Family Practice Advance Access originally published online on June 5, 2008
Family Practice 2008 25(3):139-145; doi:10.1093/fampra/cmn022
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Exploring the black box of change in improving test-ordering routines
a Department of General Practice/Centre for Quality of Care Research (WOK), Care and Public Health Research Institute, Maastricht University, PO Box 616, NL-6200 MD, Maastricht
b Division of Clinical Methods and Public Health, Department of General Practice, Academic Medical Center—University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam
c Department of General Practice, Care and Public Health Research Institute, Maastricht University, PO Box 616, NL-6200 MD, Maastricht, The Netherlands
Correspondence to Marloes A van Bokhoven, Department of General Practice/Centre for Quality of Care Research (WOK), Care and Public Health Research Institute, Maastricht University, PO Box 616, NL-6200 MD, Maastricht, The Netherlands; Email: loes.vanbokhoven{at}hag.unimaas.nl
Received 11 July 2007; Revised 17 March 2008; Accepted 21 April 2008.
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Abstract |
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Background. The effects of quality improvement strategies are sometimes limited in spite of a systematic development approach. What elements play a role in the change process is not yet fully understood.
Objective. To explore this ‘black box’ of change, by analysing the barriers and facilitators GPs perceive during the change process.
Methods. Qualitative study among GPs who participated in the quality improvement strategy arm of a randomized clinical trial on blood test ordering for unexplained complaints (UCs). The strategy was based on a national guideline that advocates delayed test ordering in patients presenting with UCs. Each GP's change process was assessed by means of a semi-structured interview about barriers to and facilitators of change.
Results. Twenty-four interviews were analysed. Important themes identified in the interviews were lack of problem awareness, the time and effort it takes to change, influence of patients and the pros and cons of the changed behaviour.
Conclusion. The themes can be summarized into one comprehensive issue: the GPs lack a sense of urgency to change. An important explanation seems to be that two questions from the problem analysis prior to the development of the strategy had not been adequately answered: "Is the GPs' current behaviour a problem and does the problem have consequences for patients?" and if so, "What is the extent of the problem?." As a result, insufficient attention was given to applicability issues, such as time investment, costs and patient and practitioner satisfaction and anxiety.
Keywords. Family practice, health care, health services research, laboratory techniques and procedures, needs assessment, quality assurance.
van Bokhoven MA, Koch H, Dinant G-J, Bindels PJE, Grol RPTM and van der Weijden T. Exploring the black box of change in improving test-ordering routines. Family Practice 2008; 25: 139–145.