How and why do Quality Circles work for General Practitioners - a realist approach

Objectives To understand how and why general practitioners in quality circles (QC) reflect on and improve routine practice over time. To provide practical guidance for participants and facilitators to implement and for policy makers to organise this complex social intervention. Design A theory-driven mixed method Setting Primary health care Method We collected data in four stages to develop and refine the programme theory of QCs: 1) co-inquiry with Swiss and European stakeholders to develop a preliminary programme theory; 2) realist review with systematic searches in MEDLINE, Embase, PsycINFO, and CINHAL (1980-2020) to extend the preliminary programme theory; 3) programme refinement through interviews with participants, facilitators, tutors and managers of quality circles; 4) consolidation through interviews and iterative searches for theories enabling us to strengthen the programme theory. Sources of data The co-inquiry comprised 3 interviews and 3 focus groups with 50 European experts. From the literature search we included 108 papers to develop the literature-based programme theory. In stage 3, we used data from 40 participants gathered in 6 interviews and 2 focus groups to refine the programme theory. In stage 4, five interviewees from different health care systems consolidated our programme theory. Result Requirements for successful QCs are governmental trust in GPs’ abilities to deliver quality improvement, training, access to educational material and performance data, protected time, and financial resources. Group dynamics strongly influence success; facilitators should ensure participants exchange knowledge and generate new concepts in a safe environment. Peer interaction promotes professional development and psychological well-being. With repetition, participants gain confidence to put their new concepts into practice. Conclusion QCs can improve practice, promote professional development, and psychological well-being given adequate professional and administrative support. Strengths and limitations of this study To our knowledge, this is the first published research that explains how and why general practitioners participating in quality circles may improve standard practice and their psychological well-being over time. The findings can be used to inform practice and policy decisions. The resulting theory relies on the detail and depth of the reports in the literature and the veracity and adequacy of the information participants revealed in interviews and focus groups. To mitigate the risk of selection bias if researchers choose underlying theories and synthesise them ad hoc, we used stakeholders’ mental model and programme documentation as our framework for analysis.