STRUCTURE AND PROCESS - THE RELATIONSHIP BETWEEN PRACTICE MANAGEMENT AND ACTUAL CLINICAL-PERFORMANCE IN GENERAL-PRACTICE

Objectives. The precise relationship between practice management (stru cture) and the doctor's actual performance (process) in general practi ce is tenuous. Analysis of their mutual relationship may yield insight into the way they contribute to outcome and into corresponding assess ment procedures. Method. In a cross-sectional study, consultations of 93 GPs were videotaped in their own practice and assessed by peer-obse rvers on medical performance and on communication with patients, follo wed by a practice visit by a non-physician observer using a validated Visitation Instrument to assess Practice management and organization ( VIP). Pearson correlations (observed and disattenuated for unreliabili ty of the instruments) between scores on 22 practice management dimens ions and scores of 16 selected cases on medical performance and commun ication were calculated. The predictive value of specific practice man agement aspects for actual performance was determined by multiple regr ession analysis, with performance scores as dependent variables and sc ores on the 22 management dimensions and GPs' professional characteris tics as independent variables. Results. Nine practice management dimen sions correlated significantly with medical performance and so did fiv e dimensions with actual communication. Overall, most associations wer e weak. Combined with demographic variables (age for medical performan ce and working single-handedly for communication), 26% of variance in medical performance scores could be explained by only three practice m anagement dimensions. One practice dimension (delegation of medical ta sks to the practice assistant) explained 11% of variance in communicat ion with patients. Organization of quality assessment activities expla ined most of the variation in medical performance. Conclusions. Practi ce management (structure) and actual performance (process) seem to be largely autonomous constructs. Quality improvement and assessment acti vities should emphasize that practice management is different from act ual performance. Structure and process may contribute to patient outco me independently of each other.