Consideration of items to be included in a national quality system for primary health care
Mapping review
|Updated
The Norwegian Knowledge Center for the Health Services was commissioned by The Department of Health and the Directorate of Health, to survey and recommend elements to be included in a national quality system for the primary health services.
Key message
The Norwegian Knowledge Center for the Health Services was commissioned by The Department of Health and the Directorate of Health, to survey and recommend elements to be included in a national quality system for the primary health services. These are the main recommendations from the present report:
- The goals for a national quality system for the primary health care should be documentation and visibility of quality, learning and quality improvement in a coordinated way, in all four levels of services; the health care worker /patient level, the health organizational level, the municipality level and the national level.
- In order to efficiently contribute to quality improvement, a partnership model for development and implementation should be adopted, with involvement of patients and users, and all stakeholders in the process.
- Patients and users need available and understandable information about quality of the services, and should to a larger extent than today be given the opportunity to query information on quality and safety, and contribute in the development of quality of the services.
- The quality of the services should be measured and visualized in a way that is useful for patients and health workers own quality improvement work.
- The development of quality indicators for all services in primary health care is an essential element of a national quality system. These should be developed according to the principles outlined in the report: Conceptual Framework for a National Healthcare Quality Indicator System in Norway - Recommendations (8).
- The lack of IKT programmes, equipment, coordination and functions in relation to possible retrieval, processing, and analysing data is a major obstacle for documentation of the quality of the services.
- In order to compare measures for quality through benchmarking, structured and goal oriented processes need to be in place in each of the services. This can be done in relation to local challenges, or by regional or national processes.
- Leaders on the national and municipality levels, and the leaders of the individual services, should to a larger extent than today query about quality of the services and make sure documentation of quality is in place. Annual quality reports from the individual services and the municipalities. In addition there is a need for more focus on patient safety, and a system for registering unwanted incidents may be established, as it is in the specialized health care services. The focus for such a registry should be on understanding the mechanisms and learning.
- To have the right competence in place is important to ensure and develop quality in the primary health care services. Both professional knowledge and quality improvement knowledge is important to ensure and develop quality of the services. Knowledge and skills in both evidence based practice and quality improvement is should to a larger extent than today be included in the basic education of health care workers, as well as in their postgraduate further education.
- More research is needed about quality improvement in the primary care sector. Improvement projects should be followed by evaluation, as should the implementation of a national quality system in the primary care services.
- To give push, pull and direction in the quality documentation, visualization and improvement work, we propose establishing a unit with particular responsibility to develop and implement at national quality system for the primary health services. Such a unit needs to coordinate and further develop the work already in place today, and establish technical and process support for the locally based quality improvement work. The main focus of the work should be learning and quality improvement, and user involvement is understood.
- Anchoring the work in the health laws would be a tremendous help in getting increased focus and resources for an increased and coordinated effort towards better quality.
Summary
Preface
The Commonwealth Fund survey from 2008 showed that our knowledge about the quality of the work performed by Norwegian general practitioners is scarce compared with other countries. The Norwegian Knowledge Center for the Health Services made, as a follow up of these findings, a survey and recommendations on how to go further with quality and quality improvement in general practice in Norway, based on Norwegian and international experiences. At the same time, the Coordination Reform was being drafted, with the basic idea that we need to see the health system as a continuum of well coordinated services. On this basis, the Department of Health decided to evaluate the various elements that can be included in a national quality system for the primary health care services seen as a whole. The assignment was given to the Directorate of Health, which asked The Knowledge Centre to do the survey.
Description of the assignment
The assignment contained two parts:
1. Describe and assess the strengths and weaknesses of various alternative elements and propose which should be included in a national quality system.
2. Describe how the national quality system can be developed and then implemented in the services, with particular focus on:
a. General practitioners
b. Physiotherapists
c. Preventive health care services
d. Nursing homes and home care services
The assignment specifies that the Report nr. 47 (2008-2009) The Coordination Reform, The National Strategy for Quality Improvement in Health and Social services (2005-2015) and the Quality Agreement between HOD og KS, are the premises for a national quality system. All relevant stakeholders should be involved in the project in a good manner. Anchoring in both management and in the services is of great importance, and the main focus of such a quality system should be the patients and users.
Methods of the survey
Organization of the project
• A steering group - the management team in the Knowledge Centre.
• An internal project group
• "Subgroups" on the four sub-areas - see paragraph a, b, c and d under Background.
• An external project group with people of high competence when it comes to quality work.
• A reference group of stakeholders, who met during two dialogue conferences, one in June and one in September 2010.
All relevant stakeholders have been involved in both planning and implementation of the project.
Methods for mapping the available documentation
We have searched for Norwegian and international experiences and research, partly through systematic search strategies, partly by the snowballing method, where we through contacts and documents have been pointed to key people with useful information, or to other documents not available through research databases (so-called “grey” literature). We have looked to previous and ongoing work at the Norwegian Knowledge Centre, like systematic reviews, policy briefs and other reports, as well as articles published online in the Norwegian Health Library. We have identified elements that can be a part of a national quality system for the primary health care services, and looked at alternatives for further development and implementation. We have discussed these elements and possibilities with our external project group and with the stakeholders described above, in particular regarding the Norwegian context. The patient organizations have been important premise suppliers, both as part of the stakeholder group, and also by commenting on the document throughout the ongoing work.
Main findings
- The goals for a national quality system for the primary health care should be documentation and visibility of quality, learning and quality improvement in a coordinated way, in all four levels of services; the health care worker /patient level, the health organizational level, the municipality level and the national level.
- In order to efficiently contribute to quality improvement, a partnership model for development and implementation should be adopted, with involvement of patients and users, and all stakeholders in the process.
- Patients and users need available and understandable information about quality of the services, and should to a larger extent than today be given the opportunity to query information on quality and safety, and contribute in the development of quality of the services.
- The quality of the services should be measured and visualized in a way that is useful for patients and health workers own quality improvement work.
- The development of quality indicators for all services in primary health care is an essential element of a national quality system. These should be developed according to the principles outlined in the report: Conceptual Framework for a National Healthcare Quality Indicator System in Norway - Recommendations (8).
- The lack of IKT programmes, equipment, coordination and functions in relation to possible retrieval, processing, and analysing data is a major obstacle for documentation of the quality of the services.
- In order to compare measures for quality through benchmarking, structured and goal oriented processes need to be in place in each of the services. This can be done in relation to local challenges, or by regional or national processes.
- Leaders on the national and municipality levels, and the leaders of the individual services, should to a larger extent than today query about quality of the services and make sure documentation of quality is in place. Annual quality reports from the individual services and the municipalities. In addition there is a need for more focus on patient safety, and a system for registering unwanted incidents may be established, as it is in the specialized health care services. The focus for such a registry should be on understanding the mechanisms and learning.
- To have the right competence in place is important to ensure and develop quality in the primary health care services. Both professional knowledge and quality improvement knowledge is important to ensure and develop quality of the services. Knowledge and skills in both evidence based practice and quality improvement is should to a larger extent than today be included in the basic education of health care workers, as well as in their postgraduate further education.
- More research is needed about quality improvement in the primary care sector. Improvement projects should be followed by evaluation, as should the implementation of a national quality system in the primary care services.
- To give push, pull and direction in the quality documentation, visualization and improvement work, we propose establishing a unit with particular responsibility to develop and implement at national quality system for the primary health services. Such a unit needs to coordinate and further develop the work already in place today, and establish technical and process support for the locally based quality improvement work. The main focus of the work should be learning and quality improvement, and user involvement is understood.
Anchoring the work in the health laws would be a tremendous help in getting increased focus and resources for an increased and coordinated effort towards better quality. The focus on users and patients has been a basis for the work as a value in its own good, but also by pointing out the forceful drive for change it is when patients query and demand quality of their services.
Discussion
A national quality system for the primary care services needs to build on the meet between the patient and the doctor, caregiver or group of health personnel caring for the patients.
The proposed elements of a national quality system have gained acceptance from the major stakeholders involved in the project. They emphasize that the system must support and contribute to local leaning and knowledge. The priority for implementation of the various elements varies between the stakeholders, but the elements: improved IKT structures, visualization of measures for quality form all levels and the focus on quality by the leaders of the health care system has a high priority amongst all.
Conclusion
There are many experiences nationally and internationally from which we can learn, regarding quality work. Building on these experiences in establishing a national quality system for the primary health services is wise, to preserve the imitative and enthusiasm health care workers have today. We have seen through this work that an important motivating factor for health care workers is to be able to give services of high quality, but there is a need for better tools, and more superior and coordinated support for this to happen. A national initiative for a quality system in the primary health care services that provides the government, the leaders, the users, and the health care workers information and data on the quality of the services seems essential. Such a system will be used for local, regional and national quality improvement work if facilitated.
The quality improvement effect of each proposed element is to some degree documented, but we do not know the effect of implementing a national quality system for the primary health services. We therefore recommend evaluation of the effects of the individual elements and the whole system, if or when it is implemented.