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

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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)

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In document QUALITE DES SOINS : REVUE A TRAVERS LA LITTERATURE DES OUTILS ET DES CRITERES UTILISES EN MEDECINE AMBULATOIRE (Page 46-64)

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