Bones

March 2012

Professional

Quality in general practice

Definitions and frameworks

Volume 41, No.3, March 2012 Pages 151-154

Karina Gardner

Danielle Mazza

Background

In 2010, the federal government introduced the first comprehensive national policy statement for primary healthcare in Australia. This policy identifies key reform initiatives with the overall aim of improving the quality of healthcare. However, what constitutes quality and how to measure it is the subject of ongoing debate both nationally and internationally.

Objective/s

In this article we explore the current experience of defining quality and implementing quality frameworks in general practice settings in New Zealand, the United Kingdom, Germany and Australia.

Discussion

There are multiple and varying definitions of quality in general practice, but most emphasise patient experience as their primary focus. The quality frameworks used in the countries investigated are all based on Donabedian’s systems-based framework of structure, process and outcome. Implementation and application varies however, with top-down approaches in New Zealand and the United Kingdom, and bottom-up approaches in Germany. Provision of high quality care is the primary goal in all the systems described. External standards, targets and incentives are important initiatives, but countries with high quality general practice excel at empowering general practice to own the quality agenda.

In 2010, the Australian Federal Government introduced the first comprehensive national policy statement for primary healthcare in Australia. The National Primary Health Care Strategy (the Strategy)1 aims to provide a national road map to guide future primary healthcare policy and planning in Australia. Importantly, the quality agenda is the foundation and driver of each of the four key directions for change identified by the Strategy. These are:

  • improving access and reducing inequity
  • better management of chronic conditions
  • increasing the focus on prevention
  • improving quality, safety, performance and accountability.

In the context of national health reform, a discussion on what constitutes quality in the general practice setting is timely and appropriate. This article explores national and international definitions of quality and implementation of quality frameworks, with the aim of providing a structure for further research in general practice quality issues.

Search strategy

A narrative review of the literature addressing quality in the general practice setting was undertaken. Utilising the key search terms described in Table 1, we searched the PubMed, MEDLINE, Embase and Cochrane Library databases. We included articles published in English and German from 1966–2011 and those that described quality frameworks in New Zealand, the United Kingdom (UK), Germany and Australia. In selecting these countries, consideration was given to the context and volume of work currently undertaken in the quality arena and relevance to Australia. New Zealand and Australia have commonality of goals in approaches to primary healthcare reforms.2 The UK has a strong primary care orientation with substantive quality initiatives that have been systemically implemented.3 Germany was selected because the quality framework it adopted is representative of the larger European experience – a less structured peer review approach based on voluntary participation known as quality circles. An algorithm representing our search is provided in Figure 1. We supplemented these articles with key opinion pieces, literature reviews, policy documents and reports obtained from the government web pages of countries including Australia, New Zealand, the UK and Germany. These were identified from the reference lists of articles included in the review.

Figure 1. Search algorithm

Figure 1. Search algorithm

Table 1. Search terms
quality in primary care, quality of care, primary healthcare, quality improvement, heathcare delivery, systems of care, improving care, quality of healthcare in Australia, quality circles, quality outcomes framework, primary healthcare strategy, quality outcomes framework, quality indicators in healthcare, quality indicators in primary healthcare, quality measures

Defining quality in general practice

There was no uniform definition of quality in general practice. Evidence of this is in the multiple examples presented in Table 2.4–9 Raleigh et al10 have suggested various domains on which to assess quality. Table 3 outlines these domains in the context of definitions of quality in Table 2. Quality of care remains fundamentally a function of what happens at the front line.6 It is how care is delivered that really matters. Patient centeredness is the one consistent domain in the definitions of quality analysed. Interestingly, the definition adopted by The Australian Commission on Safety and Quality in Health Care differs in that it emphasises on outcomes, rather than patients.9

We believe Australia needs to adopt a more comprehensive definition of quality in general practice that encompasses the different perspectives of patients and professionals.

Table 2. Current definitions of quality
Institution/author Definition
The World Organization of Family Doctors4 (Wonca) 'Quality means the best outcomes possible, given available resources that are consistent with patient values and preferences'
The Institute of Medicine5 (IOM) '... the degree to which health services for individuals and the population increase the likelihood of desired health outcomes and are consistent with current professional knowledge'
Darzi6 '... that which focuses on clinical effectiveness, safety and patient experience'
Steffen7 '... the capacity of the elements of care to achieve legitimate medical and nonmedical goals'
Campbell et al8 '... whether individuals can access the health structures and process of care, which they need and whether the care received is effective'
The Australian Commission on Safety and Quality in Health Care9 (ACSQHC) 'The extent to which a health care service or product produces a desired outcome or outcomes'

Quality frameworks

The literature is consistent in its adoption of a quality framework model based on Donabedian's classic system-based framework of structure, process and outcome.11,12 But implementation and application of this framework varies. Examples of measures that address the three elements of Donabedian's framework are outlined in Table 4. In order to measure quality effectively, there is a requirement to translate theoretical concepts to concrete representations13 while remembering that 'not everything that can be counted counts and not everything that counts can be counted'.14 Raleigh et al10 warn over-reliance on measurement could lead to neglect of aspects of quality, which are not readily quantifiable.

Table 3. Quality domains4–10
Domains Wonca IOM Steffen Darzi Campbell ACSQHC
Safety        
Effectiveness      
Outcomes of care      
Patient centred/ experience  
Timely        
Access          
Efficient          
Value for money            
Capacity            
Equity          
Health improvement            

New Zealand

New Zealand has a long history of quality initiatives aimed at improving care. In 2001, the New Zealand government introduced the Primary Health Care Strategy.15 This strategy emphasised the need to deliver quality care at all levels of interaction. The focus of the strategy was a new vision for primary care, rather than on the implementation of that vision. The strategy recommended that 82 primary health organisations be established for implementation. Implementation has varied, however, and as a result there is currently no single universally adopted quality framework in the New Zealand general practice setting. Rather, we found references to a number of quality frameworks concurrently in use. These frameworks involve development of standards (structure), rolled out in a national program (process), which are implemented and measured16 at the local level by primary healthcare organisations. Criticism of this approach is directed at the lack of clarity around its appropriateness to reflect the goals of all major stakeholders, including general practitioners.17 This ambitious strategy to revolutionise delivery of primary care and the extent to which it has enhanced quality in the general practice setting continues to be the subject of debate for policy makers and researchers.15,17

Table 4. Examples of measures addressing Donabedian's framework
Structure Process Outcome
Resources Management Patient satisfaction
Personnel Records Health status
Administration Diagnosis Completion of treatment
Facilities Treatment plan Recall pattern
Source King's Fund, 201010

United Kingdom

The Quality and Outcomes Framework (QOF)16 is perhaps the world's most substantive program to address quality in the general practice setting. The QOF is based on a system of financial incentives for provision of high quality care. The official definition states the scheme is about 'resourcing and then rewarding good practice rather than performance management'.16

The QOF addresses Donabedian's structure, process and outcome framework in four domains:

  • clinical care
  • organisational
  • patient experience
  • additional services.

Quality is measured through collection of quantified indicators for each domain. Importantly, while the QOF has gathered high profile support, the rigidity of the approach to measurement of quality has also created controversy. Critics argue that clinical performance is not synonymous with clinical care.18 They warn that core general practice activities have been distorted to focus on what is being counted, rather than on the patient and that this framework has allowed evidence based care to become a substitute for clinical judgement.19 Notwithstanding criticism, support for the QOF across the literature remains strong, both at the system and practice level, and future enhancement of the QOF is proposed, instead of its abolition.20

Table 5. Domains and dimensions in the RACGP's quality framework for Australian general practice24
Domains – influences on elements necessary for quality improvement Dimensions – measures of health system performance
Capacity Acceptability
Competence Accessibility
Financing Appropriateness
Knowledge and information management Effectiveness
Patient focus Efficiency
Professionalism Safety

Germany

Quality circle work is a practice based peer review strategy designed to achieve continuous improvement21 and represents an alternative to nationally standardised quality frameworks such as the QOF in the UK. Introduced in The Netherlands in 1979, quality circles were successively adopted by other European countries. Germany is an early adopter of this approach. One definition of quality circle work states that it is 'a process for planned activities based on performance review with the aim of continually improving quality of patient care'.21

The main objective of quality circles is the formulation of guidelines for good care. The key elements are voluntary participation and regular meetings under the guidance of a trained moderator.

A 1998 study22 investigating the nature of topics discussed in quality circles found that meetings were predominantly focused on issues of clinical relevance, such as chronic disease management and complex care. European research suggests quality circles are the most effective method of delivery of quality improvement, but further evaluation is necessary to assess their impact on provision of quality care.21

Australia

In recent years, quality in Australian general practice has focused on accreditation. In 2008, 80% of patient care was provided by general practices, which are accredited against national standards developed by The Royal Australian College of General Practitioners (RACGP).23 It is within this environment that the RACGP developed a quality framework aimed at highlighting achievements and gaps. The framework is intended to facilitate a system-wide approach to the many initiatives proposed for quality improvement in general practice.24 The framework is underpinned by the domains and dimensions described in Table 5. The framework has been designed as an evolving tool. Each domain must interact with each dimension for the framework to be successful. Potential uses of the framework documented by Booth include:24

  • planning quality improvement activities at the national or practice level
  • business planning in the setting of care
  • mapping current quality scenes to identify gaps
  • broadening the profession's thinking about what contributes to quality.

Further research is necessary to address the extent to which this framework measures quality, and whether or not it has been implemented nationally in the general practice setting.

Conclusion

Quality frameworks are systematic tools to evaluate quality initiatives and stimulate broader thinking about quality in the general practice setting. Attempts to measure quality cannot take a one dimensional approach, but must focus on the interaction between structure, process and outcome. Outcomes remain an important measure to judge quality, but good outcomes can only be achieved when robust structures and processes are in place.

Provision of high quality care is the common goal in all quality frameworks investigated, but implementation and application varies. Quality top-down initiatives in New Zealand and the UK place emphasis on clinical guidelines adherence, while bottom-up quality initiatives in Germany shift the focus to formulation of guidelines for good clinical care.

Fundamentally, a useful quality framework must support confidence in services and structures, rather than regulating or sanctioning them, and the general practice team must own the quality agenda and take on professional leadership for quality improvement. To this end, external standards, targets and incentives must support general practice, but ultimately the general practice team must own the quality agenda.

Conflict of interest: none declared.

References

  1. Roxon N. Building a 21st Century Primary Health Care System: Australia's First National Primary Health Care Strategy. In: Australian Government Department of Health and Ageing, editor. Canberra, 2010.
  2. McDonald JCJ, Harris MF, Powell Davis G, Burns P. Systematic review of system-wide models of comprehensive primary health care: UNSW, Research Centre for Primary Health Care and Equity SoPHaCM, 2006.
  3. Lester H. The UK quality and outcomes framework. BMJ 2008;337:a2095.
  4. WONCA Working Party on Quality and Safety in Family Medicine, 2006. Available at www.globalfamilydoctor.com/aboutWonca/ working_groups/quality_ass/wonca _qualityassurance.asp?refNum= 5664 [Accessed 12 July 2011].
  5. Transforming healthcare: IOM panel discusses vision and reality after crossing the quality chasm. Qual Lett Healthc Lead 2004;16:9–12.
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  7. Steffen GE. Quality medical care. A definition. JAMA 1988;260:56–61.
  8. Campbell SM, Roland MO, Buetow SA. Defining quality of care. Soc Sci Med 2000;51:1611–25.
  9. Australian Commission on Safety and Quality in Health Care. Available at www.health.gov.au/internet/safety/publishing.nsf/Content/Home.
  10. Raleigh V, Foot C. Getting the measure of quality. London: The King's Fund, 2010.
  11. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966;44:(Suppl):166–206.
  12. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743–8.
  13. Donabedian A. Criteria and standards for quality assessment and monitoring. QRB Qual Rev Bull 1986;12:99–108.
  14. Cameron WB. Informal sociology: a casual introduction to sociological thinking: Random House, 1963.
  15. Cumming J, Mays N, Gribben B. Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals? Australian and New Zealand Health Policy 2008;5:24.
  16. Quality Outcomes Framework. Available at www.qof.ic.nhs.uk.
  17. Buetow S. Pay-for-performance in New Zealand primary health care. J Health Organ Manag 2008;22:36–47.
  18. Werner RM, Asch DA. Clinical concerns about clinical performance measurement. Ann Fam Med 2007;5:159–63.
  19. Heath I, Hippisley-Cox J, Smeeth L. Measuring performance and missing the point? BMJ 2007;335:1075–6.
  20. Lester H, Roland M. Future of quality measurement. BMJ 2007;335:1130–1.
  21. Beyer M, Gerlach FM, Flies U, et al. The development of quality circles/peer review groups as a method of quality improvement in Europe. Results of a survey in 26 European countries. Fam Pract 2003;20:443–51.
  22. Gerlach FM, Beyer M. New concept for continuous documentation of development of quality circles in ambulatory care: initial results from an information system in Germany. Qual Health Care 1998;7:55–61.
  23. Australian Institute of Health and Welfare. Australia's health 2008. Cat. no. AUS 99. Canberra: AIHW, 2008.
  24. Booth BJ, Snowdon T. A quality framework for Australian general practice. Aust Fam Physician 2007;36:8–11.

Correspondence afp@racgp.org.au

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