Identification of horizontal and vertical axis.

A total of 38 papers were considered relevant for axis identification. The selection was based on 289 references out of 3,086 unique papers identified from three databases; snowballing produced another 13 papers, and 15 papers on validated instruments measuring aspects relevant to the subject (i.e., patient activation, perceived patient-physician interaction, impact of health education, shared decision making, self-management, patient assessment of care, caregivers’ teamwork) were also added (S1 File). A total of 325 items were extracted from these papers as possible actions contributing to care engagement. Discussions and clustering (by IM, JB and RW) led to seven domains with several activities (items): personalised care (27 items), shared decision making (52 items), self-management (89 items), patient as partner (39 items), supportive means (55 items), patient environment (12 items) and teamwork among healthcare professionals (51 items). The project team decided that the growth steps (vertical axis) could best be represented by different bundles of activities; the more activities in a certain care engagement domain, the stronger the growth.

Interpretation and prioritisation by patients and healthcare professionals.

The group characteristics of the three focus groups (patients, patient organisation and healthcare professionals) are presented in Table 1. The interviews lasted from 95–128 minutes. Patients prioritised autonomy, accessibility of care and practice, and continuity of care. Patient organisations wanted their caregivers to show more interest in the specific conditions of patients in relation to their environment and to deliver customised care instead of following protocols; they agreed with the patients with the need for continuity of care. The healthcare providers wanted to meet the informational needs of patients and asked for an increase in consultation time, and a decrease in the number of patients per physician.

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Table 1. Characteristics of the focus group interviews.

https://doi.org/10.1371/journal.pone.0279542.t002

A total of 916 codes were allocated in the interviews, with 821 codes attributed to elements that had already been found in the scoping literature search. Patients and patient organisations showed most interest in the themes Patient as Partner and Patient Environment. The healthcare professionals had the most codes in Personalised Care and Patient as Partner. All themes within the framework of the scoping literature search were identified in quotations of the interviews; no extra themes emerged.

The 95 “new” codes found in the focus groups were more detailed in specifications compared to the themes already found in the framework. They included items such as “continuity of care”, “more time per patient”, “higher caregiver involvement”, “patient as an expert by experience”, “flexibility in personalised care versus rigidity of care protocols”, “usage of patient peer groups” and “patient autonomy”. Overall, it could be concluded that the focus group interviews confirmed the items found in the scoping literature search, and some were reformulated.

Check with experts.

The presentation of the tool (S2 File) to two international experts in the field of care engagement led to suggestions regarding the methodological approach. They underlined our observation that defining consecutive steps (vertical axis) as in the original maturity matrix on practice organisation [38] was not realistic and supported our definition of discriminative activities. A suggestion was made to visualise the scores in a spider web diagram with a total average and average per domain, eventually in relation to a benchmark. Data provided by the tool should be merely for internal use with the possibility of sharing tools and tips with other practices. The user guide of the maturity matrix for practice organisation in primary care will be suitable. Therefore, a local facilitator will guide the discussion on care engagement based on the self-assessment with the maturity matrix in order to support a SMART improvement plan.

Feasibility and acceptance.

Five (5/54) practices initially showed interest in the pilot. Three of these withdrew for various reasons (project did not fit the organisational plan and/or untimely schedule). Two general practices in the region agreed to participate in a pilot (see Table 2 for practice characteristics); these two practices represent the predominant practice form and size in the region and are situated in a large regional town respectively in a village. At the suggestion of the facilitating organisations, a decision was made to complete recruitment and conduct the pilot study in these two practices. All members of the general practice teams (practitioner, nurse, assistant) were invited to take part. The two practice teams included 7 physicians (4 male, average working experience 18 years (7–32 years)), 10 practice nurses (all female, average working experience 17 years (5–35 years)) and 8 practice assistants (all female, average working experience 15 years (0.5–30 years)). In the Netherlands, a practice assistant performs receptionist tasks as well as simple delegated and protocolled medical procedures (such as measuring blood pressure, sampling blood, injecting medication, rinsing cerumen and removing stitches). The kick-off session was well received and considered useful, as it motivated both practices to work with the concept of patient-centred care in the future. The practices realised that there was more to a patient than their illness or condition and that a holistic view may be to the benefit of the patient. They also recognised that interacting in this way may also be beneficial in relation to others, such as colleagues. Both practices were eager to get started and expected a more practical approach. They still felt unclear regarding what they could do to change daily practice, however.

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Table 2. Characteristics of participating practices.

https://doi.org/10.1371/journal.pone.0279542.t003

Not all team members were present (n = 21/27). After two weeks, 11 of 19 (with two incorrect mail addresses) surveys were completed; 15 of the 19 surveys were completed after a reminder. Data from the Lime-Survey (Lime Survey: An Open-Source survey tool /LimeSurvey GmbH, Hamburg, Germany) were collected and transcribed on a spreadsheet; a feedback report with web diagrams for each theme was generated. Feedback reports showed results that were differentiated to the four functional levels (practice assistant, practice nurse, general practitioner and “other”).

The general practitioners and practice nurses were able complete all or most of the questions. The practice assistants indicated that approximately a quarter of the questions did not apply to their daily work. In particular, questions within the themes “Shared Decision Making”, “Supportive Means”, “Patient Environment” and “Teamwork among Healthcare Professionals”.

The teams were very interested in the results of the maturity matrix on care engagement, MM-CE. They recognised the profiles as presented in the feedback reports. There was little discussion in both practices regarding the how and what of the differences between the separate professional groups. The domains of the MM-CE were considered to illustrate the practice situation towards care engagement. The tool was thought to provide good insight into a process that was already going well and provided information on the possibilities for renewal and updating. A major barrier was the difficulty with completing the MM-CE for practice assistants. This was partly due to the abstract language used and partly because of difficulties in relating certain items in the MM-CE to their daily routines.

Both practices needed a practical approach to get off a good start and thought that the work-up provided leads to direct patient care and respects different disciplines. The facilitator session offered the opportunity to work on the themes in a teamwide manner, thereby promoting collaboration and deriving a joint solution. Participants were challenged to formulate ideas to increase the practice populations’ well-being. These ideas were prioritised by discussion and voting on three main objectives for each participating practice team (Practice A: better information towards patients by restructuring the waiting room, focusing on solution-oriented approach and lifestyle interventions; and Practice B: formulating a practice mission, giving special emphasis on lifestyle and a more efficient use of competences in the team). The teams agreed to re-evaluate their progress in three to five months. In the week after the facilitator session, a short report summarising the two sessions and the choices made was sent to the practices.

Two sessions (Box 1) were prepared and led by a professional practice facilitator of the regional facilitating organisation. The sessions were held in a common room within the practice during the working hours of the teams. The team members were paid by the practices. The practice facilitator was funded by the regional facilitating organisation. Filling in the survey was done via an online version of lime survey and was done in the individual’s own time. The practice facilitator spent an average of 8.5 hours per participating practice team (0.5 hours explaining the project and making an appointment for the sessions, 2 hours preparing the sessions, 4 hours giving the sessions (2 hours per session), 2 hours collecting and analysing the surveys and creating a feedback report). The practice coordinator on behalf of the participating practice spent an average of 5.25 hours (0.5 hours explaining the project and making an appointment for the sessions, 4 hours after the sessions and, 0.75 hours completing the survey). The other team members spent an average of 4.75 hours (4 hours after the sessions and, 0.75 hours completing the survey). The average time investment in the two participating practices is a total of 60 hours per practice. In the evaluation interview after three months, the representative of practice A described a good feeling towards the process. At the start, everyone was dedicated, there were regular meetings evaluating the changes in daily practice, and changes were made in the scheduling of patient appointments to increase consultation time for certain patients. Some of the team members followed an educational course, “Solution-Oriented Approach”. The rearrangement of the waiting room was not changed on financial grounds. Contacts had been made with physiotherapists and local social workers to arrange the coordination of lifestyle-changing interventions. In the long term, it appeared difficult to arrange all of the changes in daily practice and not every team member was equally committed to or willing to take responsibility. Another obstacle was the strictness of chronic care protocols, leaving little room for patient-centred initiatives. It is unclear what patients noticed in their daily care. In practice B, some of the team members also underwent, or planned to, an educational course “Solution-Oriented Approach”. In order to increase patient involvement, a survey on patient preferences and needs was sent out to all patients in the practice. Patients appeared to respond very enthusiastically, although preliminary results of the analyses were not available at the time of interview. Formulating a practice mission statement was still a work in progress.

1. Tool-related factors.

The instrument was developed based on an extensive literature search in which we mapped all relevant aspects of patient engagement. Relevant stakeholders and experts grouped the items and adjusted the wording. However, some items need more alignment with the practice assistant’s work. The organisations that have co-developed the instrument were recognised as reliable parties by the participating practices. However, it was still hard to recruit practices.

2. Health professional factors.

In both practices, some physicians have already expressed an interest in the concept of positive health and endorsed the benefits of patient engagement. This knowledge about positive health was not yet available to all employees. Post-intervention evaluations showed that practitioners endorsed the topic of the intervention and recognised the identified themes as being related to patient engagement.

3. Patient factors.

Our focus interviews showed that the patients did indeed feel the need to be more engaged. Therefore, the patients are behind this change. Even though there is some literature mentioning that patient engagement is not desirable in all circumstances. Patients may feel abandoned and left to their own fate, with not everyone being able or willing to be engaged and bear responsibility [22, 24].

4. Professional interactions.

The instrument was in line with the team’s need for a movement towards greater patient engagement and with a general trend in health care in the Netherlands to be patient-centred. The tool aims to increase patient involvement across the whole practice team. Therefore, all team members were asked to complete the questionnaire before starting the discussion. However, it turned out that filling in the instrument took too long and, in that sense, was a considerable investment of time for the entire team. We suggest having the team meeting prepared by a facilitator and a limited number of team members (two to three) who complete the questionnaire. The results are then discussed by the entire team in a central meeting. In addition, it proved difficult for the practices to keep patient engagement on the agenda, especially the realisation of goals and the continuation of plans after the guided session. They expressed a strong need for guidance in this process. A more intensive deployment of practical facilitators may help in this regard. Furthermore, the practices were aware of the fact that changes in their practice do not stop at the boundaries of their practice and that they also need to interact with other parties in their vicinity, both in the field of healthcare and welfare. We suggest addressing this issue from the start.

5. Incentives and resources.

The local facility organisations have invested a lot of effort into this project by organising inspiration meetings, providing experienced practice facilitators (change experts) and offering an educational course. The questionnaires were easily available electronically to the general practices. Therefore, resources were easily available, and support was given by local organisations. The initial interest of 54 practices shows that the subject has the attention of many general practices. However, taking concrete follow-up steps by introducing the maturity matrix in general practice has lagged behind. The non-participating practices indicated that the timing of the study was not appropriate for them; these practices indicated that many extra tasks were already coming their way.

6. Capacity for organisational change.

In both practices, the primary care physicians were also the practice owners; as such, they had the mandate to participate in the intervention. Together with other stakeholders (such as the regional facilitating organisations) they felt a need to initiate the change towards more patient engagement. No real opponents emerged from the interviews and surveys afterwards, nor were there any rules or regulations opposing this. Nevertheless, it appeared difficult for practitioners to keep up with the chosen direction to change the practice. Practices specify that they need practical organisational support staff to reflect on the process from time to time and to keep things moving with the help of feedback.

7. Social, political and legal factors.

Although there is a lot of discussion about changing health care budgets in the Netherlands, existing contracts are mainly focused on providing day-to-day care, so there is little room to get budgets that focus on changing organisational processes. The government continues to pursue a policy in which budgets for primary care are even more reduced. In addition, the study took place at a time when practices were experiencing increased workloads due to the more difficult recruitment of staff and increased substitution from secondary care.

It might be concluded that the prototype is not yet fully developed. O’Cathain suggested that a prototype needs further refinement and optimalisation by a series of iterations in which an assessment takes the place of acceptably and feasibility [42]. The necessary refinements and optimalisation concern revising questions due to abstract language and ambiguity, but also team members should only be exposed to items relevant to them. This should make the instrument shorter and easier to use, thus increasing acceptance. Furthermore, a team meeting could be prepared by the facilitator with two or three individuals to complete the tool. Other maturity matrices exhibited good results with the method in which the whole practice team did not complete the tool [38, 40, 41]. We believe that this will not decrease team commitment and feedback will be discussed by the whole team in a central meeting. Finally, the practice plans established in the intervention should be supported for an adequate amount of time by the facilitators through practice visits, reminders and support materials. A well-supported post-trajectory is necessary for proper change support by practice facilitation and organisational leadership [9, 35]. The relevance of practical help, reminders and support tools was also found in research on the implementation of clinical guidelines in primary care [51]. These propositions will have to be discussed with stakeholders and tested in the next pilot. Changes in general practice need to be both relevant and easy to use to avoid detracting from the day-to-day business and service demands of patients [9, 35, 51]. We imagine that the MM-CE may be used as part of a toolbox facilitating the practice team in their change towards care-engagement, combined with additional complementary tools supporting implementation action and staying on track to set goals. The literature has shown that supporting a team with a toolbox helped to broaden the mindset regarding possible action that clinicians could take to change their daily practices [52].