In May 2018, all staff physicians (n = 73) within the SMHAFHT with an established roster of patients were provided with an individualized, confidential practice report and associated self-reflection guide (together comprising the intervention) in two ways: an electronic copy sent by email and a paper copy delivered to their mailbox. The report was developed and refined by the QI program leadership (who were staff physicians themselves), with the input of SMHAFHT physician colleagues, over a 2-year period. Feedback was solicited in a range of ways, including an electronic survey, group discussions at a faculty development workshop, and ongoing discussions at general staff meetings. The first iteration of the report was provided confidentially to physicians in November 2017 with plans to distribute regularly. The report was intended to summarize physician-level data from a range of sources to provide physicians with a comprehensive view of the demographics and quality of care for their rostered patients in a way that complemented existing team-level reports prepared semi-annually. During development of the report, QI leadership was explicit that the report was to support reflection, professional development, and practice improvement and would not be used for external evaluation, reward, or punishment. SMHAFHT physicians informed what indicators were included in the report and how it was distributed; they recommended different ways in which they could be supported to make change based on the data. In response to physician recommendations, the QI leadership developed a plan to test a series of supports sequentially, each with increasing levels of social interaction. Structured self-reflection was the first type of learning support offered with the report.

The report leveraged data from the electronic medical record, provincial reports, manual audit, and a practice patient experience survey. All physicians within the SMHAFHT were provided with aggregate and practice-level as well as clinic and provincial level comparisons when available (see Additional file 1 for an example report). Quality indicators included data on access and continuity, high-risk prescribing, prevention, and chronic disease management. Multiple indicators were included to provide physicians with the ability to select areas where the data showed room for improvement and were a priority for them personally. The structured self-reflection guide that was designed to support physicians to reflect on areas of success and areas of improvement, for both their personal practice and their clinic (see Additional file 2 for self-reflection guide). Physicians who completed the self-reflection guide could submit it to the study team for continuing medical education credits (in Canada, physicians need to submit 25 credits annually to maintain family medicine certification). Physicians received reminders via email and in-person team meetings to complete the self-reflection guide.

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