ObjectivesThere is a broad call for change towards ‘new era’ quality systems in healthcare, in which the focus lies on learning and improving. A promising way to establish this in general practice care is to combine audit and feedback with peer group discussion. However, it is not known what different stakeholders think of this type of quality improvement. The aim of this research was to explore the opinions of different stakeholders in general practice on peer discussion of audit and feedback and on its opportunities and risks. Second, their thoughts on transparency versus accountability, regarding this system, were studied.DesignAn exploratory qualitative study within a constructivist paradigm. Semistructured interviews and focus group discussions were held and coded using thematic analysis. Included stakeholders were general practitioners (GP), patients, professional organisations and insurance companies.SettingGeneral practice in the Netherlands.Participants22 participants were purposively sampled for eight interviews and two focus group discussions.ResultsThree main opportunities of peer discussion of audit and feedback were identified: deeper levels of reflection on data, adding context to numbers and more ownership; and three main risks: handling of unwilling colleagues, lacking a safe group and the necessity of patient involvement. An additional theme concerned disagreement on the amount of transparency to be offered: insurance companies and patients advocated for complete transparency on data and improvement of outcomes, while GPs and professional organisations urged to restrict transparency to giving insight into the process.ConclusionsPeer discussion of audit and feedback could be part of a change movement, towards a quality system based on learning and trust, that is initiated by the profession. Creating a safe learning environment and involving patients is key herein. Caution is needed when complete transparency is asked, since it could jeopardise practitioners’ reflection and learning in safety.

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IntroductionThere is a broad call for change in existing quality systems within health care. One of the anticipated reforms, is transferring ownership back to care deliverers. A promising way to establish this in general practice care, is to combine audit and feedback with peer group discussion. However, it is unknown what different stakeholder groups think of giving prominence to this type of quality improvement. In this study we explore ideas and opinions of different stakeholder groups in general practice on the opportunities and risks that could arise.MethodsWe conducted an exploratory qualitative study, combining interviews with focus discussion groups. Included stakeholder groups were general practitioners, patients, professional organizations and insurance companies. Within a constructivist paradigm, two researchers coded the data in three rounds, using thematic analysis. After continuously comparing and discussing codes with a third researcher, a final code tree emerged, presenting us with the main themes.ResultsIn eight interviews and two focus discussion groups, 22 participants reflected upon opportunities and risks. We identified three main opportunities: deeper levels of reflection upon data, adding context to numbers and more ownership, and three main risks: handling of unwilling colleagues, lacking a safe group and the necessity of patient involvement. An additional theme concerned disagreement on the amount of transparency that should be offered: insurance companies and patients advocated for complete transparency on data and improvement of outcomes, while GPs and professional organizations urged to restrict transparency to giving insight into the process.ConclusionPeer discussion of audit and feedback could be part of a change movement, towards a quality system based on learning and trust, that is powered from within the profession. Creating a safe learning environment is key herein. Caution is needed when complete transparency is asked, since it can jeopardize practitioners’ reflection and learning in safety.Strengths and limitations of this studyExploratory study of a gap in the knowledge towards implementation of a promising intervention.Participants included the four main stakeholder groups that are involved in implementation, in order to study agreement and disagreement between different stakeholders.Additional stakeholders, such as governmental agencies, were not included. They may have offered other perspectives.This exploratory qualitative study offers insight into opportunities and risks. In order to get a broad overview of how these findings are supported by GPs in general, additional quantitative research is necessary.

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