you check your utensils and your medicine, vaccines etc.?’ ‘Do you keep a log, and how do you do it?’” (Staff-surveyor #5).
Striving for an open and natural conversation
Visual observations influencing the level of scrutiny
“If I visit at clinic where I get the impression [e.g. from the number of available spirit dispensers] that the staff washes their hands with spirit when they do different things, then I don’t ask about when they wash their hands with spirit or soap and when they do both; I would find it a bit inappropriate. But when visiting a clinic and finding at the doctor’s desk a hand disinfectant from the year 2011, and it is completely cloudy, the uh… then it perhaps seems reasonable to inquire into it” (Staff-surveyor #2).
“Well, we always have a tour around the clinic… and I as a staff-surveyor I also get around in the clinic. I see their different procedures. I see where they keep their utensils and medicine and the like. And thus, you quickly get an impression as to whether the clinic is clean and orderly and whether they keep things correctly, and discretion and so on” (Staff-surveyor #3).
“Especially when I was with the nurse and the secretary and we started to open some cupboards and saw that there wasn’t that much systematics in how things were organised. The acute medicine was placed a bit at random. Disorganised. Therefore, I realised that it wasn’t as clear cut as it was originally stated in the clinic’s documents” (Staff -surveyor #6).
“You see, it is the overall picture […]. Because if they say that here is an isolated case where it hasn’t been done, and then if there is also something else, one thing here and one thing there, then you start to become suspicious. Because suddenly there are many cases. Then we can’t describe it all as isolated cases […] Then you sharpen your attention” (GP-surveyor #1).
“…three or four records. More if there are problems. Then they get the chance 'couldn't you just show me one more'. And if I can just see that both this and that is in order, and they use standard phrases and so on then I just look at a few and then it's fine” (GP surveyor #2).
Trust in the professionals and confidence in own ability to assses compliance
Standard | Remark |
---|---|
1. The professional quality | Insufficient use of diagnosis coding (Clinic 5) |
2. Use of good clinical practice | Had not selected a specific vulnerable group and made a related procedure for managing them (Clinic 2 and 5) |
4. Patient evaluations | Had not yet performed (or finished) the audit of patient records (Clinic 5 and 11) |
5. Prevention of confusion of patient’s identity | Did not identify all patients by asking for their social security number (Clinic 3) Did not write social security number on urin cultivation kits (Clinic 5) |
9. The patient health record, data safety and confidentiality | Insufficient patient record keeping (Clinic 5) |
14. Hygiene | Inadequate dishwasher (should be replaced) / incorrect use of desinfection fluids (Clinic 2) Insufficient use of the the autoclave (Clinic 2) Insufficient use of soap in the sterilisation process (Clinic 5) Use of normal oven insufficient for sterilisation of instruments (should be replaced with an autoclave) (Clinic 5) Did not have an apron for use with contagious patients (Clinic 5 and 10) |
“We trust that people want this enough so that they will be honest about it. And sometimes we also experience that the GPs are totally honest and tell us that they are not doing things [correctly] […] where I think, oh, if you had just expressed yourself a little differently, I would have believed that everything was all right [laughing]” (Staff-surveyor #2).
“Well, I have become good at reading people by now, uh, so, or if they say something in an uncertain way or if it is incoherent and things like that, you see, but anyway, it is extremely rare that I have experienced that” (Staff-surveyor #3).
“I can’t check it, because if they tell me that they clean [the clinic every day], well then I have to trust it” (Staff-surveyor #3).
The professionals’ approach, experiences, and reflections
Generally striving for compliance with the standards
“We just have to answer straight from the heart, right? It is not about remembering what to say, you see [laughter]. We just have to tell what we do” (Clinic #4, Staff).
“I don’t think we had a need to cover up things. I don’t think so because things were as they should be, you see. Uh so, we would not, i.e. we told things as they were, you see. I think we will always do that. Well, I actually think it is like that. To me it is a fundamental thing, you see” (Clinic #1, GP).
“I think we were all in a state of alertness, I mean we were attending an examination. Therefore, things should be said properly, and, and you should be able to vouch for it, but we said it in such a way that it was presented in the best possible manner. (…) So of course, I didn’t just speak out bluntly” (Clinic #1, GP).
Misrepresentation as a rarely used tactic
“[originally] I did not intend to say that we had cleaning more than twices a week…sometimes a bit more if it is neccesary… [but] here I compromised on my principles because I did not have the energy to do otherwise […] It was an area where I considered that the accreditation was too excessive and that it was not fair” (Clinic #10, GP).
Clinic | Misrepresentions |
---|---|
Clinic 3 | Most of the professionals in the clinic did not reveal that they did not ask all patients for social security number, but occasionally used visual recognition. While one GP revealed this at the survey, he subsequently misrepresented their procedures in the follow-up call with the accreditation agency. |
Clinic 5 | • Did a thorough cleaning of the clinic right before the survey visit to ensure that the clinic appeared impeccable • The clinic had been given remark for not keeping sufficiently detailed patient records, but the GP intended to stay non-compliant in this area and did not disclose this at the survey visit Although the GP expressed intentions to change procedures for COPD care in response to the remarks of the surveyors, he had not done so at the time of our second research interview. |
Clinic 7 | GP disagreed with the requirements of always wearing short sleeves (which she did not usually do) but during the survey visit she would wear short sleeves. For some patients, the GP ensured patient identity only by visual recognition (and not through oral confirmation of social security number) but did not reveal this at the survey. |
Clinic 10 | The professionals had agreed to say that they adhered to the standard concerning cleaning of toys in the waiting areas and daily cleaning of the clinic although this was not entirely true. The GP did not label testkits with social security numbers, but placed the test sample and patient information together in a box for the nurse to complete. Nurse had taken of her rings of a couple of days before the survey visit in order to avoid questions about this. |
Clinic 12 | Did a thorough cleaning of the clinic before the survey visit although this was not usual practice. |
Survey visits generally seen as sufficient for assessing compliance
“The [doctor-]surveyor was proficient enough so that he would ask into things, and when he sensed that it was okay he went on to the next issue. So it went smoohtly, you could sense that he had a good feeling about how things should be” (Clinic #1, GP).