Interview analysis
The characteristics of interview participants at the PHN and practice levels are shown in Table 3. There were a range of stakeholders interviewed within various roles and levels of the organisations, with a good distribution of participants in practices are varying size and with prior QI experience. The interviews yielded rich insights into understanding the quantitative findings. Multiple barriers to implementation across all four NPT domains were described and summarised below.
Table 3
Interviewee characteristics from the Primary Health Networks (PHNs) and from general practices
Interview participants from PHNs (n = 7)
|
Female
|
4
|
Project Officer
|
2
|
Team Manager
|
2
|
Executive Officer
|
1
|
IT Support Officer
|
2
|
Interview participants from general practices (n = 12)
|
Female
|
9
|
Practice nurse
|
1
|
Practice manager
|
1
|
General Practitioner
|
10
|
Practice size
(number of regular patients)
|
|
< 2000
|
1
|
2001–4000
|
1
|
4001–6000
|
3
|
6001–8000
|
3
|
8001–10000
|
2
|
10001–20000
|
1
|
>20001
|
1
|
Previous QI experience
|
6
|
No previous QI experience
|
6
|
Coherence (the meaning ascribed individually and collectively to a new set of practices)
Collectively, GPs and PHN staff saw the potential value of the intervention as very high, for example: “There are a whole lot of people at risk, and they could have better outcomes….” (GP6). Access to the education modules and the two QI tools were seen as useful in identifying and providing preventive care guidelines to high-risk patients. Only one participant mentioned that internal leadership (‘Change Champion’) or practice support (‘QI Culture’) was needed to facilitate engagement with the intervention.
Cognitive participation (commitment to engage with the new)
Interviewees from both PHNs and practices noted that the timing of this project (coinciding with major PHN governance and strategy change) prohibited prioritisation of support for the intervention by PHN Staff.
Most interviewees reported they had not fully appreciated what participation in a QI project would require of them prior to the intervention, “…when I took it on I didn’t realise there was more to it, so I didn’t really understand...”. (GP1). For PHN participants this was illustrated at the highest executive level where management under-estimated the readiness/ability of practices to be enrolled in this project, along with the need for the PHN to supply adequate resourcing to support both their staff and the participant practices. “With 40 practices enrolled, the workload sometimes got overwhelming despite team members help(ing) me with 6 of the practices”. (PHN3) This lack of strategic planning and resourcing was amplified by the change in focus of PHN staff and a merger of three earlier meso-tier organisations into a single PHN. This affected directly on the PHN’s ability and commitment to supply practice level support during the intervention period.
GP engagement with the PDSA process was also extremely low. While the PDSAs were understood by most GPs as an essential part of the QI process, they were seen as time-consuming, and “…. formulaic…. uninteresting…” (GP1) and “...to be honest, no, I haven’t done one since we started.” (GP9) with only a few seeing value in this aspect of the project. “It is a problem to stay on track and keep getting things done… I had a million good intentions, and then it gets …too hard”. (P4)
Collective action (how the work does/not get done)
Participants reported a lack of both ‘QI culture’ and change champions to support engagement with QPulse. Although there was universal agreement that ‘key individuals were needed to drive the intervention forward’, this did not mean that these individuals were found, nor engaged to help with the project. “…it comes down to the culture within the practice, who is the real leader…the driver in the practice. It could be a nurse or the doctor…. but crucially you really need to have somebody who is going to take the reins, or it doesn’t happen….” (PHN5). It was clear many participants were unable to actively champion or drive the project forward due to not taking on a leadership role within their practice setting. Differing practice systems often meant each GP within the practice worked as an individual rather than part of a cohesive system of care. “It’s quite individual. That’s the way the practice is set up…. your quality control is up to you…. As long as it doesn’t add any extra work…. because no-one obviously is interested if it’s extra work.” (GP2)
Communication systems between GPs, nurses and PMs were cited as a barrier to engagement. Often there was no regular practice ‘team’ meetings or systems in place to report back about QI measures and limited ability to organise tailored educational activities. Jobs were delegated to non-medical staff (e.g. the PM or nurse) who may/not have the skills or motivation to drive the project forward due to a lack of personal engagement with the goals of the project. At one practice, a manager commented that she only became involved because: (the GP) “…didn’t want to do it, so she handed it to me… I actually didn’t know much about it.” (GP12). In addition, GP attendance at the educational sessions was sub-optimal and inconsistent, with many GPs delegating this to the PM or nurse. The scheduled monthly networking/seminar meetings were cancelled due to lack of attendance, despite most participants opting to join at the beginning of the project.
There was commentary that the QI project and data reports did not address key issues around improving engagement with patients: “It’s one thing to get the GPs to change what they do, it’s an entirely different thing to get patients to take in on board.” (GP 6) Several GPs also discussed the problem with many competing projects and lack of time: “I think the difficulty is there’s a plan for one quality of project and then another idea comes up and then the same people are looking at implementing it, or we give the nurses something else to do, and it sort of falls off the radar.” (GP6)
Pparticipants reported barriers to setting up a sustainable QI processes. This was highlighted by commentary about the difficulty of scheduling data extractions and generation of reports, low attendance at QI educational activities, no engagement with PDSA process, no evidence of sustained use of the IT tools. Several attributed this to both lack of dedicated time to do QI work and lack of any tangible incentives (financial or professional development). Many reported that GPs were not keen to engage with an activity that was not aligned with financial incentives and cited such incentives as a mechanism to achieve long-term engagement rather than as the first reason for engagement. However, engagement with individual “contracted” GPs was reported as requiring a financial incentive to engage them with doing any of the extra work involved in QI activities. “…from a practice perspective, it’s not going to be a priority. So really, the PHN needs to take on a lot of that responsibility on behalf of the practice if we’re going to get it up and running”. (PHN1)
Minor IT issues were also identified as barriers, although it was well understood by participants that IT support was readily available if asked: “I used it for a couple of weeks and found it was really useful... (when a minor IT issue arose to render the tool inactive) …it just kind of died off, my use of it.” (GP7) Finally, it was noted that the intervention did not adequately accommodate the roles of individual GPs (and patients) in achieving key outcomes (such as BP, lipids levels) and medication prescriptions. “It was all a bit clunky…I never saw the Manager’s data reports…and although I tried with Q Pulse, …if a doctor is not interested, they won’t do it ...that’s often the way around here and I just couldn’t engage them with recording the CVD measures.” (GP2)
PHN staff reported a lack of resourcing to provide individualised GP practice reports, education or face-to-face support despite observing that most practices needed significantly more support than anticipated to complete the basic requirements of the program (such as monthly data extractions, PDSAs, tidying up eMR systems). “Until you start giving monthly reports and with targeted topics and actually educating the GPs about what to do with that data, you’re just extracting data”. (PHN1)
Reflexive monitoring (the processes through which practitioners decide whether new approaches are beneficial and lends, ultimately, to the normalisation of new practices)
Normalisation of systematised QI practices was not apparent, even among the most experienced and engaged practices. This was despite many participants reporting enthusiasm for ongoing participation in QI work.. “So, we've talked about it, but we've never implemented it systematically…. most doctors are not taught these things, that's the whole problem, so we've got to re-educate the doctors, our universities haven't got it in the curriculum.” (GP7)
Even in solo practices, GPs experienced challenges with translating the project QI goals into long-term changes systematic CVD preventive care. The project learnings were discussed as a one-off piece of work rather than something to embed into everyday routine practice. “It’s the follow through which can be difficult because you will forget. I don't know that this is common to everyone, but ...if somebody is not ...pestering you and reminding you... - I've actually forgotten how to do it - it falls off the wagon.” (GP3)
The challenges associated with achieving collective action for both general practices and the PHN meant participants found it difficult to move beyond ‘new’ and toward ‘normal’. Interviewees reported a ‘project-based’ approach to QI interventions with ‘topical’ engagement and difficulty setting up systematised adoption of change due to the considerable number of competing projects.
Some GPs reported adopting new ways of approaching CVD preventive care, such as utilising CVD absolute risk assessment tools or using audit data extraction tools to identify gaps in data measures such as smoking status, BMI or waist circumference, “every single patient I see I just flick onto the summary screen of HealthTracker and just see whether the percentage is something I need to worry about, and if it’s not, then I don’t pursue it.” (GP4) However, few mentioned systematic use of the tools for the whole team. Even the most engaged general practice participants noted a difficulty in systematising QI in the day-to-day running of business. “I think (the workplace of) general practice is a barrier, it’s an unpredictable, busy, chaotic job and so things happen that get in the way. And I think the other barrier is that protected time, to set up systems is an enabler and not being in place is a barrier”. (GP6)