Practice assessment

K K Ip
Hon. Secretary, The Hong Kong College of Family Physicians

Delivery of primary medical care involves two major components, the clinic and the practising doctor. Training and professional examinations focus on the assessment of the knowledge, skills, and attitudes of the doctor. These examinations can assess only the clinical ability and the professional capability of the doctor involved. They do not test the quality of care being delivered to the patients. Practice assessment, on the other hand, tests the standard of the clinic and how the practice is being managed. This could be an objective way to test the quality of care, as evidenced by the doctor's practice management and the records made during the consultations. In line with these thoughts, practice assessment was developed as a component of our College's professional examinations. These practice assessment methods are used widely in many countries. The Royal College of General Practitioners developed 'Guide and Criteria for Fellowship Assessment'. The Royal Australian College of General Practitioners set up the 'Entry Standards for General Practices'. The Royal New Zealand College of General Practitioners published a new set of 'Standards for General Practice' recently.

The Hong Kong College of Family Physicians first introduced this assessment format for the Hong Kong Academy of Medicine Fellowship (Family Medicine) Exit Examination. The practice assessment scrutinizes the practice setup and the ability of the participant in organizing and maintaining a quality service standard for the patients. It is designed according to the unique features of the primary care practices in Hong Kong. Areas, such as drug labelling and inventory control, are not emphasized in similar assessments in other countries. Our College, however, has placed important weightings in these fields.

With the experience accumulated from the Exit Examination, the assessment process was used again in the Primary Medical Care Certificate Assessment (PMCCA). The standard and details of the examination, however, were tailored according to the requirements of the assessment. Up to the year 2000, there were 36 doctors, including both Exit Assessment and PMCCA, who attempted the practice assessment. Thirty-two passed at the first attempt and the others passed in the second trial.

Most participants found that this assessment prompted them to improve the practice standard and to look into neglected areas, where improvement was desirable. One of the participants gave the following comments, 'A highly encouraging exercise and those participating would definitely improve their practice and be committed to continuous improvement'. 'The written comments were valuable for participants to get to know their strengths and weaknesses'.

With this encouraging feedback, and realizing a demand for a practice assessment package, with which HKCFP could help individual doctors to maintain their practice standards, the Practice Assessment Package (PAP) was formulated. Interested primary care providers or organizations may use this PAP as an instrument to improve practice standards.

As a tool, the PAP may be administered in several ways. The participants could carry out the assessment in their own clinic. This is self-assessment. Another way of using the PAP would be that three or four participants may form a small group. Each participant is, in turn, assessed by the other doctors in the same group. This is peer assessment. A third method would be that institutes, health care organizations or academic colleges may train their assessors. These trained assessors are sent to the participants' practices to give ratings. This is prescribed assessment or examination. The participants may modify their practice according to the comments received and repeat the assessment later. This would be one form of continuous professional development (CPD).

The salient feature of the assessment is that neither a rating is given to a medical practice nor is emphasis put on the documentation of quality possessed by the participant. The most important aspect is the momentum generated by the PAP to upgrade or maintain standards of the medical practice. The assessors would give comments on the weaknesses of the practice and give suggestions to improve the practice.

Medical practices that could not attain satisfactory results in the first assessment would be reassessed again after three to six months. Participants could then follow the recommendations to upgrade the practice or to eliminate the deficits and deficiencies. The ultimate goal is to maintain a reasonably good standard of medical practice for all participants.

The package is self-explanatory and easy to use. This package assesses different aspects of a clinic practice, from daily management to patient records, inventory keeping to drug labelling. It covers most areas of the day-to-day clinic management. However, this list is not exhaustive. Participants may opt to include other requirements, which may not be included in this package.

Apart from the assessment process, the PAP also contains samples of practice protocols, which could be useful for clinic management. They were included in the PAP with the permission from their authors. Users may use these protocols to give instructions to the practice staff and to prime them in dealing with emergency situations. These sample protocols are not meant to be the only gold standard. Individual users are expected to update and modify them according to their requirements and practice characteristics.

This assessment process has undergone continuous modifications and amendments based on the feedback and comments received during its application. Before the launching, this package is passed to a working group for comments. One of the criticisms is the lack of standards in certain areas, such as the list of consultation instruments, the list of emergency drugs, the protocols to deal with complaints, and the standards for sterilization. This deficiency has been recognized, but everyone would agree that setting such standards is not an easy task. It is very difficult to balance between 'sub-standard' and 'unrealistic expectation' of a primary care doctor. Perhaps our College should take a leading role in organizing a task force dedicated to establish primary care practice standards.

The PAP is now presented to our members as an insertion with this issue of our journal. This package is not intended to be used as a pass or fail benchmark. However, I hope it could serve as a catalyst towards better quality care. Any medical practitioners who wish to upgrade the standard of care, may use this package for selfassessment or peer assessment. Again, I wish to emphasize that the ultimate goal is to maintain a reasonably good standard of medical practice for all participants.