The National Program of Quality Measurement in the Community (QM) has been implemented for over a decade, with the voluntary participation of all four health plans. In 2010, MJB was commissioned by the Israeli National Institute for Health Policy Research to conduct a study of the perceptions and attitudes of primary care physicians towards all aspects relating to the program. The study found that most of the physicians (87%) felt that it was important or very important to monitor the measures and many were in favor of its continuation (72%). At the same time, many felt that the program caused excessive administrative pressure (58%), increased workload (63%), and over-competition (47%). Following changes in the program since the previous survey (e.g. publishing the measurement by health plan), the National Institute commissioned MJB to conduct a follow-up study.
To examine the perceptions of managers and primary care physicians at the health plans and senior personnel in the healthcare system and the National Program regarding the program and the changes it has undergone, and to compare the findings with those of the previous survey.
- 18 semi-structured in-depth interviews with managers and key position-holders, between May and October 2018
- An internet survey among primary care physicians randomly sampled from the four health plans between May 2019 and January 2020. The response rate was 62% (450 respondents)
- The data were weighted to ensure representativeness
The in-depth interviews with the managers and holders of key positions: The interviews revealed that quality measures continue to play a considerable role in the discourse at the health plans. The vast majority of the interviewees were interested in more outcome measures and fewer process measures. According to the interviewees, the health plans have to contend with over-competition, administrative pressure, and burden of work, which they endeavor to prevent. The interviewees addressed the question as to who would head the program (the current academic body or the Ministry of Health) and expressed support of the program and its continuation but also voiced criticism, e.g., physicians are usually not provided with feedback on the impact of the measurement and the physician’s interventions on morbidity.
The physician survey: The findings from the physician survey revealed that most of the physicians (81%) believe that it is important or very important to monitor performance on the quality measures and most (60%) believe that the program contributes to the improvement of the quality of care, and that the program should be continued (65%). Many physicians (65%) cited considerable challenges in the implementation of the program. Fifty-eight percent feel to a great or very great extent an increased workload and 48% feel to a great or very great extent that it causes over-competition. Sixty percent feel to a great or very great extent excessive administrative pressure.
The study found that broad support for the program continues in the current survey. At the same time there were several noteworthy differences between the physicians’ perceptions as revealed in the 2010 survey and those of the physicians in the current survey:
- A decline in the percentage of physicians who report being overburdened (from 63% to 58%), but no substantial change in the percent experiencing over-competition (about 50% in both rounds) and administrative pressure (about 60% in both rounds)
- A decline in the percentage of physicians who feel that it is important to monitor the performance on the quality measures (from 87% to 81%)
- A decline in the percentage of physicians who believe that the program contributes to the improvement of the quality of care (from 66% to 60%)
- A decline in the percentage of physicians who feel that the program improves their relations with the patients (from 54% to 46%)
- An increase in the percentage of physicians who are very satisfied with their work (from 26% to 42%), along with a decline in the percentage of physicians who indicated that the program improves their job satisfaction (from 48% to 37%)
Finally, while most of the physicians believe it is important that the program will continue, the percentage nevertheless declined (from 72% to 65%).
The findings reveal that physicians in the field regard the program as an inherent part of community healthcare. It can be assumed that many of them, like many other staff members at the health plans who started work after the implementation of the program, have never known community medicine without the program.
As in the past, now, ten years after the previous study, discussion continues as to the way to implement the program and the number of measures it includes, and today, too, many physicians working in the field report challenges that were also raised by the managers.
Recommendations for Policymakers
The study findings can inform the development of the QM program at the national level and help address some of the problems raised. One of the strengths of community healthcare in Israel is the cooperation between the health plans and the physicians, which allows for open discussion of the need for program improvements and the promotion of policy in the area of community health.
- To focus on reducing the challenges in the program: Reduce the emphasis on published reports on comparisons among the health plans; make the measures more accurate and focused; reduce the frequency of measurement; add staff; build automatic measurement tools that do not require intervention by the physician
- To change the mix of measures and place greater emphasis on outcome measures
- To provide the physicians with feedback on the impact of the measures, with an emphasis on reducing morbidity and mortality
It is now generally understood that it is important to monitor the professionals’ experience with the implementation of health care programs. In this study, we addressed certain aspects related to this experience, in the context of quality measurement in community medicine. The findings of this study contribute to the knowledge about the professionals’ experience. Implementation of some of the recommendations arising from it, could help raise physician satisfaction with the program and promote their continued cooperation with the program.