L'évaluation de la qualité des soins en médecine ambulatoire et tout spécialement en médecine générale est l'un des premiers défis lancé en ce début de 3e millénaire à la médecine moderne. À l'instar de l'industrie une révolution des mentalités est probablement nécessaire pour que la profession adopte et utilise les outils de la qualité des soins.
Cependant, l'amélioration de la qualité des soins en secteur ambulatoire devrait s'inscrire dans une dynamique globale impliquant les paramédicaux, l'hôpital et les institutions.
Dans l'état actuel des connaissances, les concepts « qualité » développés à l'hôpital sont probablement adaptables à la médecine ambulatoire comme la médecine hospitalière a pu adapter les concepts industriels.
De nombreux outils sont à la disposition des professionnels de santé : audit, groupe de pairs, revues médicales, informatique, recommandations, etc. Leur évaluation respective est inégale et il n'est pas possible de désigner une méthode plutôt qu'une autre. Toutefois, certaines ont été mieux étudiées, comme l'audit clinique. En fait, chaque médecin devra trouver les outils qui lui conviennent le mieux et être en mesure de démontrer l'amélioration ou le maintien d'une qualité des soins.
Le choix de critères de mesure de la qualité des soins est un domaine très difficile. Les nombreuses études consacrées à ce sujet ont montré les divergences entre les autorités de tutelle, les professionnels de santé et les patients. Certains points majeurs méritent d'être soulignés, comme la nécessité de choisir des critères basés sur un niveau de preuve et acceptés par les professionnels et les patients. Il est nécessaire de démontrer les raisons du choix des critères pour pouvoir les utiliser.
Face à ces différents challenges, il sera sans doute nécessaire de proposer une méthode de travail nouvelle basée sur la confiance mutuelle des différents protagonistes permettant aux médecins d'auto-évaluer la qualité de leur pratique et d'améliorer la qualité des soins qu'ils dispensent à moindre coût pour la société.
Dans de nombreux domaines les preuves manquent quant à la pertinence ou l'efficacité des méthodes et des critères d'évaluation et d'amélioration de la qualité des soins, en particulier en France. Les pouvoirs publics et les associations professionnelles doivent encourager des études, en France, afin de répondre aux nombreuses questions qui ne sont pas résolues.
A NNEXE I
Table 1. Physician behaviour reported by patients to be decisive for their evaluations (n = 963 utterances from n = 30 patients) Performance
Task performance (I) Information giving
(A) General
(B) Drugs and treatment (C) Examination (D) Illness (II) Questions
(III) Action
- explained well, in plain spoken language, gave (good) advice
- explained about: treatment, intended effect treatment, treatment possibilities, daily living regiments, side-effects of medicines
- discussed: what were examination findings, which examinations had to be done, what the burden of the examination is on the patient
- discussed: cause, duration, severity, when to return, explained symptoms
- asked questions about my complaints thoroughly, asked what was the reason for coming, asked how are you, asked what had happened
- examined me, referred me, ordered for bloodtests, contacted another physician, wrote referral letter, showed me how to do the exercises, showed in picture were my complaints were situated
(IV)Medical-technical competence (A) General
(B) Burden on patient
- examined well, observed well, worked according to certain order: first listening, judgements only after examination, examinations and actions done in proper way, gave good solutions, knew: answers, causes, what to do, what patient could expect, shows no doubts in diagnosing
- no unnecessary pain, no unnecessary treatments, started with light medicines Affective performance
(V) Socio-emotional behaviour (A) Body movements (B) Social conversation (C) Understanding (D) Support (E) Enough time
(F) Friendliness (VI) Partnership building
(A) General (B) Continuity
(C) Participating questions
(VII) Other
- gave hand, tapped shoulder, showed place to sit, looked at patient, made eye contact, smiled, sat down
- introduced herself, said: “sit down”, called me by my first name, spoke to me informally, made remarks in between for example about the doctor’s children, about my clothing, about my children
- listened well, I had the feeling the physician: understood what was my problem, went into my situation, took me seriously, showed interest
- set me at ease, agreed with me, admitted mistakes, was emotionally concerned, said: it will be all-right, you do not have to worry, I can imagine you feel lousy
- gave me enough time, was calm, not rushed, relaxed, gave space, had plenty of time, I could tell my story, let me finish my sentence, did not interfere, listened calmly, observed calmly, asked calmly, sat down calmly, paid attention
- was friendly, pleasant, spontaneous, good-humoured, kind
- patient used “we” as sentence stem in interview or patient reported the doctor used “we” as sentence stem: what we can do about it, we will work on it, consulted together, discussed together
- reports of a longer lasting doctor-patient relation: “he knows I easily panic”, “he knows who I am”,
“I know it makes sense to go to her”, always the same doctor
- asked: what do you think?, do you have an idea what causes it?, can you do something with this?, are you afraid of something?, what treatment do you want?
(A) Do not know, not applicable in this consultation
(B) Does not feel competent to judge, cannot judge, but convinced the GP has the quality: - doctor will know, I take that for granted, has studied for it, I had that feeling, gives me that impression, I confide in my doctor
D’après l’article de Jung, 1998 (65)
A NNEXE II
A NNEXE III
A NNEXE IV
A NNEXE V
A NNEXE VI
A NNEXE VII A
A NNEXE VII B
A NNEXE VIII
A NNEXE IX
A NNEXE X
Overview of the AMAP Office Site Review
The site surveyor will utilize the EOC Office Site Review Criteria with Scoring Guidelines. The AMAP office site review will be scheduled following the processing of the physician’s AMAP application. A time and date will be scheduled that is convenient for the physician and office staff and confirmed in writing. The site review should occur approximately thirty to sixty days after receipt of the physician’s AMAP application. Included with the written confirmation will be instructions on how to prepare for the visit and instructions on how to provide a p hysician-specific medical record sample. The entire office site review will take approximately two hours. It is the physician’s responsibility to inform office staff to cooperate in setting up the site review. Declining the site review or refusing to schedule the site review will result in the physician not meeting the AMAP accreditation standard and in nonaccreditation.
Elements of the Physician Office Site Review 1. Facilities – Environmental Safety
The surveyor will
a) Survey the sterilization, disinfection, and disposal policies and procedures to determine if such policies and procedures ensure protection of staff, patients, and visitors from potentially infectious materials or conditions;
b) Survey medication storage and dispensing procedures for both controlled and non-controlled substances, including sample medication supplies. [Additional elements will include the identification and disposal of expired medications and storage and usage of prescription pads.]; c) Note the existence, placement, and condition of appropriate safety equipment.
[Such equipment includes, but is not limited to, fire extinguishers and exit signs.];
d) Evaluate equipment and personnel available for response to a medical emergency in the office;
and
e) Note regular maintenance procedures, current certificates of inspection, and any necessary license for medical equipment; and assess current certificates reflecting training and/or licenses of personnel authorized to operate the equipment.
2. Facilities – Physical Appearance and Access The surveyor will
a) Observe physical accommodation for the needs of all patients in general and disabled and elderly patients in particular;
b) Assess the ability of the reception area, washrooms, and examination rooms to accommodate the normal volume of patient activity; and
c) Note condition and cleanliness.
3. Office Administration Systems
The surveyor will assess the ability of the practice to accommodate the range of patient needs from health maintenance to emergencies by reviewing hours of office operations, scheduling procedures, after-hours coverage, and telephone triage procedures.
4. Staffing and Staff Performance
The surveyor will check for the presence of current licenses and certification documents and policies regarding lines of authority and responsibility to determine whether physicians and staff have the appropriate training, continuing education, and supervision for their assigned duties.
5. Medical Record Review
A registered nurse will review six contemporary medical records of patients for whom the applying physician is the primary physician. The complete medical record sampling methodology will be included in the AMAP Environment of Care Survey Manual.This review will determine that the medical record supports quality care and quality improvement efforts througt consistent and complete information, proper documentation, and comprehensiveness. Examples of the elements to be
considered are 1) standardization of chart formats; 2) legible, dated, and signed entries; and 3) medical history.
The medical records review segment of the office site review includes a subsection, “Clinical Performance and Patient Care Results” (CP & PCR), which overlaps with Standard 22S. Currently being pilot tested, CP & PCR Standard 22S will not as yet grant supplemental points. Accordingly, the CP & PCR subsection of medical records does not warrant supplemental points and will not affect the AMAP accreditation at this time. For more detailed information concerning the relevance of this segment of the medical records review, please refer to the annotation to AMAP Standard 22S.
Exit Interview and Feedback
The reviewer will conduct a brief exit interview with the physician and office staff to provide preliminary findings of the office site review. A final and more comprehensive report will follow within a month of the visit.
Estimated Time Required for Site Survey Preparation
Preparation time is both variable and optional. Given the AMAP Environment of Care Office Site Review Criteria with Scoring Guidelines beforehand, some office managers and staff may want to conduct a preliminary office site review at their discretion.
Site survey
Approximately two hours for most sites Exit interview
Approximately 15 minutes
Extrait du document American Medical Accreditation, 1999 (72)
R ÉFÉRENCES
1. Centre for Quality of Care Research. Research programme and results. Maastricht, Nijmegen:
Nijmegen University, Maastricht University; 1995.
2. Lawrence M, Olesen F. Indicators of quality in health care. The EQuiP working party on indicators. Eur J Gen Pract 1997;3:103-8.
3. Le palmarès des 512 hôpitaux français. Hôpital édition 1998. Science et Avenir septembre 1998.
4. Hôpitaux et cliniques. Spécial maternités. Science et Avenir septembre 1998.
5. Tourbe C. Une ordonnance sur 50 est dangereuse.
Science et Avenir 1999;629:7-9.
6. Ville par ville, le palmarès des 500 hôpitaux de France.
Les meilleurs, les moins bons et ceux qui posent problème. Le Figaro septembre 1999 (cahier n° 3).
7. Le guide 1000 médicaments et leurs génériques passés au crible. Science et Avenir juin 1999.
8. L'homéopathie au banc d'essai. La Recherche 1998;310:57-87.
9. Agence Nationale d'Accréditation et d'Évaluation en Santé. Le coût de qualité et de la non-qualité à l'hôpital.
Paris: ANAES; 1998.
10. Lindstrom K, Berg L, Rylander B, Hagman A, Olsson L, Bengtsson C. A model for quality assessment in primary health care using the tracer condition technique with insulin treated diabetes as one of the tracers. Scand J Prim Health Care 1995;15:92-6.
11. Ministère des Affaires sociales et de la Solidarité. États généraux de la santé. Soins: un impératif de qualité.
Document thématique. Available from: http://www.
sante.gouv.fr/egs/2-thèmes/208M.htm 1999.
12. Mair F. Performance indicators for general practice.
Emphasis is changing from quality assurance to continuous quality improvement [letter]. BMJ 1995;311:1167-8.
13. Agence Nationale pour le Développement de l'Évaluation Médicale. Mise en place d'un PAQ dans un établissement de santé. Principes méthodologiques.
Paris: ANDEM; 1996.
14. Agence Nationale d'Accréditation et d'Évaluation en Santé. Mise en place d'un programme d'amélioration de la qualité. Les enseignements des expériences mises en oeuvre dans 60 établissements. Paris: ANAES; 1999.
15. Maguerez G. The CQI/TQM journey in France. Jt Comm J Qual Improv 1997;23: 33-7.
16. L'Europe des inégalités. Science et Avenir juillet 1999:36.
17. La résistible ascension de l'ISO 9000. Stratégie Santé 1996;79:22.
18. Roland M. Quality and efficiency : enemies or patners ? Br J Gen Pract 1999;49:140-3.
19. Christoffel T, Loewenthal M. Evaluating the quality of ambulatory health care. A review of emerging methods.
Med Care 1977;15:877-97.
20. Grol R, Baker R, Wensing M, Jacobs A. Quality assurance in general practice : the state of the art in Europe. Fam Pract 1994;11:460-7.
21. Guyatt GH, Rennie D. Guides d'utilisation des publications médicales. JAMA H 1994;6:14-5.
22. Bignolas G. Évaluation des résultats de la FMC. In : Gallois P, Abramovici F, Baumann F, Beaupère J, Bergmann JF, éditeurs. La formation médicale continue : principes, organisation, objectifs, méthodes et évaluation. Paris: Médecine Sciences Flammarion; 1997.
p.262-72.
23. Durieux P, Chaix C, Durand-Zaleski I, Guillo S, Falcoff H, Huttin C, et al. Analyse des facteurs d'évolution des comportements des médecins dans leurs pratiques cliniques et efficacité des dispositifs de régulation et autres méthodes destinées à influencer les pratiques ou comment influer sur les pratiques professionnelles des médecins ? Paris: Institut d'Études des Politiques de Santé; 1998.
24. Norwegian Association of General Practitioners, Norwegian College of General Practioners. Quality development in general practice - a Norwegian model.
The use of indicators in peer groups. Skien: SATS;
1996.
25. Worrall G. Revue : les RPC pourraient ne pas améliorer le devenir des patients traités en milieu de soins primaires. EBMJ 1999;14:29.
26. Feder G. Les recommandations de bonne pratique améliorent le suivi des malades. EBMJ 1996;3:31.
27. Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice:
observational study. BMJ 1998;317:858-61.
28. Freemantle N. Revue : des supports pédagogiques imprimés ne modifient pas le comportement des médecins ni le devenir des patients. EBMJ 1998;10: 31.
29. Shea S. Revue : les aide-mémoire informatisés augmentent le taux d'utilisation des actes de prévention les plus utiles. EBMJ 1998;10:32.
30. Painchaud G. Influence de la formation à la relation médecin-malade (Balint) sur la pratique de la psychothérapie . Union Méd Can 1985;114:160-4.
31. Grol R, Lawrence M. Quality improvement by peer review. Oxford: Oxford University Press; 1995.
32. Gerlach FM, Beyer M, Römer A. Quality circles in ambulatory care : state of development and future perspective in Germany. Int J Qual Health Care 1998;10:35-42.
33. Grol R, Mokkink H, Schellevis F. The effects of peer review in general practice. J Royal Coll Gen Pract 1988;38:10-3.
34. Margerit C. Groupe de pairs. Documents de recherche en médecine générale 1994;44:22-4.
35. Matillon Y, Durieux P. L'évaluation médicale. Du concept à la pratique. Paris: Flammarion, Médecine et Sciences; 1994.
36. Eliasson G, Berg L, Carlsson P, Lindström K, Bengtsson C. Faciliting quality improvement in primary health care by practice visiting. Qual Health Care 1998;7:48-54.
37. Agence Nationale pour le Développement de l'Évaluation Médicale. Formation médicale continue en médecine ambulatoire. Pratiques d'évaluation. Paris:
ANDEM; 1995.
38. Varroud-Vial M, Mechaly P, Boulard N, Chapiro O, Attali C, Mace F, et al. Évaluation de la prise en charge des diabétiques non insulino-dépendants en médecine de ville. Rev Prat MG 1997;11:30-6.
39. Medical audit in general practice. I. Effects on doctors' clinical behaviour for common childhood conditions.
North England Study of Standards and Performance in general practice. BMJ 1992;304:1480-4.
40. Gillies A. Improving patient care in the UK.Clinical audit in the Oxford region. Int J Qual Health Care 1995;8:141-52.
41. Hearnshaw H, Baker R, Cooper A. A survey of audit activity in general practice. Br J Gen Pract 1998;48:979-81.
42. Grol R, Wensing M. Implementation of quality assurance and medical audit : general practitioners' perceived obstacles and requirements. Br J Gen Pract 1995;45:548-52.
43. Senez B. Application de l'audit clinique à un médecin généraliste isolé. Rev Prat MG 1995;9:50-2.
44. Norton PG, Dunn EV, Beckett R, Faulkner D. Long-term follow-up in the Peer Assessment Program for nonspecialist physicians in Ontario, Canada. Jt Comm J Qual Improv 1998;24:334-41.
45. van den Hombergh P, Grol R, van den Hoogen HJM, van den Bosch WJHM. Assessment of management in general practice: validation of a practice visit method. Br J Gen Pract 1998;48:1743-5.
46. Palmer RH, Hargraves JL, Orav EJ, Wright EA, Louis TA. Leadership for quality improvement in group practices. Med Care 1996;34:SS40-SS51.
47. Revue : une information sur les coûts modifie le comportement des practiciens et réduit les dépenses.
EBMJ 1999;15:33.
48. Audry MA. L'assurance qualité et la stérilisation. Tech Hosp 1997;619:17-25.
49. Marco Garcia T, Cabrera de Leon A , Lana AT, Perez Mendez LI, Marquez Montero MA, Lopez AS.
Continuous quality improvement in primary health care.
A five year project. Eur J Public Health 1999;9:131-6.
50. Fox CH, Mahoney MC. Improving diabetes preventive care in a family practice residency program: a case study in continuous quality improvement. Fam Med 1998;30:441-5.
51. Ormières JJ. Démarche qualité en médecine générale.
Expérience de mise en place d'un programme d'amélioration de la qualité dans un cabinet de médecine générale. Rev Prat MG 1999;13:1244-9.
52. Agence Nationale pour le Développement de l'Évaluation Médicale. La tenue du dossier médical en médecine générale. États des lieux et recommandations.
Paris: ANDEM; 1996.
53. Organisation Mondiale de la Santé, Bureau Régional de l'Europe. Politique des associations nationales de médecins dans le domaine de l'amélioration de la qualité des soins. Les recommandations du présent document ont été approuvées lors du Forum européen des associations de médecins et de l'OMS (Utrecht, 28-29 janvier 1993). Genève: OMS. 1993.
54. Sullivan F. L'informatique améliore la performance des cliniciens. EBMJ 1996;3 :32.
55. Tang PC, LaRosa MP, Newcomb C, Gorden SM.
Measuring the effects of reminders for outpatient influenza immunizations at the point of clinical opportunity. J Am Med Inform Assoc 1999;6:115-21.
56. Lafont M. Évaluation et recherche en qualité des soins.
Que faire et que prévoir ? Paris: ANAES; 1997.
57. Stephan JC, Goupy F. La "qualité des soins" en
58. Jankowski RF. Performance indicators in general practice [letter]. BMJ 1993;307:356.
59. Société Française de Médecine Générale. Annuaire statistique 94/95 de l'observatoire de la médecine générale. Documents de Recherches en Médecine Générale 1998;52.
60. Ram P, Grol R, van den Hombergh P, Rethans JJ, Van der Vleuten C, Aretz K. Structure and process: the relationship between practice management and actual clinical performance in general practice. Fam Pract 1998;15:354-62.
61. Ram P, van der Vleuten C, Rethans JJ, Grol R, Aretz K.
Assessment of practicing family physicians: comparison of observation in a multiple-station examination using standardized patients with observation of consultations in daily practice. Acad Med 1999;74:62-9.
62. Baubeau D, Labram C, Derenne Y, Cong HQ, Delnieppe F. La mesure de la satisfaction du patient dans les établissements de santé. Résultats d'une enquête prospective. Informations Hospitalières 1997;45:55-66.
63. Wensing M, Grol R, van Weel C, Felling A. Quality assessment using patient's evaluations of care. Eur J Gen Pract 1998;4:155-8.
64. Jung HP, Wensing M, Grol R. What makes a good general practitioner: do patients and doctors have different views? Br J Gen Pract 1997;47:805-9.
65. Jung HP, Van Horne F, Wensing M, Hearnshaw H, Grol R. Which aspects of general practitioners' behaviour determine patients' evaluations of care? Soc Sci Med 1998;47:1077-87.
66. Safran DG, Kosinski M, Tarlov AR, Rogers WH, Taira DA, Lieberman N, et al. The primary care assessment survey. Tests of data quality and measurement performance. Med Care 1998;36:728-39.
67. Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Stange KC. Patient satisfaction with time spent with their physician. J Fam Pract 1998;47:133-7.
68. Smith CH, Armstrong D. Comparison of criteria derived by government and patients for evaluating general practitioner services. BMJ 1989;299:494-6.
69. McColl A, Roderick P, Gabbay J, Smith H, Moore M.
Performance indicators for primary care groups : an evidence based approach. BMJ 1998;317:1354-60.
70. Campbell SM, Roland MO, Quayle JA, Buetow SA, Shekelle PG. Quality indicators for general practice:
which ones can general practitioners and health authority managers agree are important and how useful are they? J Public Health Med 1998;20:414-21.
71. Wensing M, Grol R, van Montfort P, Smits A.
Indicators of the quality of general practice care of
patients with chronic illness : a step towards the real involvement of patients in the assessment of the quality of care. Qual Health Care 1996;5:73- 80.
72. American Medical Association. Reference manual 1999 edition. American Medical Accreditation Program.
Chicago (Ill): AMA; 1999.
73. Syndicat National des Médecins de Groupe. Guide d'auto évaluation du fonctionnement des cabinets de médecins de groupe. Version 1.1. Paris: SNMG; 1998.
74. Majeed F, Voss S. Performance indicators for general practice. Will lead to league tables of performance. BMJ 1995;311:209-10.
75. Wensing M, van der Vleuten C, Grol R, Felling A. The reliability of patients' judgements of care in general practice: how many questions and patients are needed?
Qual Health Care 1997;6:80-5.
76. Wensing M, Grol R, Asberg J, van Montfort P, van Weel C, Felling A. Does the health status of chronically ill patients predict their judgements of the quality of general practice care? Qual Life Res 1997;6:293-9.