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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Appendix C

General practice surveyors

Definition of peer surveyor

A ‘peer’ is defined by the RACGP as a general practitioner (GP) who has the experience and currency of practice to meet the requirements outlined below.

It is the RACGP’s position that two surveyors undertake survey and assessment for the purposes of accreditation of general practices. One surveyor must be a GP.

Expanded definition: non GP surveyors of general practice

The RACGP recognises that a practice nurse, practice manager, allied health professional or Aboriginal health worker, can also assess and survey against the RACGP Standards for general practices.

General practice surveyors are health professionals with qualifications, experience and technical expertise relevant to general practice who have been selected according to the guidelines below.

Guidelines for the selection of general practice surveyors (peer and non peer)

The selection of general practice surveyors needs to be a reliable and transparent process.

Surveyors need to be selected to provide a balance of skills and experience and to match the needs and characteristics of individual general practices, taking into consideration cultural appropriateness and geographic location.

General practice surveyors need to demonstrate the following:

  • contemporary knowledge of general practice, sufficient to make a reliable assessment of the competence of the general practice to provide safe, high quality products, processes or services
  • thorough knowledge of the RACGP Standards for general practices and relevant assessment method and documentation
  • familiarity with applicable legislation (e.g. drugs and poisons legislation, registration requirements, environment protection requirements)
  • thorough knowledge of and experience in risk management, including the ability to analyse systems and their potential for failure
  • health professional background with qualifications relevant to general practice
  • substantial technical experience in at least one area relevant to general practice (e.g. practice management)
  • the ability to communicate effectively
  • declaration of conflicts of interest (eg. relationship with the general practice seeking external review such as previously employed by the general practice and/ or provided consultancy services to it).

At all times the practice has the right to veto suggested surveyors. The RACGP recommends practices have access to the curriculum vitae of proposed surveyors to enable the practice to make an informed decision about the survey team.

Guidelines on the training of surveyors

1. Initial training of new surveyors

New surveyors require thorough orientation, supervision and mentoring in order to provide a consistent and credible service to general practice.

The RACGP believes that new surveyors require the input of the RACGP in the following areas:

  • theoretical concepts of RACGP Standards development
  • aspects of Standards assessment (eg. observation, document review, patient feedback, interview).

2. Continuing professional development of surveyors

Surveyors need continuing professional development for skill development, including the input of the RACGP in the following areas:

  • interpretation of RACGP Standards for general practices and other standards developed for special interest areas (eg. cosmetic medicine, skin cancer medicine, Aboriginal medical services)
  • discussion of areas of inconsistent interpretation as reported to the RACGP.

Appendix C

Focus groups

Introduction

This section is included to provide guidance about running focus groups as a means of obtaining patient feedback on their experience of your health service (Criterion 2.1.2). The RACGP publication Patient feedback guide: learning from our patients should be closely studied to ensure that you align your focus group methodology with RACGP requirements for this criterion. Remember that any practice-specific patient feedback methods used for the purpose of gaining accreditation against the Standards need RACGP approval before they are used. For more information or to obtain an application form, contact standards@racgp.org.au. Application fees apply.

Remember, too, that if you are planning to use an RACGP-approved focus group for accreditation purposes, questions should cover the six categories of the patient experience:

  • access and availability of care in your practice
  • information provision to patients
  • privacy and confidentiality of care in your practice
  • continuity of care
  • communication skills of clinical staff
  • interpersonal skills of clinical staff.

Again, see the Patient feedback guide for more information.

What is a focus group?

A focus group is a small group of people, led by a facilitator in a group-interview format, and brought together to discuss a particular topic or issue. Focus groups provide a forum for health services to discuss issues and explore selected matters with their clients. These issues could include expectations, attitudes and feelings about various aspects of the health service, and experiences of services or programs.

Key characteristics

Focus groups are usually:

  • held with a group of about 10 to 12 people
    • participants are generally chosen because they share some common characteristics. For example, they are all parents of young children, or are participating in a behaviour modification program, such as smoking cessation
  • led by a facilitator (usually two) in a group-interview format. The facilitator should be in a position where they can be neutral or impartial about the comments given by participants. It is best not to have the manager of the services or programs under discussion as facilitator
  • of 1½ to 2 hours in duration
  • used when largely qualitative information is required.

Focus groups tend to:

  • produce qualitative data – the goal is not to reach a consensus, solve a problem or make a decision
  • seek to obtain insights into attitudes, perceptions, beliefs and feelings of participants
  • use a questioning approach that uses predetermined, sequenced, open-ended questions.

Frequently a brief questionnaire is used during the focus group interview as a method of structuring feedback and of obtaining more precise data, such as priorities and preferences.

Purposes

Focus groups are appropriate methods to use for:

  • identifying client needs and expectations
  • obtaining regular snap shots of your service
  • testing attitudes to proposed service enhancements or new methods of delivery
  • probing for perceptions and experiences relating to a particular service or service feature
  • obtaining feedback on a recently introduced initiative
  • getting feedback for improvement
  • understanding how clients think
  • obtaining more detail about service gaps identified in quantitative research.

Advantages of focus groups

Some of the advantages of using the focus group method are:

  • they allow probing for more in-depth responses and opinions
  • clarification can be obtained if statements are ambiguous or obscure
  • they are flexible and offer the opportunity to go in different directions if desired
  • group discussion allows respondents to build on each other’s responses
  • they provide real-life data in a social environment
  • their flexibility allows changes to be made to future focus groups
  • they provide high face validity
  • they can generate speedy results
  • they can be of low cost, especially if the service already has an experienced facilitator to gain sound feedback data.

Disadvantages of focus groups

Some of the disadvantages of using the focus group method are:

  • they don’t provide a representative view of the whole population
  • they don’t provide quantitative information of statistical significance
  • they are mainly subjective and qualitative information is obtained
  • unless managed well, the discussion can go in directions that are unproductive
  • more articulate individuals may dominate the discussion
  • personal bias – of the facilitator and of the participants – may distort the data
  • some participants may feel inhibited in expressing their opinion
  • they take time to conduct, write up and analyse
  • groups can vary considerably
  • groups can be difficult to assemble
  • the environment needs to be conducive to discussion
  • facilitators require special skills
  • data can be difficult to analyse.

Planning focus groups

Focus groups require a lot of planning, especially if more than one group will be conducted. These are the steps that need to be followed:

Determine your purpose in holding a client focus group

  • Keep your attention to one general purpose.
  • Ensure that focus groups are the best method for addressing this purpose.
  • Choose appropriate participants for that purpose.
  • Restrict your focus of enquiry to issues that can be addressed in about 1 to 1½ hours.

Determine the focus group scope and process

  • Aim for a sampling process, particularly for a large client population.
    • This may mean more than one focus group or interview, to obtain the full spectrum of input.
  • Arrange separate focus groups for sub-groups within a larger, more diverse client group. Ensure that each group has reasonably similar membership, so that all people feel they have the opportunity to contribute.
  • Determine other elements of the process – such as the exact issues to be addressed, how they will be addressed and the specific nature of the questions to be asked. It is useful to review previous patient feedback data, as well as CQI actions and results, to help you determine the appropriate areas to concentrate on.
  • Use a standard format so that the findings can be reliably interpreted.
  • Develop a discussion guide or interview schedule, so that this standard format can be followed.
  • Plan and design the means by which the results need to be recorded, collated, presented, analysed and communicated.
  • Choose facilitators who are of sufficient experience and seniority to have the respect of participants.
    • It is best not to have a service manager facilitate a focus group on the services they are responsible for delivering. It is difficult for them to be impartial and participants may feel reluctant to give honest feedback in their presence. Your state or territory NACCHO affiliate may be able to offer some assistance here.
    • At the same time, make sure they are people who are reasonably familiar with the service, who can interpret feedback accurately and clear up any misunderstandings.
    • It goes without saying that your preference should be for people with good communication and people skills.
  • Aim to have two facilitators in a focus group; this has the advantage of allowing you to choose facilitators according the above criteria. Also, one can conduct the discussion while the other takes notes and acts as backup. For remote services it is preferable to have male facilitators for a men’s focus group, and female facilitators for a women’s focus group.

Consider using a structured questionnaire

You may choose to ask participants to complete a short questionnaire to obtain certain kinds of data and to use as an interview tool. This can:

  • provide opportunities for everyone to participate
  • ensure that you cover all areas, even if some don’t come up in discussion
  • allow for more private views to be aired
  • provide some structure
  • allow for more quantifiable information to be collected, through the use of measurement devices such as rating scales.

Generally the administration of a questionnaire would occupy a small amount of the total interview time (say 5 to 10 minutes), and the facilitator would supervise the completion of the forms. Questionnaires should be well designed and administered, to ensure the results are valid and not distorted by poor design or undue influence of the focus group facilitator.

Determine how many and which clients are to be invited to a focus group

  • Aim to invite people who can give you the highest quality information for the topic you are addressing.
  • Consider who is likely to obtain most from the interview; they are the people who are most likely to respond to your invitation (for example, people who frequently use your service are more likely to attend than infrequent users; people who have problems with your service are also more likely to attend).
  • Be aware that results can be distorted because of sampling bias (for example, there may be some people who will want to participate because they have a particular line to push or represent a particular interest group; this may not be the best forum for them to have their say, as there is the risk that they may dominate).
  • Involve your health service staff and managers in the selection process, as they will have the best ideas on appropriate focus group membership.
  • You will need to invite more people than the numbers you want – at least twice as many; sometimes more. Even so, be prepared for fewer or greater numbers than you plan for.
  • If large groups are involved, you will need to use a sampling approach; consider calling in external experts.

Determine the times, dates and locations of the focus groups

  • Choose a time and venue that are likely to be attractive and appealing for your invitees.
  • Make sure your arrangements are as convenient as possible for prospective participants, even if they are at some inconvenience to you.
  • Remember that these people are going out of their way already in giving up their time to assist you.
  • If participants need to travel, it is appropriate to reimburse their travel costs and to provide adequate refreshments and accommodation, if required.
  • Generally refreshments are offered on arrival in all focus groups, but do make sure this doesn’t occupy too much time.

Invite focus group participants

  • Agree a method for inviting focus group participants. This could be by community visits or notices in the health service or public areas, or by telephone and confirmed by mail or email.
  • Ensure invited participants have a clear understanding of the purpose of the focus group and the use to which the findings will be put.
    • Ensure consent is freely given, based on that understanding.
  • Also advise participants how issues of confidentiality will be handled (see section on ethical issues).
  • If you plan to audio or video record the focus group, advise prospective participants of this so their consent to participate is given with this knowledge.
  • Always make sure there is some phone contact, preferably initiated by someone known to the participant, to remind people of the details and to answer any questions.
  • Be aware that many of your clients may not have participated in focus groups and may want some information about what is involved – and particularly what their role is expected to be – before they will agree to participate.
  • Sometimes an incentive – such as an opportunity to have lunch afterwards with the board, a free nutrition class or a movie voucher – may need to be offered in order to encourage participation.

Conducting focus groups

The actual conduct of focus groups generally follows the sequence outlined below.

Preparation

  • Ensure the room is comfortable and that the seating allows participants to see and interact with each other.
  • Select two people to conduct each focus group.
  • Agree who will take the lead interviewing role and who will take notes and keep time.
  • Provide refreshments on arrival, but make it brief.
  • Bring with you a copy of any correspondence to the participants, the interview schedule, copies of any questionnaire used and writing paper.
  • The RACGP requirements for patient feedback are that six categories of the patient experience are covered (for more information on these categories see the RACGP Patient feedback guide:
    • access and availability
    • information provision
    • privacy and confidentiality
    • continuity of care
    • communication skills of clinical staff
    • interpersonal skills of clinical staff.

Conducting the focus group

General discussion

  • Greet each participant and start the session with introductions.
  • Open by thanking the group for their time.
  • Introduce yourselves and group members – quickly!
  • Restate the purpose of the focus group, the beginning and ending times, and the respective roles of the two facilitators – in other words, one to manage the discussion and one to take notes.
  • Outline any ground rules of the session.
  • Make a clear statement about the confidentiality of the information provided by participants: no statement made will be attributed to a particular person and no identifying details – about participants or any people referred to – will be disclosed.
  • Ask participants to respect confidentiality too.
  • Ask if they have any questions before you start. Keep further explanation brief and to the point.
  • Remind them of the main purpose of the focus group: to collect information about the issue, not to have a gripe session or to solve problems.
  • Explain what will be done with the information after it is collected, including the opportunity to review the focus group transcript.
  • Work through your general questions with the group. Encourage discussion but keep the pace moving, to be sure you cover the areas you wish to cover.
  • Encourage all members to participate, especially about more complex issues. Encourage those who talk less to share their thoughts and don’t allow one or two members to dominate the sessions.
  • Ensure all participants have reasonable airspace; invite quiet members to comment.
  • If there are criticisms of your service, probe for information to better understand the issue and ask how it could be done better.
  • If necessary explain (briefly) why problems may have occurred and perhaps apologise briefly but don’t become defensive, as this will stifle further criticism.
  • Ensure the discussion is focused on key elements of the service under discussion. If your interview is concluded without having learned about the most important aspects from your client’s point of view, it has failed to achieve its purpose. Don’t concentrate on one topic at the expense of others.
  • If there is specific positive feedback, record it to pass on to the people involved.
  • If there is a specific problem aired, take notes and follow up later.
  • If you begin to run out of time, there are several options, and you will need to be sensitive to the atmosphere in order to propose the best option:
    • ask if you can extend the current focus group time
    • work quickly through the key questions in the remaining time
    • finish before having all your questions answered
    • allow for follow-up feedback to be given – for example, by telephone or email.

Recording and note-taking

  • Consider the value of having the focus group audio or video recorded, or using a live scribe pen with a recorder, with participants’ prior permission.
  • Both facilitators may take brief notes, but one needs to have primary responsibility for note taking.
  • Notes should summarise the key points being made by focus group participants.
  • Try to record the comments legibly and in the appropriate order, so that minimal sorting has to be done later.
  • Avoid bias; ensure comments are recorded accurately and objectively.
  • Where there is agreement between several group members on an issue, just tick the comment by the number of people who agreed (even nonverbally) to it.
  • Record good quotes verbatim, as they can provide a flavour to the report.

Closure

  • Summarise the key issue raised and key points made.
  • Explain that the focus group records will be returned to the participants to check for accuracy.
  • Repeat what actions will be taken as a result of participants’ feedback, and how this will be communicated.
  • Thank the group for their time and input.

Follow up

  • Clean up and clarify your interview records immediately so that they can be understood at the report writing and collating stage.

Responsibilities of the focus group facilitator

The focus group facilitator is clearly the most critical factor influencing the effectiveness and usefulness of focus groups. They conduct the whole session, and guide the flow of group discussion across the specific topics selected. It goes without saying that focus group facilitators need to have particular skills and characteristics. Key amongst these are experience in handling small groups, cultural awareness, enthusiasm, self-organisation, energy and open-mindedness.

Key tasks of focus group facilitators are to:

  • be clear about the nature and purpose of the focus group they are running
  • prepare well, so that the topics and issues are understood before the focus group begins
  • establish rapport with the group, and set the scene for productive discussion
  • achieve a good balance between encouraging lively discussion and maintaining a focus on the topics to be discussed
  • stay alert to group dynamics, to recognise threats to productive group discussion
  • manage group dynamics so that discussion flows smoothly and people feel comfortable sharing their thoughts
  • stay open-minded themselves so that preconceptions about the topic and the participants are minimised
  • prepare a report that accurately captures the responses of the group
  • maintain confidentiality.

Ethical Issues

There are a number of ethical issues that focus group facilitators need to be aware of and to address appropriately. The most important are:

  • the voluntary nature of focus groups
  • the need to respect confidentiality and anonymity.

Consent

No person should be compelled to participate in a focus group, nor should they be made to remain if they want to leave. Consent (in most cases, verbal consent is sufficient) should be obtained from each participant prior to the focus group, and a clear statement of the purpose of the focus group should be provided, to allow prospective participants to make an informed decision. No use should be made of the information provided in a focus group other than for the purpose for which consent was given.

Confidentiality

People who participate in focus groups need to be assured that no information will be revealed that can identify them, and that comments they make are not reported (either verbally or in writing) in such a way that specific people or incidents can be identified. People will either not participate in a focus group if they are not given that assurance, or they may distort or suppress information if they feel it is going to be used for other purposes.

In addition to these two key issues, the actual conduct of focus groups requires attention to more subtle matters of ethics. In conducting a focus group, facilitators need to:

  • avoid judging focus group participants by their appearance or other known characteristics
  • treat all people and the comments they make with respect
  • avoid influencing a response by asking leading questions
  • observe confidentiality with focus group discussions so that minimal information is revealed that could be used to identify personal details of focus group participants or any people to whom they refer.

Communication skills

There is a set of communication skills that need to be employed in focus groups. The facilitator needs to judge when particular skills are needed.

Nonverbal skills

  • Adopt a relaxed, open posture.
  • Listen with your eyes as well as your ears – look at the speaker.
  • Listen for basic fact and main ideas.
  • Listen for attitudes, opinions, or beliefs.
  • Do not interrupt the speaker.
  • Use positive, non-verbal communication to prompt the speaker.
  • Be aware of the speaker’s non-verbal communication.

Active listening

Active listening is a valuable but underused skill. It basically consists of summarising your understanding of what the other person is trying to say by:

  • repeating key phrases: ‘more specific information ...’
  • summarising messages: ‘So, what you’re wanting to see here is…’
  • showing empathy: ‘It must have been really frustrating …’

You can also use active listening to:

  • repeat your understanding of their comments in your own words
  • ask the speaker if that is correct and for any clarifications
  • make sure key points by the speaker are captured
  • ask as a check to verify understanding.

Use active listening when:

  • the person isn’t being clear
  • you are reacting defensively to what is being discussed
  • you want to demonstrate that you understand
  • you want to defuse the situation
  • you want to sum up what has been said
  • you want to elicit more information
  • you want to move on.

Probing questions

In order to gain additional insight into the process, use some of the following types of probing questions.

  • Open probe: questions that begin with how, what, which, when and who. Effective to encourage responsiveness and reduce defensiveness.
  • Compare and contrast: questions that ask the other person to look for and discuss similarities or differences. These kinds of questions help the responder to develop and express ideas while allowing the interviewer to steer the direction of the interview.
  • Extension: a question that builds on information already provided.
  • Clarification: questions designed to get further explanation about something already said.
  • Laundry list: techniques where the interviewer provides a list of choice options to the interviewee. This encourages the other person to see beyond a single choice and to state a preference

Assertion skills and tactics

Assertion skills

Assertion skills – being clear, firm and respectful – may be called for when a focus group is not going in the desired direction. Key assertion skills the facilitator requires include:

  • active listening
  • selective ignoring, where you ignore an unhelpful or provocative comment (don’t overuse this)

Assertion tactics

Key assertion tactics the facilitator requires include:

  • Knowing when to use I statements – ‘I’d like to move on…’
  • using appropriate muscle level if you are concerned that a participant may derail the focus group, perhaps by dominating the discussion, demanding a solution to a problem, or provoking conflict with other participants. Appropriate muscle level means ensuring that your first intervention is mild (‘Let’s hear what other people have to say’), moving to a higher muscle level if they fail to respond (‘Perhaps we can make an appointment to talk about this another time. What I would like to do now is invite other people to contribute so that we can hear everyone’s opinions’)
  • addressing the process, not just the content – ‘We’re going off the track here’.

How we react to criticism

Generally we react to criticism by becoming defensive – a natural response to perceived attack. Focus group participants may criticise us, our service or our organisation in ways that make us feel defensive. As a result we react by:

  • giving reasons as to why things are the way they are (frequently seen as excuses)
  • not listening
  • reacting angrily.

Handling criticism

  • Get sufficient information to report the criticism accurately.
  • Understand the nature of the problem – use open questions, clarifying questions, active listening.
  • Understand the extent of the problem.
  • Show concern, empathy.
  • Indicate willingness to ensure it is addressed.
  • Don’t attempt to problem-solve.

Aim for balance between questions as planned and unexpected directions, remembering at all times:

  • an individual’s desire to tell their story and the need of the group to fully participate in the discussion
  • positive and negative feedback. If an individual has a horror story to tell, you may need to see whether there are more positive stories of the same service
  • emotions (your own feeling response to what is being said) and reason (your professional responsibility to manage the discussion)
  • empathy with a participant and bias that prevents you from seeing the situation from another point of view

Remember, if the going gets tough:

  • use your own judgement
  • tune into the atmosphere of the group
  • two heads are better than one
  • use a combination of listening skills and assertion skills.

Preparing a focus group report

Just as it is best not to have the manager of the services or programs being discussed as the facilitator of the focus group, it is also wise not to have them prepare the focus group report. It is a common human characteristic to become defensive when faced with criticism, and this can influence the content of the focus group report. However, it is quite appropriate – and indeed necessary – to invite the manager and their staff to comment on the focus group report before actions are agreed.

Organise input

More qualitative information, such as that obtained from interviews and focus groups, can be difficult to organise. However, it is important that feedback is documented and presented in a digestible form, otherwise the purpose in holding the discussion has been lost.

The feedback from your focus groups should be collated, aggregated (if you conducted any structured questionnaires) and presented in such a form as to make decision-making reasonably straightforward.

Keep in mind that information obtained from focus groups can go through various filters, depending on how carefully you listened to what was said, how accurately you recorded it, how promptly you developed a more detailed focus group report, and how carefully you then collated all your focus group findings.

Generally a focus group report will consist of summaries of key points or themes made in response to each question. These need to be as objective as possible, and should try to capture the mood or response of the whole group, or the majority of its members. If divergent views were expressed, this could be reflected in the report too. Frequently quotations will help illuminate the general meaning of what was said, though quotes should only be used when they reflect a widely held view. The report could be seriously distorted, otherwise.

Remember that focus group results are qualitative and not perfectly representative of the general population. Care needs to be exercised in constructing a report for readers and decision-makers who were not there to pick up nuances or differing views.

Once again, the objectives of the focus group project would determine how and for whom the information needs to be reported. As a general rule, numbers and percentages are not appropriate for focus group research and are not be included in report. Reporting is more descriptive and presents the meaning of the data as opposed to a summary of data.

  • Report participants’ words but do not identify them by name.
  • Describe main participant characteristics. The RACGP advises that demographic information (such as age, gender, ethnicity, educational achievement, socioeconomic information and whether any participant has been diagnosed with a chronic disease) should be collected for each participant.
  • Use descriptive phrases or words used by participants as they discussed the key question.
  • Identify themes in the responses to the key questions.
  • Identify sub-themes indicating a point of view held by participants with common characteristics.
  • Include a description of participant enthusiasm or other group characteristics if relevant.
  • If there was inconsistency between participant comments and their reported behaviors, record this.
  • Suggest new avenues of questioning that could be considered in future: should questions be revised, eliminated, added, etc.
  • Summarise the overall mood of discussion.
  • In giving meaning to the descriptions, be careful about your own biases in interpretation.

Communicate your findings

Communicate the results – even an executive summary – to the relevant groups, keeping in mind that the clients who participated in the focus groups should be at the top of your list.

Final comments

The above guidelines for using focus groups as a means of obtaining patient feedback are suggestions only. They cannot cover every possible situation that might arise, and may offer advice that is not appropriate to a particular circumstance. Draw from the guidelines judiciously, discuss issues and approaches with other staff, and, most importantly, ensure that you are familiar with relevant guidelines in the RACGPPatient feedback guide.

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