Key elements of high-quality practice organisation in primary health care: a systematic review

There has been a growing international evolution of the role and purpose of quality improvement in primary care; particularly in the United Kingdom, Europe, Australia and New Zealand. Research has focused on improving clinical care programs, with a corresponding focus on the identification and development of clinical measures and indicators of quality care. Subsequently, attention has been given to the role of clinical governance in the delivery of high-quality care in general practice, and exploration of the relationship between clinical management and patient health outcomes.1-5

The past 12 years also witnessed an international movement from funders paying for activity to paying for outcomes. The UK introduced “pay for performance” in 2002, resulting in general practices receiving up to 25% of their funding from measuring and reporting against 134 quality benchmarks.6 The United States debated options including significant bundled payments to family practitioners for quality targets.7 New Zealand developed a framework to guide clinical quality in primary care.8 Australia's quality measures, including the Practice Incentives Program and Service Incentive Payments, were introduced in 2002, but their funding has been progressively decreased over recent years. The Royal Australian College of General Practitioners standards form the basis of Australian general practice accreditation, and include elements such as infrastructure and clinical management.9

There is a growing international consensus regarding the impact of organisational elements on the delivery of high-quality care and as enablers of successful continuous quality improvement.10-12 Elements include leadership; practical and human resources; active engagement of all staff; and attention to multifaceted interventions and coordinated action at all levels of the health system, such as investment in training and development of robust and timely data through supported information technology.13-15 The relationship between practice assessment, organisational development and assessment, and quality improvement is complicated. An understanding of the elements of high-performing practices may contribute to the development of organisational and cultural assessment processes, which in turn lead to organisational development relevant to primary care as part of the broader concept of successful continuous quality improvement. Conversely, undertaking successful continuous quality improvement through activities associated with organisational development, and using organisational assessment approaches may, in turn, indicate elements integral to high-quality practice performance (Box 1). Indeed, there is dearth of evidence related to the impact of organisational components of general practice and patient outcomes.16

In this article, we sought to identify elements, contained in the literature, which have been demonstrated as integral to high-quality practice performance. For the purpose of this study, practice organisation was defined as “‘systems, structures and processes aimed to enable the delivery of good quality patient care', excluding clinical processes and clinical outcomes”.17

We defined the term tools as surveys, questionnaires or assessment instruments designed to measure overall or specific elements related to practice organisation, as defined above.

Methods

We undertook a narrative systematic literature review. The specific questions addressed were:

• What elements (attributes or characteristics) are integral to high-quality primary care practice organisation?
• What are the current key considerations relating to organisational performance in primary care?

Key methods are summarised below; full details can be found in Appendix 1.

We searched several electronic databases: PubMed, the Cochrane Library, CINAHL, Embase, Emerald Insight, PsycInfo, the Primary Health Care Research and Information Service (PHCRIS) website and Google Scholar. Additional articles and reports were identified through the reference lists of all reviewed studies. A complete description of the search strategy, including search terms and study eligibility criteria, is found in Appendix 2.

Data were extracted from eligible articles and reports using a data extraction form guided by the template used by Dunbar and colleagues.18

A qualitative inductive thematic approach was used to explore the discussion sections of all articles (surveys; trials; frameworks, models or approaches to organisational improvement or assessment) to explore information about the application and perceived impacts of tools and frameworks. Incorporating this information added further clarification, particularly of the relevance of identified elements to general practice settings.

Data were configured at the study level to allow for the inclusion of findings from a broad range of study types (systematic literature reviews, trials, frameworks, descriptive, knowledge-building papers and key informant discussions). Results were compared and combined to identify the elements of organisational assessment in primary health care that are integral to high-quality practice performance.

Results

A total of 241 manuscripts were obtained for review. Of these, 210 manuscripts were excluded due to no or insufficient information about the tool and elements of practice performance. Tools that focused on elements of patient safety (eg, the Frankfurt Patient Safety Climate Questionnaire for General Practices; the UK National Health Service [NHS] Manchester Patient Safety Framework – Primary Care; NHS Education for Scotland's SafeQuest) or on the developing patient role in health care decision making (including the General Practice Assessment Questionnaire and Europep) were excluded from data extraction.19-25 A full description of the systematic review screening process is presented in Box 2.

All citations were imported to Endnote. A total of 31 articles were included for data extraction, including one systematic review; 25 developmental trials or surveys of organisational assessment and tools or guides and six descriptive articles or reports. Of these, three were Australian; 13 were from the US; 14 from the UK and Europe; and two were Canadian. These articles included information on 10 organisational assessment tools or methods.

Elements identified as integral to high-quality practice performance

We identified 10 elements that were integral to high-quality organisational performance in general practice. Appendix 3 lists these elements according to the tools that include them. It should be noted that this table highlights elements that were specifically contained in the tools. However it should also be noted that several externally facilitated tools could draw out broader issues in practice management during facilitation.

The following 10 elements were most frequently included in existing organisational assessment tools:

Patient-centred approaches: This element included tailoring service delivery to the context of family and the broader local community; the importance of a community focus; use of community resources; and cultural competence in relation to a knowledge and understanding of the local community the practice serves.

Leadership and leading: This included the concepts of knowledge of, and attitudes to, practice leaders in practice organisation, administration and clinical care. The element also related to individual practice members who may lead in relation to innovation and change; it addressed concepts of effective leadership and “leading” behaviours, regardless of individual positions and roles.

Focus on staff: This element contained the concepts of staff satisfaction, autonomy, skills and professionalism. It also addressed monitoring of staff workloads and job stresses.

Clinical governance: Closely associated with the element of communication and collaboration, the element of clinical governance related to the formal systems and structures in place to ensure effective care delivery and clinical safety, such as patient complaints procedures; patient call-back processes and medicine alerts; with a specific emphasis on clinical care structures and risk management.

Multiprofessional teams: This element contained concepts of the ease of forming multiprofessional teams in practice; effective teamwork in relation to important diseases; and relationships between clinical and non-clinical staff, including understanding each other's roles and the ability to learn through conflict.

Communication: This element encompassed a range of concepts — formal and informal processes of communication internal to the practice, including delegation; environmental and cultural factors that support effective collaboration and linkage between the practice and outside services; methods of timely referral; and sharing of patient information. It also encompassed environmental factors that supported sharing information with patients.

Education and training: This element was seen as a fundamentally important part of quality improvement. It relates to provision of, and access to, appropriate training for staff, as part of existing roles. It also included education and training tailored to changes undertaken in the practice.

Process improvement: Closely linked to the element of performance results, this element also most commonly related to clinical processes of care, the systems in place for monitoring the process of practice health care delivery, and internal improvements to the practice.

Performance results: This encompassed processes to support reporting of results of performance measures internally and externally. It included benchmarking against other services.

Information and information technology: Finally, the use of information and information technology included aspects such as the effective collection and use of information and the effective use of technology (eg, practice clinical software). This element most commonly focused on the use of patient clinical information, less common was the inclusion of information and data on practice finances and billing, and data related to human resource management. It also encompassed the sharing of patient clinical information internally, and between the practice and external services.

Three less commonly included characteristics were identified from the discussion sections of descriptive articles and trials of some tools. During the inductive thematic review, phrases were grouped into the most commonly occurring themes or attributes associated with high-quality practice performance, namely:

Incentives and rewards: This attribute included the capacity for all staff to receive recognition and reward for their work — not just financially, but also in recognition from peers, ability to attend conferences or join professional groups. Financial incentives as part of organisational development facilitated and sustained effective team-based approaches to care. However, this element was not specifically included in existing tools but was linked to discussions in organisational governance and change management.

Organisational governance: This element included the definition of a shared direction, mission and values; strategic planning and implementation; and collection and inclusion of administrative data.

Change and change management: This attribute included the ability, willingness and flexibility of the practice staff to adapt to new standards and procedures; the ability and willingness of the practice staff to make, manage and sustain change. A practice with a history of change was also identified as an important structural part of successful and ongoing performance improvement.

Synthesis of results

Combined, these 13 elements represent the characteristics of organisational context that are integral to high-performing practices (Box 3). Rather than being discrete elements, they are also interlinked. For example, the element of communication — information availability, defined as the sharing and communication of information internally and externally, is closely linked to the development of multiprofessional team-based care approaches. The element of education and training for all staff and incentives is integral to successful change management and ongoing readiness for change.

Discussion

Most existing quality improvement tools are designed for tertiary care settings or for non-health care organisations.5 Those developed for general practice and primary health care are single strategies such as audit, professional education (continuing medical education) and frameworks for patient safety and risk management. A review of organisational assessment tools used in the UK concluded that while externally led quality improvement approaches, such as accreditation, are reasonably well developed, internally led approaches are much less so.46

There are several considerations relating to organisational performance. First, a primary health care tool should define elements essential to primary health care, be sensitive to clinical management, enable the users to better understand their own practice context, and include staff in the process of identifying and addressing improvement activities of relevance. Second, as health care delivery becomes more complex and technology-driven, the organisational context in which qualitative improvement initiatives take place becomes a crucial determinant of their effectiveness.10,11 Research on primary care practice development identified these contextual elements as “adaptive reserves”, or features that represent a practice's internal capability.47 Finally, many of the elements identified here are also organisational attributes that enable the success of practice-based improvement initiatives.13 Thus, the challenges are to develop a tool bespoke to primary care with a whole-of-practice approach; that can fit a wide range of contexts; that is relevant to the clinical management aspects of general practice and effectively takes into account organisational aspects of care; that includes elements relating to organisational culture; that is low or no cost; and that can be used effectively as part of an internally led quality improvement process.

The literature in relation to quality improvement is large and diverse; however, studies relating specifically to practice management performance are poorly defined in relation to specific search terms. We deliberately used broad search terms to capture the totality of elements, domains and characteristics included across all tools, frameworks, models and approaches.

There are presently no validated organisational improvement tools, designed specifically for primary care, which can be used internally in a best-practice approach that facilitates both organisational improvement and also raises awareness about the present culture of a practice. Based on the findings from this systematic review, we have now undertaken the development and pilot of a new internally led Primary Care Practice Improvement Tool (PC-PIT), incorporating the elements identified here.49 A national trial is now underway, and future work will explore the link between improved organisational performance and patient outcomes at the practice level. With the continued focus on the important place of general practice and primary health care in the broader health care context, and a refocus on the importance of organisational aspects of practice in relation to quality care delivery, the time is now right to focus on a standardised internally led approach to improving practice performance, designed for the dynamic context of primary health care.

1 Relationship between key terms

2 Flow diagram depicting selection process of studies for analysis