Supporting family physicians in British Columbia: The experience of the Practice Support Program

In order to better understand the decline in family practice, and to develop strategies to reverse this trend, the General Practice Services Committee (GPSC) held consultations in 2004 and 2005 called Professional Quality Improvement Days with about 1000 general practitioners. 

At that time general practitioners in BC were leaving full-service family practice or were limiting the services they provided. The consultations indicated that the exodus could be stopped if general practitioners felt valued, were paid appropriately for their work, and had adequate ongoing training and support to provide good care for the increasingly complex patient population that is typical in the province.

In response to the Professional Quality Improvement Days consultations, the committee established the Practice Support Program (PSP). This program was designed to address the training and support components of physicians’ needs identified through the consultations. 

The program was developed with expert groups of family physicians reviewing draft learning modules; these physicians had experience with the specific practice redesign change components of each module. Regional workshops were held in the spring of 2007 introducing the program and inviting physicians to engage with their health authorities. F

unding for the progam was provided through the noncompensation change management support allocation to the General Practice Services Committee.

Practice enhancement learning modules
The Practice Support Program offers practice enhancement learning modules and support in three areas: clinical improvement, practice management, and information technology. Continuous learning and improvement are supported by regional teams and peers. 

The aim is to have physicians assess their practices and determine ways to shift their practice design to become more efficient, improve access to care, achieve better patient health outcomes, improve the patients’ experience of their care, and improve provider satisfaction in a full-service family practice setting. 

The Practice Support Program is administered provincially and delivered regionally. The five provincial health authorities each have support teams in place to assist, mentor, and coach general practitioners and their medical office staff through practice redesign changes. 

The health authority teams comprise approximately 250 individuals across BC. Each team consists of GP Champions, Medical Office Assistant (MOA) Champions, a variety of other clinical peer leaders, quality improvement/change management coordinators, and data support resources. 

The teams provide the expertise for clinical practice and information management technology transformations to physician offices; they also engage with family physicians and other health professionals to introduce and embed evidence-based changes into routine clinical practice. 

The Practice Support Program, working with Impact BC, developed four initial learning modules that were made available to general practitioners and their medical office assistants beginning in April 2007. These learning modules consist of a series of in-person, peer-group learning sessions, alternating with in-practice “action periods” between the learning sessions. 

Thus, a learning module may have three learning sessions and two in-practice action periods (one between the first and second learning session and one between the second and third learning session). The four initial learning modules were Advanced Access, Chronic Disease Management (CDM), Group Medical Visits, and Patient Self-Management.

As part of the evaluation of these learning modules, 215 general practitioners and 161 medical office assistants, representing response rates of 26% and 21% respectively, completed surveys after the last learning session of Advanced Access, CDM, Patient Self-Management, Group Medical Visits, or a combined module for Patient Self-Management/Group Medical Visits. 

The physicians and medical office assistants were asked several questions regarding their satisfaction with the learning module and their perception of the module’s impact on physicians and patients. In addition, 21 physicians who had not completed learning modules answered questions regarding why they had not completed the modules.

The evaluation of these initiatives (up to December 2008) indicates that the learning modules help general practitioners improve both the efficiency and effectiveness of their practices. These results are consistent across types of practice, time period, geographic area, and type of learning module. For the interested reader, a full report of the end-of-module survey evaluation and other information about the Practice Support Program can be accessed at practicesupport.bc.ca. 

Information about the General Practice Services Committee and Impact BC can be accessed at primaryhealthcarebc.ca/ phc/gpsc_initiatives.html or bcma.org/ popular-topics/gpsc-overview and impact
bc.ca.

Advanced Access Learning Module
Table 1 presents findings related to the impact of the Advanced Access Learning Module on average wait times. Wait times were significantly shorter after completion of the module than they were before the module. For example, for physicians who were able to reduce wait times, the wait time for the third next available appointment went from 5.5 days before attending the learning module to 1.4 days after attending the learning module. 

Overall, 49% of physicians were able to reduce wait times for urgent appointments. The comparable percentages for regular appointments and third next available appointments were 74% and 73%, respectively. Finally, 64% of physicians indicated that they had been able to reduce their patient backlog, 61% stated that they were able to start and end their day on time, and 15% were able to take more time off.

Chronic Disease Management Learning Module
Table 2 presents the percentage of physicians who agreed with each statement in a survey completed after they finished the Chronic Disease Management Learning Module. The survey used a five-point scale that ranged from Agree Strongly to Disagree Strongly. For simplicity’s sake, the Agree and Agree Strongly categories were combined as were the Disagree and Disagree Strongly categories in the presentation of results here.

Patient Self-Management and Group Medical Visits modules
Physicians who completed the Patient Self-Management Learning Module were asked what impact patient self-management had on both their patients and themselves. Those who completed the Group Medical Visits Learning Module were asked similar questions regarding group visits. 

Phy­sicians who completed the combined Patient Self-Management/Group Med­i­cal Visits Module were asked the module-specific questions from both the Patient Self-Management and the Group Medical Visits modules. Table 3 presents findings regarding Pa­tient Self-Management, while Table 4 presents findings regarding Group Medical Visits. 

Impressions and impacts
As part of the survey, general practitioners and medical office assistants were also asked about their overall impressions of the learning modules, satisfaction with the learning sessions and action periods, and the perceived impacts of the learning modules. Table 5 provides data on the respondents’ overall impressions and perceived impacts of the learning modules. 

Over 85% agreed with each of the four statements about the learning sessions. Many respondents also stated that the learning modules had positive impacts on a number of key dimensions of practice. 

With regard to the learning sessions themselves, over 80% of respondents agreed with the statements that “The content was informative” and “The networking was helpful.” Possible improvements were also identified. For example, about one-third of general practitioners and medical office assistants agreed with the statements that “The pacing of the sessions was too slow” and that they “already knew much of the material.” 

With regard to the action periods, over 80% of general practitioners and medical office assistants agreed that “The required activities could be completed in the allocated time,” “The activities to be performed were clearly understood,” and “The Practice Support Team and GP Champions were available when needed.”

Of the 21 physicians who did not complete a learning module, half indicated that the Practice Support Program approach to providing learning sessions and action periods was effective. Respondents indicated that they had not completed the learning module because they had already incorporated much of the material into their practice (48%), they felt that the pacing was too slow (33%), they did not have the time to continue with the learning module (33%), the learning sessions took place at a time that was not convenient (29%), and/or they were already familiar with the material (24%).

New modules to come
Based on the above data, the Practice Support Program learning modules appear to have been successful at increasing both the efficiency and effectiveness of physician practices. 

In addition, anecdotal information indicates that the combination of Practice Support Program learning modules and the development by the General Practice Services Committee of incentive payments to allow physicians to spend more time with their patients are having a positive impact on family practice and encouraging at least some physicians who were considering retirement to remain in practice. 

Based on the success of the initial four learning modules, the Practice Support Program will introduce learning modules for other important areas of practice, such as diagnosing and assisting mental health patients. At a recent conference on office practice redesign sponsored by the Institute for Healthcare Improvement, international observers noted that British Columbia is at the forefront of assisting family physicians through the Practice Support Program’s learning modules and approach to practice support.

Competing interests
Dr MacCarthy and Ms Kallstrom are em­ployed by the British Columbia Medical Association. Drs Miller and Hollander were paid by the Ministry of Health to conduct an evaluation for the GPSC. The evaluation was independent and not influenced by the GPSC.

Dr MacCarthy is director of Professional Relations at the British Columbia Medical Association. Ms Kallstrom is lead of Change Management and Practice Support at the British Columbia Medical Association. Ms Gray is lead of Change Management and Practice Support at the BC Ministry of Health Services. Dr Miller is the vice-president, research and evaluation at Hollander Analytical Services Ltd. Dr Hollander is the president of Hollander Analytical Services Ltd.