Prior to the visits, most practices only had a vague notion of what to expect from facilitation, and their understanding of the intervention was generally limited. Also the practices did not appear to experience a strong need for change. The dominant reasons for participating in the intervention was to get help with the DCM (because it became mandatory), or because the visits were seen as an occasion to get started with developing more systematic procedures for chronic care check-ups. A few practices had merely signed-up because a colleague had mentioned the intervention. Most of the observed practices chose the DCM as their main topic while two practices focused mainly on developing new chronic care procedures for diabetes and COPD (i.e. written descriptions of the workflow in the practice for a given disease, e.g. division of labour between GPs and nurses and amount and content of systematic check-ups). The topics of the visits are described in Table 1.
At the first visits, the practices decided on the topics of the visits. However, there was no introductory dialogue about the practices’ expectations or preferred facilitation approach and a limited clarification of their existing level of knowledge within the chosen topic. During the visits, the facilitators mainly engaged in various forms of knowledge dissemination, practical support and process management. Although the intervention design also comprised a more coaching based approach to support internal discussions and reflections (e.g. about existing and future procedures) this approach was not enacted during the observed visits. Still, the majority of the respondents were pleased with the visits and did not wish for this sort of facilitation approach. Several respondents appreciated the knowledge and inspiration offered by the facilitators, and some did not envisage that there was sufficient time at the visits for more elaborate discussions about their practice organisation. Nevertheless, two practices were quite dissatisfied with the visits because they had mainly expected the facilitators to engage the participants in an inspirational discussion about what changes were needed and how to implement them. Instead, they experienced the facilitators taking an educative stance which did not involve asking the participants reflective questions and which lacked a focus on implementation:
it is not what a facilitator is supposed to do. When [the facilitator] is sitting on the side-line if you [the practice] are sitting and talking in the group, it is primarily making sure you do not lose focus, but also providing ideas in the process, saying… So that was what I had expected more of, more on the side-line, and then that we as a practice had tried to talk about how we would organise this. (GP, Practice 12)
One of these practices described that they rarely set time aside for discussions about practice development. Therefore, they had hoped that the visits would have focused more on supporting their internal discussions and development processes, but they related that if a temporary doctor in training had not single-handedly taken upon her the task of making new procedures, they would not have accomplished much. In the other practice, the GPs were so disappointed with the facilitation style (being too educative and not enabling internal discussions) that they declined more visits.
Across the observed practices, profound changes in direct patient care were generally not initialised after the facilitation visits, but there were several examples of practices having initiated changes in some areas. Several practices increased their use of diagnosis coding and some installed and signed-up for the DCM, corrected the system set-up, and improved their data registration. However, none came as far as using the DCM data for quality improvement. Two practices formulated new chronic care procedures, and one of them had begun to implement it after the last visit. Additionally, a few practices expressed increased attention towards some of the addressed issues, e.g. annual chronic disease check-ups and the webpage for municipal chronic care activities. However, some practices did not express any tangible changes and some reported limited or no impact from the visits.
Knowledge and skills
The facilitators provided factual knowledge about International Classification of Primary Care (ICPC) diagnosis coding of individual consultations in the electronic patient records, the content of chronic disease check-ups, the DCM, and websites on professional guidelines and municipal chronic care services to which GPs can refer patients. This was either done by presentations, by showing demo versions of the DCM, by demonstrating relevant websites, or by hands-on guidance in the practices’ electronic patient record systems [9]. Prior to the visits, most practices had not used the DCM. Some had not yet installed it and some had not managed to set up the programme to generate accurate data. Further, they rarely diagnosis-coded individual consultations and they had little knowledge (and made little use of) the various websites introduced by the facilitators. On this background, the practices experienced that the facilitation visits increased their knowledge and awareness both of new tools and how to use them, and of errors in the set-up of the DCM. Some respondents stated that the knowledge provided by the facilitators ensured a faster implementation process due to knowledge being more easily accessible, and others perceived the knowledge, especially about the correct set-up of the DCM, as being essential for progress, because they would not have figured it out themselves:
We found out that we did not do it, that the computer was not set up properly... it turned out that the nurses’ computer was not set up to register the diagnosis-coding, which we had done through half a year. (Nurse, Practice 7)
Respondents generally described the content of the visits as relevant, because they had chosen the topics themselves, and because these topics were closely related to their daily practice and specific challenges (experienced prior to and in-between visits). The respondents also found that conducting the facilitation meetings in the practice constituted a beneficial frame for knowledge provision. Contrary to lectures in larger settings, the facilitation visits focused on them, there were no disturbing questions from other practices, and they felt safe asking questions and revealing their weak points. Likewise, some appreciated that joint meetings in the practice increased the likelihood of the knowledge being applied, and relieved the GPs from spending time conveying it to the staff. However, other GPs preferred meetings without the staff so that the meetings focused on the needs of the GPs.
Regarding patient related data for quality improvement, the practices generally did not review their own data prior to or in between the visits. However, practices that looked at such data during the visits valued this experience. For them, the facilitation visits improved their appreciation of the relevance of patient data, helped them to identify problems, gave them an opportunity to consider data (which they could not usually find time for), and reinforced them to improve the registrations even more. A few practices also improved their skills in using their information systems due to the hands-on approach. The practices were generally satisfied with the technical knowledge of the facilitator. Nevertheless, some facilitators lacked knowledge about the specific IT systems used by the practice (there are 11 IT systems in Danish general practice), and several times they asked practices to contact their IT-providers with questions and problems they could not handle themselves. Some practices would have preferred a facilitator that had experience with their specific IT system, while others did not perceive this as a barrier. Several practices experienced IT challenges such as limited user-friendliness, errors in setting-up the DCM, and insufficient support from their IT system providers between the visits. This seemed to slow down the implementation process as some practices did not complete tasks or did so at a slower pace.
At the first visit, the facilitators did not clarify exactly what the visited practices wanted to focus on within a given topic or the level of their existing knowledge. Thus, although most practices reported that they obtained new knowledge from the facilitation visits, some of the knowledge provided was not new to everyone in the practices. While the GPs had generally gained little new knowledge from the presentations on medical and organisational aspects of chronic care, the practice staff often found this knowledge more relevant; not because it directly affected their own work, but because it improved their understanding of the GPs’ work. There were also several examples of participants forgetting the knowledge provided during the visits and several participants still had questions about the correct use of the DCM after the last visit. Some felt that too little time had been spent on some of the topics, that the visits had not been sufficiently structured and requested more written material on both the DCM and the facilitators’ organisation:
One might have been given a sort of a template. Because the problem is that you forget it a bit afterwards…what is it you need to remember to implement it… perhaps one might have needed that. So a small action card. How to do it… because we cannot remember it now, right. (GP, Practice 13)
Motivation and confidence to change
According to most respondents the facilitation visits increased their motivation and confidence to change. They experienced the process of change as demystified and more manageable because the facilitators showed that the DCM was easier to use than they had assumed, and the facilitators’ descriptions of their own chronic care procedures gave them something to build upon:
It might seem a bit less unmanageable and hopefully a little less time consuming than I feared it would be. (GP, Practice 5)
It was really good to get it [description of facilitators’ chronic care procedures], so you did not have to reinvent the wheel. (Nurse, Practice 7)
Further, the facilitators’ descriptions of the benefits they had gained from making the changes in their own practices as well as the content of their chronic care procedures inspired the practices by increasing their sense of the changes being usefulness in daily practice. Most GPs found that it added to the credibility of the facilitators that they were peers with personal experience and knowledge of life in general practice. This meant that the GPs generally perceived the facilitators’ statements as relevant, trustworthy, and transferable to their own practice:
I think it is true that a general practitioner will reach us more easily. We listen because there is a professional respect ... We listen more sharply and take it more seriously … than if it was a nurse… she would initially have to struggle against whether we could use it for anything. (GP, Practice 2)
The GPs did not perceive the descriptions of the facilitators’ own practice organisation as something to be directly copied, but as a credible source of inspiration. The practices generally did not experience disadvantages from the facilitators being peers. Some could not see how the facilitators could have other professional backgrounds, while a few did not regard the peer component as crucial for the process. However, one of the previously mentioned dissatisfied practices felt provoked when the facilitator presented them with factual and experience-based knowledge because they did not perceive the facilitator as an expert or someone with an outstanding practice but just as a random GP. Also, while most GPs were motivated by the visits, some still expressed a feeling of obligation toward the DCM and doubted whether they would use the system beyond the required registrations:
Well, it is the obligation that does it, because it is something that we have to do. If we had not had to, the question is whether we would have done it. That I don’t know. (GP, practice 3)
Additionally, the technical problems experienced in the process triggered increased frustration with the DCM:
Well it is just difficult to mobilise any energy among the doctors, who are to sit and code, if the shit does not work, excuse my directness. Then I bloody do not want to, and again I swear. Then I do not want to sit there and spend my time on something like that. Then it must be left to its own device until it is working. (GP, Practice 1)
Internal conditions for change
Three aspects of the intervention, which did not relate to the specific content of the visits nor to the specific skills and actions of the facilitator, influenced the change process and how the practices assessed the intervention.
First, the visits offered an occasion to focus on and initiate changes and provided protected time for this, which was much valued by the respondents, who reported on busy workdays where time was usually not set aside for practice development meetings with both GPs and staff attending. Thus, the visits were described as a timeout for development that accentuated the focus on the chosen topics:
It also just helps quite a lot by creating a focus, because we devote an hour to it and sit here all of us together. Instead of in our busy workdays, where we just quickly went in and looked, and had set aside half an hour and then were fifteen minutes late and just got to look at something. Then this gives it much focus. (GP in training, Practice 2)
However, sometimes the observed visits were delayed and sometimes people were absent or left during the meeting. Thus, while most respondents – for practical reasons – appreciated having the facilitator meetings in the clinic, some mentioned that this also increased the risk of interruptions and delays since patients were waiting before, during, or after the visits.
Second, practices reported that the visits supported task definition and delegation and increased the sense of obligation, agreement, and mutual responsibility because the whole practice attended the visits. However, from the observations it was clear that the clarity and systematisation of task definition and delegation varied and occasionally clear tasks were not explicitly defined.
Third, several practices described how the return of the facilitator at subsequent visits came to function as a reminder and deadline during the process. According to some respondents this speeded up the change process and ensured the completion of initiated projects that otherwise might not have been prioritised in a busy working day:
So you knew, that you had a meeting at this and that date and suddenly, you were a bit more motivated to go in and code and do things…. So the meetings have another function than just being a meeting, they also have the function of keeping you up to scratch. (GP, practice 3)
Thus, several practices managed to perform their delegated tasks and/or to set a deadline for their implementation before the next visit. Still, most practices rarely discussed the tasks or changes in the time between the visits and they explained this limited attention to the change process by referring to the daily time pressure in general practice.