Best General Practice - Can you help?

Here's your chance to say what you think.

Take the survey
http://www.surveymonkey.com/s.aspx?sm=S1a5cMZu5mQmIqYCXBy4ng_3d_3d

There are only seven questions in the survey. I think its fairly easy & quick to complete, but let me know if you think otherwise. I will feed back results via this webpage in due course.

Remember you don't need to be a GP to complete the survey, just complete the sections relevant for you.

If you have any other ideas or suggestions about
   Innovations that can improve general practice or
   How to spread improvements faster in general practice

Please send your suggestions to tk@elpmek.demon.co.uk

This page represents the work in progress of my sabbatical/prolonged study leave October 2009-May 2010.

‘Not enough time’ is the commonest complaint by GPs. In addition to the daily pressures on the time with patients, many planned and important improvement projects in practices never get started or finished because of the pressures on time. This project is about finding ways to be more effective and efficient using the available time.

Section 1: The project: Improving the Diffusion of Innovations in Service Organizations. This section includes the ‘specific outcomes’ of the project.

Section 2: The questions about innovation that will be asked to guide the project. The answers to these questions will be the ‘learning outcomes’ of the project

Section 3: The questions about general practice that will be asked to guide the search for innovations in the project.

SECTION ONE

The primary project: Improving the Diffusion of Innovations in Service Organizations.

Professor Trisha Greenhalgh wrote a Dept of Health commissioned systematic review with recommendations in 2004 on this subject http://www.milbank.org/quarterly/8204feat.html. This review provides valuable guidance for the planning Section 2 of this project. My project will seek to discover, document and disseminate the current best national and international practices in primary care that

• are transferable
• can improve quality of care for patients and
• save some time each week for busy GPs

If this project does help disseminate better working practices and save some time each week for the 45,000 NHS GPs it will be equivalent to providing an extra resource worth millions of pounds for the NHS.

During the course of this six months prolonged study leave I will address the questions about innovation in section 2 and the problems from general practice detailed in section 3. This includes literature reviews networking with people who are knowledgeable sources of information, relevant national and international conferences and site visits to innovators and adaptors of quality improvement in primary care. The site visits will include visits to local, national and international primary care centres of excellence or general practices, which have some recognisable special expertise.

The Outcomes of this project

The specific project outcomes are

1. Document ten innovations appropriate for British general practice that are transferable, can improve quality of care for patients and save some time each week for busy GPs.
2. Agree piloting of these ten innovations in one or more Bristol general practices during 2009-11

SECTION TWO

The learning outcomes to will be to answer some of the specific questions raised in the Trish Greenhalgh Dept of Health 2004 systematic review ‘Diffusion of Innovations in Service Organizations’. These questions about innovation will guide the project. These are

1. How do innovations in health service organizations arise, and in what circumstances? What mix of what factors tends to produce “adoptable” innovations (e.g., ones that have clear advantages beyond their source organization and low implementation complexity and are readily adaptable to new contexts)?
2. How can innovations in health service organizations be adapted to be perceived as more advantageous, more compatible with prevailing norms and values, less complex, more trialable, with more observable results, and with greater scope for local reinvention? Is there a role for a central agency, resource center, or officially sanctioned demonstration programs in this?
3. How are innovations arising as “good ideas” in local health care systems reinvented as they are transmitted through individual and organizational networks, and how can this process be supported or enhanced? How can we identify “bad ideas” likely to spread so that we can intervene to prevent this?
4. What is the nature of interpersonal influence and opinion leadership in the range of different professional and managerial groups in the health service, especially in relation to organizational innovations? In particular, how are key players identified and influenced?
5. What is the nature and extent of the social networks of different players in the health service (both clinical and non clinical)? How do these networks serve as channels for social influence and the reinvention and embedding of complex service innovations?
6. Who are the individuals who act as champions for organizational innovations in health services? What is the nature of their role, and how might it be enabled and enhanced?
7. Who are the individuals who act as boundary spanners among health service organizations, especially in relation to complex service innovations? What is the nature of their role, and how might it be enabled and enhanced?
8. To what extent do “restructuring” initiatives (popular in health service organizations) improve their ability to adopt, implement, and sustain innovations? In particular, will a planned move from a traditional hierarchical structure to one based on semiautonomous teams with independent decision-making power improve innovativeness?
9. How can we improve the absorptive capacity of service organizations for new knowledge? In particular, what is the detailed process by which ideas are captured from outside, circulated internally, adapted, reframed, implemented, and routinized in a service organization, and how might this process be systematically enhanced?
10. How can leaders of service organizations set about achieving a receptive context for change; that is, the kind of culture and climate that supports and enables change in general?
11. What is the process leading to long-term routinization (with appropriate adaptation and development) of innovations in health service delivery and organization?
12. What steps must be taken by service organizations when moving toward a state of “readiness” (i.e., with all players on board and with protected time and funding), and how can this overall process be supported and enhanced? In particular, (1) how can tension for change be engendered? (2) How can innovation-system fit best be assessed? (3) How can the implications of the innovation be assessed and fed into the decision-making process? (4) What measures enhance the success of efforts to secure funding for the innovation in the resource allocation cycle? and (5) how can the organization’s capacity to evaluate the impact of the innovation be enhanced?
13. What are the characteristics of organizations that successfully avoid taking up “bad ideas”? Are they just lucky, or do they have better mechanisms for evaluating the ideas and anticipating the subsequent effects?
14. What is the nature of informal interorganizational networking in different areas of activity, and how can this be enhanced through explicit knowledge management activities (such as the appointment and support of knowledge workers and boundary spanners)?
15. What is (or could be) the role of professional organizations and informal interprofessional networks in spreading innovation among health care organizations?
16. What is the cost-effectiveness of structured health care quality collaboratives and comparable models of quality improvement, and how can this be enhanced? To what sort of projects in what sort of contexts should resources for such interorganizational collaboratives be allocated?
17. What are the harmful effects of an external “push” (such as a policy directive or incentive) for a particular innovation when the system is not ready? What are the characteristics of more successful external pushes promoting the assimilation and implementation of innovations by health service organizations?
18. By what processes are particular innovations in health service delivery and organization implemented and sustained (or not) in particular contexts and settings, and can these processes be enhanced? This question, which was probably the most serious gap in the literature uncovered for the review, would benefit from in-depth mixed-methodology studies aimed at building up a rich picture of process and impact.
19. Are there any additional lessons from the mainstream change management literature (to add to the diffusion of innovations literature reviewed here) for implementing and sustaining innovations in health care organizations?

Although it will be impossible to answer all these questions, their important function is to guide the project to ask and answer the most important questions. I expect to be able to report some progress with most of these questions.

SECTION THREE

These questions about general practice will be asked to guide the search for innovations in the project. These are questions that have accumulated in my working life as a GP and educator. It is unlikely that all these questions will be answered in the time available. Many of the answers to these questions will be disseminated through this webpage and GP publications. The questions include:

1. Can we improving access to appropriate health care? What are the local blocks to providing efficient and effective care ?
2. Can we improve routine communication across primary-secondary care interface locally?
3. Using the new IT - how will the patient record make a difference in the way we work? Can we disseminate good working practice quickly across the primary-secondary care interface?
4. Patient Choice – what constitutes informed choice and patient-centred care? Patients are being persuaded to take primary and secondary preventative care investigations and treatments without any real understanding of their absolute risk reduction eg The risks and benefits of mammography
5. Health Inequalities – how do we assess and measure health inequalities at the patient and practice level? E.g. The Institute for Healthcare improvement Triple Aim project
6. Procedural medicine & surgery – what are the latest procedures and investigations that are currently undertaken in secondary care? Can GPs recommend, have direct access and prepare patients for these procedures?
7. How do we make risks scoring make sense for doctors and patients using NNT from EBM?
8. Is there an easy to use pain or symptom score sheets (for continuing assessment of pain)?
9. Why do hospitals often have the wrong GP’s name on their records?
10. What new technologies may be easily applicable in primary care e.g. ultrasound scanning?
11. What self-monitoring techniques may patients may be able to use now or in the near future?
12. What is the patient’s journey in hospital like in 2009/10? Can it be improved? How do we ensure real time feedback from patients?
13. Communication with hospital – How can this be improved
14. Urgent care & out of hours care – Can we reset the primary care/secondary care interface? Can we improve the appropriateness of referrals & admissions to secondary care?
15. How can we improving the health care of patient who travel overseas before, during and after their trips?
16. Can Practice Based commissioning improve service for patients?
17. Access – what do our patients really want?
18. Can we make the NHS patient satisfaction questionnaires fit for purpose to improve primary care? Research (published in BJGP in Sept 2007) suggests the NHS sanctioned questionnaires for QoF are flawed. Personal experience suggests they are not a useful tool for feedback.
19. How will Revalidation = Relicensing + Recertification? Can GPs influence the implementation of this scheme? The processes are still under development and these processes will shape continuing professional development for GPs for the next generation. It is important to develop robust process with optimal outcomes
20. Appraisal – is there an optimal model for appraisal and revalidation?
21. What is the best way to evaluate the teaching and training of GPs and the learning of medical students and junior doctors?
22. The new GP curriculum – are their omissions? What else needs to be learnt and why?
23. How do we assess and improve the teaching & learning doctors in training ST1, 2 & 3
24. Can we develop an educational research strategy and culture in the local GP school
25. Total & integrated continuing professional education – what should this look like in 2010?
26. Retirement planning – e.g. what are the sensible exit strategies for clinical careers, do ‘retired’ GPs have a role in the NHS?
27. What is the best strategy for information mastery in practices? Do all practices have to developing their own intranets and website as a resource?
28. Can we develop and maintain a useful medical educational & management thesaurus?
29. How to recognise a high quality PCT and SHA. What separates the best from the rest? Will feedback from GPs improve their performance?
30. What is all the new jargon? How can we keep up to date with it?
31. Discover the tacit knowledge used to explain explicit decisions in the NHS?
32. How can we detect and expose irrationality in medical management?
33. What are the normal features of aging and how do we best prepare patients for aging?
34. How will Revalidation = Relicensing + Recertification? Can GPs influence the implementation of this scheme? The processes are still under development and these processes will shape continuing professional development for GPs for the next generation. It is important to develop robust process with optimal outcomes see: Revalidation
35. What tasks and processes can we safely abandon? How to reduce low-value clinical activity: where there is an unexplained or unwarranted above average activity or intervention level and no clear evidence of effectiveness
36. How to reduce complications and eliminating defects in care, so that the costs incurred in dealing with the consequences of these are reduced: for example, reducing complication rates which lead to longer lengths of stay and greater expenditure on drugs and readmissions, and reducing waste and error which lead to wasted clinical time, including unnecessary repeat investigations and tests
37. How to gain greater value from previously under-utilised sources. This may include: enabling patients, carers and communities to manage and improve their own health and/or contribute to the process of healthcare; empowering members of the healthcare team whose contribution is at present limited owing to lack of training for example; and/or removing barriers that are standing in the way of obtaining full value from all members of the healthcare team
38. Retirement planning – e.g. what are the sensible exit strategies for clinical careers, do ‘retired’ GPs have a role in the NHS?

This list continues to grow. As part of the educational journey with this project I will inevitably run into other areas and these may be reflected in my final report.