27/04/2015
Oral presentation
IMPLEMENTATION OF
GUIDELINES IN
DUTCH QUALITY CIRCLES
Why and how is it organized?
Bas Spelberg,
General practitioner,
Scientist at the Dutch College of General Practitioners
Qualityconsultant Network Coordinator
Location
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The GP in the Netherlands
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8,879 GPs / 4970 practices
Central position/gatekeeper
Listed patients: 2300 patients
2 GP organizations
– National Association of GPs (LHV; trade union)
– Dutch College of GPs (NHG = scientific organisation)
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Dutch College of GPs (NHG)
• Scientific society of GPs
• Mission: to improve and to support
evidence-based general practice.
• Funding: member fees, insurance
companies, project funding
• 12.000 members (90% of practicing GPs
and trainees)
Dutch College of GPs (NHG)
• 140 employees
• Main activities
– Evidence-based guidelines (104; 19 in English)
– CME Materials, e-learning
– Educational programs, practice tools
– Programmes for practice accreditation
– Scientific journal ‘GP & Science’
– Prevention programmes and guides
– Tools for patient education / shared decision making
Registration Rules Dutch General
practitioner
• 6 years of medical study
• 3 years of specialisation
And after that…..
• Every 5 years re-registration
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Rules on re-registration
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Started in 1996
16 hours/week work in a GP practice
50 hours/year duty in out of office hours
40 hours/year accreditated postgraduate
education
• Since 2009: at least 2 hours/year in quality
circle
Different types of postgraduate education
• Central
• Regional
• Local
Examples of Central postgraduate education
• NHG congres:
– More than 2000 participants
– One central theme
– Oral presentation and workshops
• NHG Science Day
– 300 participants
– Presentations on research in the GP practice
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Examples of Regional Postgraduate
Education
• Agenda made by the regional GP’s
• Sometimes in cooperation with
the regional healthcare
organisations
• Programs independant
Local post graduate education: quality circle
• Evidence based effective
• Independent: by and for GP’s
• Making the interdoctor variation
transparant
• Registration of conclusions
• Quality consultant is compulsory
Why Quality circles?
Lourens Kooy 2005:
• 17 % qual. circles
• 43 % regional
• 27 % country
• 8 % farm.industry
• 5 % individual
Bas Spelberg 2013
• 20 % qual. circles
• 32 % regional
• 32 % country
• 6 % farm. industry
• 10 % individual
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Effect of a Practice-Based Strategy on Test Ordering
Performance of Primary Care Physicians. A
Randomized Trial
Wim Verstappen, Dutch GP, in Jama
2004
– 2 groups 13 quality circles
– Each group had interventions on 3 subjects:
• Group 1: cardiovasculair; upper abdominal complaints;
lower abdominal complaints
• Group 2: astma/copd; vague complaints; articular
complaints
– Group 1 was the referal group for group 2 and v.v.
Theory Wim Verstappen
• The number of diagnostic tests ordered by
GP’s is growing although many of these tests
are seen as unnecessary.
• Possible explanations:
– test ordering routines
– more defensive attitude
– lack of knowledge
– patients more actively ask for tests
Intervention
Wim Verstappen
• Multifaceted strategy:
– personal feedback
– guideline dissemination
– quality meetings in small groups of GP’s
• Social interactions were used as an important
motivator for change
• Aim: to achieve sustained improvements in test
ordering working in line with the national,
evidence-based guidelines.
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Conclusion Wim Verstappen
• Strategy using guidelines, feedback, and social
interaction give modest improvements in test
ordering
Effectiveness of
pharmacovigilance training of GP’s
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Practice based GP’s had significantly better documented
report than the lecture trained GP’s
The effect persisted en did not diminish over time
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Gerritsen R. e.a. in Drug safety sep. 2011
Effects of educational interventions on
primary dementia care: a systematic review
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Educational interventions for Primary Care Providers that
require active participation improve detection of dementia
Educational interventions alone do not
Perry, M. In Int. Journal of Geriatric Psychiatry;
jan 2011
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Also: prevention burnout?
Denemarken 379 (83%) GP’s
• 25% burnout
• No member Quality circle: more
risk of burnout
Brondt A. Continuing medical education and burnout
among Danish GPs. Br J Gen Pract 2008
“Burn out? Are you crazy girl! It’s
at the most a heavy depression…”
Central theme in Quality Circles:
Making the interdoctor variation transparant
– Where are the differences?
– Why are there differences?
– How should we do it?
– How can we change our everyday habits?
Diffirent types of quality circles
• Educational programs on quality guidelines
• Farmaco therapeutical meeting: meeting between
local GP’s and farmacists about coherent
prescriptioning
• Intervision: intercollegial exchange of experiences
and problems on communication, collaboration and
professionalism
• Groupewise training on skills or special subjects
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Rules for the Quality Circle
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At least 3 GP’ s
One of them = Quality Consultant (QC)
At least 2 x 1 hour/year (mostly average 6-10 hours/year)
Start with a year planning
Report after each meeting
Signed attendance list of each meeting
Controlled and advised by a Regional Accreditation
Contributor (RAC)
Control System in central computer
ABC1
RAC
QC
QC
RAC
QC
QC
QC
RAC
QC
QC
QC
QC
Rules for the Quality Consultant
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Start: 2 days of training on
– Rules of accreditation & task of the QC
– Which subjects do I choose?
– What is the best form of education?
– Group dynamics
– Ways of Implementation
Every 5 years re-registration as a QC
– Enough experience as a QC (8 hours/year)
– Enough education on QC subjects (4 hours/year)
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