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World Book of Family Medicine – European Edition 2015 The set of indicators used within EPA was developed with science-based methods and instruments. A modified RAND/UCLA appropriateness method was used as the scientific basis. An expert panel consisting of international scientists and experts from daily practice rated the indicators according to clarity and relevance to generate a usable set of indicators. Expert knowledge as well as patients’ perspectives were included to generate practical indicators. Assessment process The process of EPA is based on an assessment where indicators are measured and results are presented to the participating healthcare provider. There are five steps covering the whole process of assessment with EPA. In a first, initial step of the assessment, all staff involved are informed about EPA and the assessment process. As a second step, the situation of the healthcare provider is analysed to evaluate performance using a self assessment questionnaire, a patient survey and a staff survey. All three instruments are based on the indicators defined previously. In a third step, the healthcare provider is visited by an expert facilitator who collects more data using a check-list and an interview guide. In a subsequent team meeting, the facilitator presents the result from the assessment to the whole team. The team thus gets feedback for every indicator of the assessment of the healthcare provider and can also benchmark its result against all participating providers. As a last step, the team of the healthcare provider itself plans activities and measures to improve the quality of care provided. By working with quality indicators, improvements can be recognized exactly where they are necessary and useful. Figure 1 shows the overall structure of EPA and the results of an assessment as seen by the healthcare provider during the feedback session. Our unique software Visotool® visualizes the results of the assessment via a pentagraph and allows benchmarking against all other participating providers. Figure 1: Pentagraph representing the results of the individual healthcare provider compared to the mean value of other participating providers in the five domains The pentagraph shows; • results of all indicators/data collected for an individual provider (continuous red line) • mean value of all facilities which have so far taken part in the EPA process (dashed blue line) • potentially best value to be reached by a provider and the benchmark group for this provider (black external line) The closer the lines are to the edges of the five domains (the black external line), the better the results in each of these domains, dimensions and indicators. Each indicator is measured via items which are part of the instruments used during the assessment. To generate these lines, all indicators and items are transferred into degrees of goal achievement between 0% and 100% (e.g. yes = 100% and no = 0% goal achievement for a specific item). Table 1: The overall structure of EPA shown with an example of the domain Quality and Safety Domain Dimension Indicator Item Quality and Safety Critical Incident Reporting There is a critical incident register Does the facility have a critical incident register? Instrument: Interview Results EPA has been successfully implemented in various European countries and is currently being tested in an international context. So far, the results have been encouraging. They show; improved quality of care and higher standards of service delivery increased transparency and competition among healthcare providers increased job satisfaction by staff 238
World Book of Family Medicine – European Edition 2015 improved confidence and experiences by clients/ patients motivation for practice teams for measurable change and improvement Further perspectives The strength of the EPA approach lies in the transparency it generates. A direct and detailed feedback and the possibility to benchmark against participating healthcare providers can be used in various settings and healthcare systems. It can be used to focus healthcare services provided by healthcare specialists or be tailored to illuminate health system aspects such as health financing, leadership, drugs, human resources as well as clinical areas. It may, furthermore, be adapted to special fields of interest. Take home messages Improvement starts with measuring (indicators). Motivates healthcare providers for measurable change and improvement. Shows strengths and weaknesses to providers. Initiates quality improvement activities where they are necessary and useful. Has a high and scientifically well proven impact on change of performance. Original abstract http://www.woncaeurope.org/content/ws-56-european-practice-assessment-epa-practice-assessment-and-quality-managementindicators References Engels Y, Campbell St, Dautzenberg M, Hombergh P, Brinkmann H, SzecsenyiJ, Falcoff H, Seuntjens L, Kuenzi B, Grol R. Developing a framework of, and quality indicators for, general practice management in Europe. Fam Pract 2005; 22: 215- 222 Engels Y, Dautzenberg M, Campbell S, Broge B, Boffin N, Marshall M, Elwyn G, Vodopivec-Jamsek V, Gerlach F, Samuelson M and Grol, R. Testing a European set of indicators for the evaluation of the management of primary care practices. Fam Pract 2006; 23: 137-147 Goetz K, Campbell S, Broge B, Brodowski M, Steinhaeuser J, Wensing M, Szecsenyi J. Job satisfaction of practice assistants in general practice in Germany: an observational study. Fam Pract 2013, 30:411-417 Grol R, Dautzenberg M, Brinkmann H. (Eds). 2004: Quality Management in Primary Care. European Practice Assessment. Publisher: Bertelsmann Foundation Szecsenyi J, Broge B, Eckhardt J, Heller G, Kaufmann-Kolle P and Wensing M. Tearing down walls: opening the border between hospital and ambulatory care for quality improvement in Germany. Int J Quality Health Care 2012; 24:101-104 Szecsenyi J, Campbell S, Broge B, Laux G, Willms S, Wensing M, Goetz K. Effectiveness of a quality-improvement program in improving management of primary care practices, CMAJ 2011; 183: 1326-1333 Szecsenyi J, Götz K, Campbell S, Broge B, Reuschenbach B, Wensing M. Is the job satisfaction of primary care team members associated with patient satisfaction? BMJ Qual Saf 2011; 20: 508-514 239
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