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
| 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