Measuring quality in primary healthcare – opportunities and weaknesses

Personal health data from patient records should always be used in a way that guarantees patients’ privacy and confidentiality in the doctor-patient relationship (6).

Quality indicators reflect simplified measurable dimensions of more complex phenomena. Many of the goals and values in primary care can’t be measured, e.g. ethics and humanism in consultations or if priorities are set right in everyday practice. Quality indicators are useful as starting points for discussions about complex reality as part of a process to initiate, stimulate and support local improvement work.

Primary care quality depends on each employee’s competence, responsibility, initiative and sense of context. It is therefore important to support internal drivers for improvement. Quality development must be an integrated part of all primary care. GPs are urged to monitor systematically the quality of their own and their team’s work as well as their working environment. The measurements should cover the different aspects of quality, e.g. patient centeredness, access to, equity in and content of care, process and clinical outcome measurements and work satisfaction of physicians and other personnel. Drilling down to individual patients for acting on care gaps should be possible for the GPs caring for the patients in the target population (7).

Comparisons with other primary care settings (benchmarking) can be useful, e.g. by using national quality indicators. Peer group education using benchmark data is a strong educational tool that enables for the discussion of outcomes in their own context between professionals. These comparisons can form the basis for a deeper analysis of reasons for differences in working methods and resource use.

Electronic health records should be developed so that it is easy to extract data for quality work on a local basis or, preferably, electronic health records and quality measurement tools should be integrated.

Results of quality indicators should not be used as a basis for payment. Payment for quality (payment for performance) has not shown to be beneficial to patients. When payments are made for some aspects of the healthcare, these will be in focus, while other aspects than the measured tend to be ignored while internal motivation for good quality is declining (8).

External reporting should be performed in a way that does not identify individuals, i.e. in an aggregated form. External quality measurements should be limited to a reasonable number of indicators and should concentrate on the aspects of care that contribute most to better and safer patient care.

Data collection should not demand time, staff or financial investment beyond the benefits that may be attained in quality improvement and/or increased patient safety (9). Indicators that are used for any kind of external evaluation should be discussed and approved by health professionals before their use. Several confounding factors may impact more on results than quality in GP practices.