Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Maria Milano, Giampaolo Collecchia, Lino Gambarelli,Paolo Longoni, Massimo Tombesi, Antonio Nicolucci

CSeRMEG, Istituto Mario Negri

The TUCORI study part II: is a mailing list a suitable tool for peer review about organization and management of GP’s

practice?

HOW DID YOU DO IT ?

There is no conflict of interest

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Nowadays many different organizational settings are possible in Italy and not much is known about the adopted procedures

Background

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

“If there are no objectives there is nothing to evaluate”

W.W.Holland, NIS, 1985

What could we learn from each other?

Could we build goals together?

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

is to share GPs’

experience about practicability, efficiency and effectiveness of different solutions adopted in their organizational

setting of practice

Objective

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

MethodsThrough a closed mailing list by Internet

1st step: Hanlon method -> selection of the most critical priorities in the organization and management of the GP’s practice

2nd step: simplified Delphi method -> sharing adopted solutions for each critical priorities

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Criteria of selection

Only GPs, max 40, with special interest in organization and management and with ability in Internet use

The protocol in 2 closed mailing list of researchers and trainers most of all GPs (about 800 people): 240 of them answered

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

• Bartoli Marco, Marina di Massa (MS)

• Bini Isabella, Ala (TN)

• Bondielli Giuliana, Massa

• Calcini Filippo, Santa Croce sull'Arno (PT)

• Capelletti Danilo, Cremona

• De Luigi Gianni, Moncalieri (TO)

• Del Carlo Alessandro, Viareggio (MS)

• Della Vedova Roberto, Gradisca d‘Isonzo (GO)

• Donato Giuseppe, Cerveteri (Roma)

• Filippi Severino, Pontremoli (MS)

• Giovannoni Stefano, Prato (PO)

Participating Investigators:

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Participating Investigators:

•

Maggioni Alessandra, Ala (TN)

•

Malavasi Paolo, Carpi (MO)

•

Mantovani Licia, Soliera (MO)

•

Marchetto Marco, Collegno (TO)

•

Marino Rosanna, Venaria (TO)

•

Mascaro Sonia, Greve in Chianti (FI)

•

Maurri Sandro, Firenze

•

Messina Emanuele, Firenze

•

Mola Ernesto, Lecce

•

Montanari Ugo, Fiumicino (Roma)

•

Mori Maria Grazia, Regello (FI)

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Participating Investigators:

•

Musso Marina, Mathi (TO)

•

Pastacaldi Guido, Agliana (PT)

•

Perlot Maria Pia, Trento

•

Piazza Gianpietro, Schio

(VI)

•

Polenzani Loretta, Prato

•

Ranzani Luca, La Loggia (TO)

•

Sabbi Diego, Arquata Scrivia (AL)

•

Sarotto Maurizio, Fossano (CN)

•

Suzzi Fabio, Imola (BO)

•

Zoli Romeo, Scandicci (FI)

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Results11 26

Have a secretary 85,7%Have a nurse 34,3%

Give the cell n. to patients

77%

Work in more than 1 practice 40%Solo practice 5,7% Patients files in computer database 77.1%

37

GPs:

52 61 years42

age: 88,5 % (47-56)

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Results 1st step

35

GPs

64

priorities

organized in 31 topics

5 Main domains

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Main DomainsLocal Health

District difficulties Personal GP’s

development

Professional communication

Practice structure

managementPractice clinical

processes

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

The 2nd step studySimplified Delphi method:

every participant fills in an open questionnaire

the moderator weekly

thread with his own experience

efficacy (score 0,5-1,5)

effectiveness through the PEARL factors (score 0 or 1) for propriety, economic feasibility, acceptability, resource availability, legality)

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

The open questionnaire

How does it work in your practice?

And for how long ?

Why have you adopted this method?

Is there anything you do not like? What would

you change?

What prevents you from changing it?

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Results

799 mails from 18/01/06 to 01/05/07

only 2 drop - outs in all this time

22% (8/37) declared they changed and improved

something during this experience

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Interests

Everybody can express oneself completely

Everybody can take enough time when one wants

Everybody feels free from leader’s influence

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Drawbacks

Very exhausting job for the coordinator

Tiring for everyone because lasted so long

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Conclusions

A virtual professional community succeeded in meeting for 1

year and a half sharing reflections about organization and

management of GP’s practice

22% of them improve something in their own organizational

setting during this experience

… a qualitative sociologic analysis is running now on the 432

questionnaires

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

milanomar@gmail.com

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Practice clinical processes

• Management of the urgencies • Chronic diseases management • Patients records visited at home• Multi-therapies management• Prevention to patients at risk• The

use of the computer

• Sharing guidelines in the team• Audit

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Practice structure management

• Management of the access to the practice • Management of more practices• Secretary duties • Administrative

management

• Nurse duties • Intrusiveness and utility of the telephone • The pressure of the impatient patients

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Professional communication

• Problems of communication in the team

• Rules, dynamics and objectives

• Choice of the partners

• Relationships with other operators of the area

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Personal GP’s development

• Professional and economic de-motivation• Professional Solitude•

Management of the extra clinical working time for research, review of the patient’s records and to study

•The pleasure to work without exhausting

performances

• Insufficient time for ones own general cultural• Management fatigue: does free time exist?

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

Local Health District difficulties

• Excessive paperwork • Management of certification for sick leave•

Drugs covered by the NHS only for some conditions

•

How to deal with Disease-mini-clinic appointments

•

Local Health District protocols, guidelines, rules

• Legal Problems• Inadequate sanitary programming

Re-Thinking Primary Care in the European ContextA new challenge for General Practice

Wonca Europe Regional Conference, Paris – October 17-20, 2007

The critical priorities

Critical priorities Number of GPs

Score average (range)

Management of the access to the practice

23 9 (4-10)

Secretary duties 16 7 (3-10) Intrusiveness and usefullness of the telephone

14 7 (4-10)

Impatient Patients 13 9 (4-10) Relationship with Specialists 13 8 (3-10) Nurse duties 11 8 (5-9) Management of the urgencies 11 7 (5-9) Local Health District difficulties 11 7 (3-9) Chronic Diseases management 10 8 (5-10) Extra clinic working time management

9 8 (3-10)

Relationship in the team 9 8 (1-10) Sharing of the guidelines in the team 8 7 (3-10)