Of the 215 practices on the waiting list for a VIP assessment, 49 (23%) agreed to participate in the present study. After matching according to practice size, 26 practices were allocated to the intervention condition (six single-handed and 20 larger practices) and 23 practices were allocated to the control condition (six single-handed and 17 larger practices). Although all intervention practices completed the intervention, a total of two intervention practices (one due to illness and one due to a reported lack of interest on the part of the team members) and two control practices (one due to moving the practice and one due to lack of time) did not complete all the questionnaires, which meant that we completed post-test measurements of 24 intervention and 21 control practices. All interventions took place between December 2001 and February 2004.
Number and quality of improvement projects undertaken
In the year before the intervention period, the practices in the control group undertook an average of 2.4 improvement projects and the practices in the intervention group undertook an average of 1.5 projects. The practices in the control group also met their self-defined objectives more often at pre-test than the practices in the intervention group (). After correction for these initial differences, the practices in the intervention group can be seen to initiate significantly more improvement projects during the intervention period than the practices in the control group with means per practice of 3.9 and 2.6, respectively. All of the steps needed for effective quality improvement were performed for a significantly larger percentage of the projects undertaken by the intervention group than by the control group with the exception of the identification of barriers (). The practices in the intervention group met the self-defined objectives for 80% of their projects; the practices in the control group did this for 69% of their projects.
Overview of projects following different steps for improved management of primary care services (percentage of initiated projects).
Changes in dimensions of practice management
In sum, the intervention practices improved on 15 dimensions of practice management and declined on four dimensions. The control practices improved on 11 dimensions and declined on nine dimensions.
In both the intervention and control groups, the practices frequently selected accessibility and availability of practice services, which includes access by phone and organisation of the appointment system, as a topic for improvement: this was done on 30 occasions by the intervention practices and on 17 occasions by the control practices during the intervention period. The patients of the intervention practices reported being as satisfied with the accessibility and availability of the practice at post-test as at pre-test, as well as the patients of the control practices (). Also the time before the practice picks up the phone remained unchanged in both research groups.
Other favourite topics selected for improvement were ‘medical care’ topics, such as the chronic disease management and preventive care (17 and 11 times by the intervention and control groups, respectively, during the intervention period). Given that the delivery of chronic disease management is a relatively new development, there was no separate measurement of this specific aspect of the management of primary care services available for analysis. Nevertheless, the supply of preventive care was found to be about the same for the intervention and control groups at pre-test and to also increase more or less equally for the two groups at post-test. The delegation of health promotion tasks, including diabetes care, increased from 39 to 46% for the intervention group and stayed the same (38 and 39%) in the control group.
Topics related to ‘infrastructure’ were chosen 13 times in the intervention group and nine times in the control group. Of the VIP dimensions that more or less covered these topics, the ‘hygiene and facilities in the treatment room’ improved slightly from 55 to 63% for the intervention group and stayed the same in the control group (60 and 58%, respectively).
Regular meetings with the practice team was selected as a topic for improvement by several of the practices (eight and five times by the intervention and control groups, respectively). The GP meeting time with practice assistants did not change in the intervention group but decreased by some 16 minutes in the control group. Similarly, the weekly meeting time with colleagues in the intervention group remained about the same (42 minutes at pre-test and 46 minutes at post-test) as well as in the control group (38 and 35 minutes, respectively).
A total of seven practices in the intervention group and three practices in the control group selected improved medical registration (that is, computer registration) as a topic for improvement. In the intervention group, this dimension of practice management was found to shift from 56 to 67% while no change was observed in the control group. Although improved communication with hospitals and pharmacies was not selected as an actual topic for improvement by any of the practices examined in our study, both the intervention and control practices showed improved electronic communication with hospitals and pharmacies during the intervention period.
None of the preceding differences between the intervention and control groups after control for the pre-test values were found to be statistically significant ().