Academic journal article Australian Health Review

Constructing a Framework for Quality Activity in Primary Care

Academic journal article Australian Health Review

Constructing a Framework for Quality Activity in Primary Care

Article excerpt


Over the last 30 years there has been increasing recognition of the value of a strong and integrated primary care sector for the effective and efficient delivery of healthcare services.1 In many countries including New Zealand, however, there has been considerable change and reorganisation of primary care over the past few decades. Health sector reforms since the early 1980s have lefta legacy of organisational models that emerged out of necessity and evolved in response to new structural and funding arrangements. The 'quality landscape' of New Zealand primary care, is consequently both fragmented and crowded, and centrally developed quality activities jostle with local initiatives for time and financial resources. 'Grass roots' providers thus face increasing pressure on administrative and clinical workload.

In 2009, the Royal New Zealand College of General Practitioners (RNZCGP), identified the need to delineate a strategic direction for quality in primary care, and commissioned the development of a framework to facilitate quality-improvement activity in primary care settings.2

The framework was to be based on both theoretical and empirical data, and provide a platform to enable policy makers, primary care practitioners and organisations to plan, map and rationalise existing and new quality-improvement activities within the context of day-to-day clinical work. It was to be drawn from, and focussed at, the level of the individual general practice, but be applicable to other healthcare settings.

This paper details the development of the framework and discusses its value for deconstructing and constructing healthcare quality activity. The framework, while developed for and within a New Zealand primary care setting, is applicable internationally and within other healthcare settings.


The development of the framework involved three streams of work.

Literature review

A review of the international and New Zealand literature was conducted on theoretical concepts of healthcare quality, and use of frameworks. MEDLINE and Cochrane/Evidence Based Medicine databases from 1966 to 2008, the PubMed database and free text searches using the Google search engine, were utilised. The following keywords were used: frameworks, indicators, performance, quality, health outcomes, quality assessment, quality improvement, audit, clinical governance and benchmarking. A filter for family practice/primary care/physicians family/general practice/ physicians practice patterns was added to refine the search. Author searches were undertaken on recurring author names on useful articles.

Field work

A mixed methods approach was utilised to identify quality initiatives underway within primary care, and investigate issues affecting their conduct. This involved: strategic and organisational level key-informant interviews, a national survey of general practices and a series of facilitated meetings with practice teams. National multiregion ethical approval was obtained.

Strategic interviews

Seventeen interviews were undertaken with stakeholders in leadership positions in the New Zealand healthcare sector. Participants were selected purposively to obtain a variety of high-level policy perspectives. RNZCGP, primary health organisation, health sector management, governance, academic and indigenous Maori strategic perspectives were represented. Participants' backgrounds included general practice, pharmacy, nursing and practice management.

Organisational interviews

Interviews were conducted with the Quality Manager or Chief Executive Officer of 20 primary health organisations sampled from a list of 80 extant organisations. The sample was purposively selected to ensure a range of differing sizes, population demographics and geographic spread.

All interview participants were initially approached by telephone, and then interviewed face-to-face between late 2008 and early 2009 (strategic interviews); or by telephone in mid 2009 (organisational interviews). …

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