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Implementing a complex innovation in general practices: from a universal to a practice-centred approach


Gijs J Brouwer ,

Maastricht University, NL
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Marieke D Spreeuwenberg,

Maastricht University, NL
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Marielle E A L Kroese Kroese,

Maastricht University, NL
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Marijn H C Clement-Verburg,

HuisartsenOZL, NL
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Dirk Ruwaard

Maastricht University, NL
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Introduction: In one of the nine pioneer sites appointed by the Dutch Ministry of Health,  namely MyCare MijnZorg in the Southern part of the Netherlands, the healthcare costs per capita are among the highest of the country. The regional primary care organization HuisartsenOZL and healthcare insurer CZ started ‘the Plus Practices’ initiative together with fifteen out of the approximately 75 general practitioner GP practices in the MyCare region. The goal of these stakeholders is to improve on Triple Aim  outcomes of the ‘Plus Practices’ patient population. The ‘Plus Practices’ aspire to become the best general practices in the near future by combining innovative interventions focused on three main topics, namely patient-centred care, efficiency, and community-centred care.

Objective: The aim of this study is to describe the approach of primary care organization HuisartsenOZL in guiding, facilitating and stimulating the ‘Plus Practices’ to innovate in order to improve on Triple Aim outcomes.

Methods: A qualitative approach was used. The researcher had a role as participant-observer and made observational notes of meetings. Provisional insights of the researchers were shared with HuisartsenOZL, CZ and GPs in order to improve the implementation of the ‘Plus Practices’. Interviews n=13 with the stakeholders were conducted to complement the data. The Consolidated Framework for Implementation Research CFIR was used to analyse the data.

Results: The initiative started with selecting a set of possible interventions related to the three main topics. Every ‘Plus Practice’ was expected to implement this same set. However, an analysis for each of the practices revealed that the performance indicators, such as referrals to hospitals and prescribed medication, differed substantially among the practices. Based on the results and in close collaboration with the GPs, norms for each of the indicators were formulated as a next step. Subsequently, practices that performed below a certain norm were asked to draft a plan e.g. how will your practice decrease the number of patients for whom expensive medication was prescribed in order to work towards achieving the norm. Finally, each practice started to implement a selection of the broader set of interventions.

Discussion: Based on a close collaboration between the primary care organization, the GPs and the researchers, the initial initiative shifted from a universal to a practice-centred approach.

Conclusion: The preliminary results indicate that a practice-centred approach is most feasible to implement a complex intervention to improve on Triple Aim outcomes.

Lesson learned: A practice-centred approach is needed for innovation in general practices.

Limitations: Data saturation is not yet achieved. However, preliminary results will be complemented with several interviews.

Suggestions for future research: The process of how dissemination of the experiences of best practices to the other practices can be supported will be studied and the effect on Triple Aim outcomes will be monitored. 

How to Cite: Brouwer GJ, Spreeuwenberg MD, Kroese Kroese MEAL, Clement-Verburg MHC, Ruwaard D. Implementing a complex innovation in general practices: from a universal to a practice-centred approach. International Journal of Integrated Care. 2018;18(s2):372. DOI:
Published on 23 Oct 2018.


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