INTRODUCTION

Quality assessment at the individual clinician level maybe viewed in many ways. Traditional measures tend toconcentrate largely on what might be called ‘technical’or ‘competency’ based measures. These include doorto needle time for thrombolysis in acute myocardialinfarction; pancreatitis post-endoscopic retrogradecholangiopancreatography (ERCP); and cerebro-vascular accident post-carotid endarterectomy.

Traditional quality assessment measures in medicinethus tend to focus on the doctor as technician, ratherthan as part of a system or as a service provider. Privatepractice presents a range of challenges for the busy clinician and the relevance of traditional quality measures for doctors in private practice may be limi-ted, in part because of the time required to completethis style of assessment. The increasing pressures inprivate business practice, notably increased patient andcommunity expectations, financial pressures (e.g. theGST) and a worsening medicolegal climate suggestthat quality measures aimed at assessing a physician’spractice systems and thus overall service delivery may be of some benefit. Ultimately, all clinicians in private practice are business people and good businesspractice is reflected in good service delivery.

System failure may be a cause of significant in-hospital morbidity in this country.1,2 A private practicerepresents a ‘system’ that might hold the potential forfailure. The author believes that it is not possible todivorce a physician’s individual skills from their clinical systems. College-based continuing educationprogrammes may lack relevance for assessing a physician’s clinical practice, in part because of theirnarrow focus on ‘doctor’ or technical factors. Suchstructured programmes may not offer a global or ‘warts and all’ view of a practice’s overall service delivery.

The lack of readily available and affordable optionsfor assessing a practice’s service delivery led to the

development of a programme which the author’s practice has successfully implemented. Ballarat Gastro-enterology is a sole physician, consultant gastro-enterology practice based in Ballarat, providing privateand public services throughout much of westernVictoria, a drainage population of over 200 000 people. The aim of the programme was to assess thepractice from the viewpoint of the general practitioner(GP) as the key consumer stakeholder. The practicehas an ongoing program of patient assessment that will not be discussed in this paper. It was felt that atraditional business approach of stakeholder analysiswould allow an assessment of the practice from a service delivery perspective, the key question being‘how is this service viewed?’.

METHOD

A business consultant was contracted to assist with theassessment.

The consultant was provided with a list of all active(i.e. still in practice) referring GPs over the practice’s10 years life. The author was blinded to the consultant’schoice of a group of about 10 GPs from each of thehigh, middle and low referral groups, with the aim ofachieving a broad view of the practice’s service. TheGPs were contacted individually, the majority (over70%) indicating a willingness to contribute.

Involved GPs were interviewed in person or by phoneand asked a series of questions detailing their percep-tions of the practice’s service delivery in a number ofkey areas (including professional competence, leader-ship, service standards and quality of service). In eachkey area they were asked to judge the practice on avisual analogue scale (0–10). General practitionerswere asked to comment specifically upon perceivedstrengths and weaknesses of the practice. An overallview of the practice from the viewpoint of referring GPswas obtained.

J. Qual. Clin. Practice (2001) 21, 118–119

Quality assessment in private practice: The clinician as service provider

GRANT PHELPS BMBS FRACP

Ballarat Gastroenterology, 1002 Mair St, Ballarat, Victoria 3350, Australia (Email: grant@ballaratgastro.com.au)

Abstract Assessment of quality in the private practice setting may be difficult. The author has taken the viewthat service delivery is a key outcome of private clinician practice. A method of assessing service delivery in a private consultant physician practice setting is described.

Key words: business; private practice; quality assessment; service delivery; specialist.

RESULTS

The view of the practice was highly favourable. In par-ticular, the practice was well regarded with respect toprofessional performance (7.9/10), ease of contact andprovision of information to the referring doctor (8.1/10)and technical competence (9.0/10). The service wasrated highly on the question of ‘service meets patientsneeds’ (8.3/10).

Importantly, a number of key issues were raised asproblems or potential problems. These issues werelargely raised in discussion with the interviewer, ratherthan during the formal survey component. Key issuesof potential concern were waiting time for appoint-ments, concern about communication issues and anawareness of inadequate physician manpower withinthe practice, reflecting the problems of inadequatephysician numbers in rural areas.

DISCUSSION

Traditional quality assessment methods may need tobe made more relevant to be useful to cliniciansinvolved in medicine as a business. In the business setting, the delivery of the promised service remainsvital. It is likely that as health consumers become moreaware and active in their decision making regardingtheir health, that an ability to provide a meaningful andapproachable service will become more important. Thispresents significant challenges for private practice in an era of increasing business costs and regulatory pressures.

The process described has provided an objective viewof the practice. It is unlikely to be biased towards a favourable view of the practice, as the consultantdeliberately asked GPs from all referring groups to be involved. I remain unaware of which GPs con-tributed to the practice review. It is presumed that GPs from the low referring group are more likely

to have a negative view of the practice than those who refer often. The process thus has the potential to provide a broad-based view of the practice as a service provider.

The author believes that practice quality can be measured outside of traditional frameworks. A tech-nique of formal stakeholder analysis has helped theauthor’s practice to highlight areas of service deliverythat require attention and to develop specific responsesto those issues. Assessment techniques common in the business world can thus be readily translated tomedical practice and offer a clinician in private prac-tice a chance to view their practice in a more globalfashion as a service.

The author’s practice has become more business like,more consumer focused and ultimately more fulfilling.The practice has developed methods to involve GPs inits forward planning and has encouraged greaterpatient involvement in the referral and consultationprocess. The practice has continued to develop a posi-tion of partnership with its stakeholders. Interestingly,the majority of GPs involved in this assessment pro-cess were pleased to have the opportunity to commenton a colleague’s practice and service delivery.

It is the author’s view that clarifying a practice’s ability to deliver a service may offer that practice asignificant opportunity to refine its systems andimprove its service delivery. A medical practice, like anyother service-based business, must be able to deliver aquality service in order to remain viable.

REFERENCES

1 Wilson RM, Runciman WB, Gibberd RW, Harrison BT &Hamilton JD. Quality in Australian Health Care Study. Med.J. Aust. 1996; 164: 754.

2 Wolff AM. Limited adverse occurrence screening: usingmedical record review to reduce hospital adverse patientevents. Med. J. Aust. 1996; 164: 458–61.

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