Exploring the black box of change in improving test-ordering routines.
BACKGROUND
The effects of quality improvement strategies are sometimes limited in spite of a systematic development approach. What elements play a role in the change process is not yet fully understood.


OBJECTIVE
To explore this 'black box' of change, by analysing the barriers and facilitators GPs perceive during the change process.


METHODS
Qualitative study among GPs who participated in the quality improvement strategy arm of a randomized clinical trial on blood test ordering for unexplained complaints (UCs). The strategy was based on a national guideline that advocates delayed test ordering in patients presenting with UCs. Each GP's change process was assessed by means of a semi-structured interview about barriers to and facilitators of change.


RESULTS
Twenty-four interviews were analysed. Important themes identified in the interviews were lack of problem awareness, the time and effort it takes to change, influence of patients and the pros and cons of the changed behaviour.


CONCLUSIONS
The themes can be summarized into one comprehensive issue: the GPs lack a sense of urgency to change. An important explanation seems to be that two questions from the problem analysis prior to the development of the strategy had not been adequately answered: "Is the GPs' current behaviour a problem and does the problem have consequences for patients?" and if so, "What is the extent of the problem?." As a result, insufficient attention was given to applicability issues, such as time investment, costs and patient and practitioner satisfaction and anxiety.
Department of General Practice/Centre for Quality of Care Research (WOK), Care and Public Health Research Institute, Maastricht University, PO Box 616, NL-6200 MD, Maastricht. loes.vanbokhoven@hag.unimaas.nl
Marloes A
MA
van Bokhoven
Hèlen
H
Koch
Geert-Jan
GJ
Dinant
Patrick Je
PJ
Bindels
Richard Ptm
RP
Grol
Trudy
T
van der Weijden
D001291:Attitude of Health Personnel; D003955:Diagnostic Tests, Routine; D004059:Diffusion of Innovation; D005260:Female; D006302:Health Services Research; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D010821:Physicians, Family; D010818:Practice Patterns, Physicians'; D011785:Quality Assurance, Health Care