Almost half of the Danish general practitioners have negative a priori attitudes towards a mandatory accreditation programme

As a part of the agreement between the Organisation of General Practitioners in Denmark and the Danish Regions [1], all general practices are completing an accreditation programme beginning in 2016. The programme is in accordance with the Danish Healthcare Quality Programme (DHQP), which is a national programme of accreditation managed by the Danish Institute for Quality and Accreditation in Healthcare [2].

Accreditation is a widely used tool for quality management in healthcare systems worldwide, and many resources have been used to develop and implement accreditation schemes [3]. In order to be accredited, the healthcare organisation needs to meet predetermined criteria and standards established by a professional accreditation agency [4, 5]. Accreditation in primary care was first established in Australia more than two decades ago [6]. Since then, a number of countries have developed accreditation standards for primary care [4]. In general, research on the nature and uptake of accreditation in primary care is sparse. Moreover, there is only little knowledge about how accreditation affects outcomes of care, healthcare utilisation and costs [6].

In addition to being seen as a tool for quality improvement, clinicians may also perceive accreditation as an external, bureaucratic control instrument [4, 7]. Some health professionals have expressed concerns about the utilisation of resources for accreditation purposes [3, 4]. Health professionals’ attitudes towards accreditation is assumed to be is a key factor in achieving an effective implementation as their understanding of accreditation affects their engagement in the accreditation process [8]. However, we have not identified
studies that have explored GPs’ a priori attitudes and expectations towards accreditation [4, 7, 9, 10].

Hence, the aim of this study was to analyse Danish GPs’ a priori attitudes and expectations towards a national accreditation scheme.

Many Danish general practitioners have negative a priori attitudes towards accreditation.

METHODS

Setting

General practice in Denmark is publicly funded and all patients are listed with a GP to whom they have free and unlimited access. The GPs act as gatekeepers to the rest of the healthcare system. GPs are self-employed and work under a mixed capitation and fee-for-service system [11].

The accreditation scheme

The accreditation standards were developed by the Danish Institute for Quality and Accreditation in Healthcare in collaboration with representatives from the Organisation of General Practitioners in Denmark, the Danish College of General Practitioners, Danish Regions, Danish Patients and the Danish Association of Practicing Medical Specialists. A preliminary version of the set of standards was pilot-tested in 26 practices in 2012 [12]. Subsequently, the set of standards was further adjusted and the current version was approved by the Danish Regions and the Organisation of General Practitioners in 2014.

The Danish Healthcare Quality Programme (DHQP) comprises 16 standards for general practice. The standards represent four themes: Quality and patient safety, Critical patient management, Good continuity of care, and Management and organisation of the clinic [1]. Participation in the accreditation scheme is mandatory for all practices. However, practices that are expected to close within five years may ask to be exempted. Practices are notified one year before the scheduled accreditation of their practice. All general practices have been randomly allocated to accreditation within the time period from January 2016 to December 2018. By the end of 2018, all practices are expected to have undergone accreditation.

Data collection

All 3,403 Danish general practitioners (GPs) working under the national public reimbursement system in December 2014 were invited by e-mail to participate in an electronically administered survey. The Danish Medical Association provided e-mail addresses together with data on age, gender, region and practice type for all GPs. Questionnaires were e-mailed to the GPs on 22 January 2015. Two reminders were sent two and four weeks later, respectively. Data collection was terminated on 23 March 2015.

Questionnaire development

The questionnaire was developed by healthcare researchers within the Research Units of General Practice in Odense, Aarhus and Copenhagen. The development was stepwise. First, the themes to be covered were agreed upon by drawing on existing literature [3-7, 13, 14] and the researchers’ experience. Second, the specific items were developed, and each item was discussed within the research group until consensus was reached. A total of 13 items were included and divided into the following themes: a) attitudes towards various aspects of accreditation, b) present organisation of specific tasks in the practice, c) job satisfaction, and d) general practice organisation. A text field (with unlimited space) for comments was inserted after all items.

Third, a pilot test focusing on content validity,
relevance, acceptability and feasibility was conducted among nine GPs from four of the five regions in Denmark. In general, the questionnaire was perceived as comprehensive, relevant, acceptable and easy to complete. A few participants noted that they found it difficult to assess the expected time consumption of the accreditation process. However, no changes were made to the pilot test questionnaire.

Statistical analysis

Using univariate analyses, we compared the potential confounders – gender, age, region and practice type – between respondents and non-respondents by means of the chi-squared test. Response rates stratified by allocated year of accreditation were also compared by means of the chi-squared test.

In the explanatory analyses, we defined GPs attitudes towards various issues and accreditation elements as:

Positive if the GPs had stated they were very positive or positive, neutral if the GPs had stated they were neutral or did not know and negative if the GPs had
stated they were very negative or negative.

The association between a negative attitude and selected outcomes was analysed in a multiple logistic regression analysis adjusting for gender, age, region and practice type. An example of the construction of the variables in this analysis is presented below:

“Accreditation is a tool for quality improvement in general practice?” The response agree includes the responses agree a lot and agree, neutral includes the responses neutral and do not know and disagree includes the responses disagree a lot and disagree. The full list of definitions is available in an online appendix [15].

A p-value < 0.05 was considered statistically significant. All statistical analyses were performed with SAS version 9.4 (SAS Institute, Cary, NC, USA).

Trial registration: The survey was recommended by the Danish Multipractice Committee (MPU 02-2015) and evaluated by the Danish Data Agency (2015-41-3684).

RESULTS

Out of 3,403 survey invitations sent, a total of 1,906 respondents (56%) completed the questionnaire. The respondents did not differ from non-respondents regarding age, gender, region and practice type (Table 1). Respondents with planned accreditation in 2016 had a higher response rate than practices that will be accredited in 2017 and 2018 (59% versus 55% and 54%, p = 0.04).

A total of 861 GPs (45%) were negative towards future mandatory nationwide accreditation, whereas 23% were positive. Older GPs, male GPs and GPs working in singlehanded practices were more likely to be negative towards accreditation (Table 2). As for regional differences, 54% of the respondents in the Region of Northern Denmark had negative attitudes compared with 43-46% in the other Regions (Table 2). Importantly, no difference in attitudes towards accreditation was detected related to year of accreditation.

A large majority (83%) regarded accreditation as a tool for external control. 27% (517) stated that accreditation was only an external control tool and not a tool for quality improvement, while 32% (611) perceived that accreditation was a tool for both external control and quality improvement. Only 3% (50) stated that they regarded accreditation as a tool for quality improvement but not as a tool for external control (Table 3).

In the logistic regression analysis, a negative attitude towards accreditation was associated with a lower probability of perceiving accreditation as a tool for quality improvement (odds ratio (OR) = 0.018 (95% confidence interval (CI): 0.013-0.025)), a higher probability of perceiving accreditation as a tool for external control (OR = 1.87 (95% CI: 1.18-2.95)), a higher probability for stating that time consumption of the accreditation process is not acceptable (OR = 24.40 (95% CI: 13.55-43.94)), a higher probability of expecting accreditation to affect job enthusiasm negatively (OR = 21.88 (95% CI: 16.10-29.72)), a higher probability of stating that there rarely is sufficient time to perform tasks as a GP (OR = 1.58 (95% CI: 1.25-1.99)), and a higher probability of being less satisfied with present job situation (OR = 2.51 (95% CI: 1.85-3.41)) (Table 4).

DISCUSSION

This is the first study to examine GPs’ a priori attitudes and expectations towards a future mandatory accreditation programme. Almost half of the Danish GPs had negative a priori attitudes towards the nationwide mandatory accreditation programme. The negative attitudes were more prominent among older GPs, among male GPs, and among GPs working in single-handed practices. Furthermore, a negative attitude was associated with perceiving accreditation as a tool for external control, believing that the accreditation process would affect job satisfaction negatively and being less satisfied with present job situation in general.

Weaknesses and strengths of the study

A total of 56% of all GPs in Denmark responded. Apart from some differences between respondents and non-respondents in relation to the allocated year of accreditation, we did not find any differences between respondents and non-respondents. The knowledge that a nationwide mandatory accreditation scheme would be implemented in Denmark from 2016-2018 may have led the most opposing GPs to complete our questionnaire. Hence, our study may possibly overestimate the negative attitudes and expectations towards accreditation. On the other hand, the most critical GPs might have refrained from participating in a survey regarding the impending accreditation process, which in turn would result in an underestimation of the negative attitudes and expectations.

The questionnaire was developed among healthcare researchers based on the literature and subsequently pilot tested. The GPs participating in the pilot test generally found that the questionnaire was relevant and easy to fill out. Therefore, we believe that the results of this survey represent the a priori attitudes and expectations towards the accreditation scheme among GPs in Denmark.

Interpretation of the results

Professionals’ understandings of accreditation can be expected to affect how they engage in implementation [8]. In this study, many GPs had negative attitudes towards accreditation and perceived accreditation to be a control tool. Adding the fact that the DHQP programme is mandatory, such perceptions may decrease the intrinsic motivation of GPs to engage with the DHQP programme for purposes of quality improvement, and lead to various forms of resistance among GPs. Here, our results underscore the need to acknowledge a tension between accreditation perceived as an external control mechanism and accreditation perceived as a mechanism for continuous quality improvement [4]. This perception of accreditation as a control tool may have been augmented in the Danish context where the Organisation of General Practitioners recently had a significant political conflict with the Danish Regions related to issues of public control and GP’s autonomy.

Moreover, primary care providers have previously reported a lack of resources, i.e. time and support, when undergoing accreditation [6]. This is also seen to be a concern among GPs in the present survey and is highly correlated with negative attitudes towards accreditation (OR = 24.40). Concerns that the resources occupied by accreditation could be more effectively applied may explain why some of the respondents expected the DHQP programme to actually decrease the quality of care in general practice. However, to understand the specific reasoning of GPs on such issues, other research methods should be applied [14, 16].

It is interesting that 60% of the respondents expected that working with accreditation would affect their job enthusiasm negatively. Furthermore, older GPs, male GPs, and GPs in singlehanded practices were generally more negative towards working with the DHQP programme. If this affects GPs’ decision on when to withdraw/retire from general practice, this may represent a problem due to the shortage of GPs as well as the high proportion of GPs above the age of 60 years in Denmark. However, in the agreement between the Organisation of General Practitioners and the Danish Regions, an exemption from the DHQP accreditation programme is offered to older GPs who expect to close their practices within five years.

Our study showed regional differences in attitudes towards accreditation with GPs from the Northern Region of Denmark being more skeptical towards the DHQP programme than the rest of Denmark (OR = 1.46 (95% CI: 1.02-2.09)). This may reflect the effects of an expected increased workload on GPs working in areas with a significant lack of GPs.

Our cross sectional national survey among all GPs in Denmark was conducted approximately one year before the DHQP accreditation started. The study provides knowledge on the current attitudes and expectations among GPs, but longitudinal follow-up is needed and planned in order to survey how these attitudes affect the implementation and outcomes of the accreditation scheme.

CONCLUSION

A substantial proportion of Danish GPs had negative a priori attitudes towards a nationwide mandatory accreditation scheme. Future research should investigate how these attitudes affect the implementation and outcomes of accreditation.

Correspondence: Frans Boch Waldorff. E-mail: fwaldorff@health.sdu.dk

Accepted: 3 June 2016

Conflicts of interest:Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk

Acknowledgements: We thank the general practitioners who volunteered to take part in this study.