Quality in Primary Care Open Access

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Principles of Quality Management - (2012) Volume 20, Issue 1

Primary care quality digest

Alison Price*

Library Manager, Lincolnshire Knowledge and Resource Service, Lincoln, UK

Corresponding Author:
Alison Price
Library Manager
LKRS Beech House
Waterside South, Lincoln LN5 7JH, UK
Tel: +44 (0)1522 550658
Fax: +44 (0)1522 516723
Email: library_lkrs@lincolnshire.gov.uk

Received date: 30 June 2008; Accepted date: 21 July 2008

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Papers and reports

Accelerating improvement

The author of this paper outlines the structured im-provement process used in all work programmes by the NHS Institute for Innovation and Improvement, or the NHS Institute as it is more commonly known. The background to the development of the improve-ment process is described and the author reports that it is a process that would be of assistance in finding more timely solutions to specific challenges in im-proving health care.

Mugglestone M. Accelerating the improvement process.

Clinical Governance: an International Journal 2008; 13:19–25.

Barriers to implementing hypertension guidelines

This American study examined the role of ‘clinical inertia’ in treating hypertension, by evaluating the knowledge, attitudes and practices of a group of family physicians. Through a series of interviews, the authors found that although 94% of physicians reported fam-iliarity with the current Joint National Committee on

Prevention, Detection, Evaluation and Treatment of High Blood Pressure guidelines, many difficulties in applying the guidance in practice were identified, including a lack of time to discuss management with patients, lack of confidence in accurate blood pressure monitoring by staff, and difficulties in encouraging life-style modification and medication compliance amongst patients. The authors conclude that this study high-lights contradictions between provider knowledge and the application of this knowledge, and call for im-provement initiatives including competency training and continuing education.

Holland N, Segraves D, Nnadi VO et al. Identifying barriers to hypertension care: implications for quality improvement initiatives. Disease Management 2008;11:71–7.

Healthcare quality assurance across Europe

This paper discusses the considerable variation within systems of quality assurance for health care across Europe and suggests a potential role for the European Union in tackling this issue, which is being highlighted by the increased mobility of both patients and pro-fessionals.

Legido Quigley H, McKee M, Walshe K et al. How can quality of health care be safeguarded across the Euro-pean Union? BMJ 2008;336(7650):920–3.

Impact of the Quality and Outcomes Framework on general practice

This study, undertaken by researchers at the UK National Primary Care Research and Development Centre explored general practitioners’ and nurses’ thoughts about changes to general practice arising from the introduction of the Quality and Outcomes Framework (QOF). Twenty-two nationally represen-tative practices were selected. The authors report that those interviewed believed the financial incentives of the QOF had been enough to change behaviour and to achieve targets, and that its aims in terms of disease-specific improvement of patient care had been met. However, unintended effects were also identified, focus-ing upon the relationship between doctors and nurses and also the nature of the patient consultation.

Campbell SM, McDonald R and Lester H. The experi-ence of pay for performance in English family practice: a qualitative study. Annals of Family Medicine 2008;6:228–34.

Industry influence upon quality measures

This paper looks at the impact of pay for performance on quality measures from a US perspective, specifi-cally the need to ensure that clinical evidence and expert consensus alone underpin such measures.

The authors note that two types of organisation have influence over the content of quality measures – those that develop the measures, and professional medical societies. Both may have direct and indirect ties to industry, ties that may increase as organisa-tional dependence upon industry revenue grows. The authors cite examples of inappropriate industry influ-ence upon the drafting of clinical guidelines from professional societies, and discuss policy options for reducing the risk of such influences.

Rose J. Industry influence in the creation of pay-for-performance quality measures. Quality Management in Health Care 2008;17(1):27–34.

Making improvement happen

This paper explores the drivers for improvement in the NHS and further afield, by outlining these drivers and examining the underlying motivating factors for each one. The common attributes of successful health-care improvement practice are discussed and the author identifies four fundamental skill and knowledge sets – leadership; performance and metrics; the right tools and processes; and relationships. How these can be used to build service improvement capacity and speed up the improvement process is explored.

Crump B. How can we make improvement happen?Clinical Governance: an International Journal 2008; 13:43–50.

Non-clinical quality of care criteria

The survey is a tool commonly used in quality-of-care research to explore issues of structure, process and outcome. Few surveys have focused upon patient prior-ities for quality. This paper uses over 100 000 records of survey interviews to describe the relative importance of eight areas of non-clinical quality of care, taken from the ‘health systems responsiveness’ concept developed by the World Health Organization (WHO). These in-clude issues such as dignity, confidentiality, commu-nication, quality of amenities and prompt attention. The authors explore the importance of such issues by geographic and population variables and report that their results provide a ranking of criteria of non-clinical quality of care which could be considered during health reform processes.

Valentine N, Darby C and Bonsel GJ. Which aspects of non-clinical quality of care are most important? Results from WHO’s general population surveys of ‘health systems responsiveness’ in 41 countries.Social Science and Medicine 2008:66(9):1939–50.

Quality assurance for self-management of oral anticoagulation

Thispaperevaluatedexternalquality-assessmentmethods used in patient self-management of oral anticoagula-tion within general practice in Sheffield. Practices involved in the study were randomly allocated to a formal external quality-assessment scheme of patients performing the test either independently at home, or under supervision at their practice. With reliability of results as the outcome measure, the proportion of tests in range was significantly higher for the patients per-forming the test independently, leading the authors to conclude that patients are able to undertake a formal external quality-assessment scheme reliably at home. Murray ET, Jennings I, Kitchen D, Kitchen S and Fitzmaurice DA. Quality assurance for oral anticoagu-lation self management: a cluster randomized trial. Journal of Thrombosis and Haemostasis 2008;6:464–9.

Quest for quality in the NHS

On gaining power in 1997, the Labour government introduced an ambitious and wide-ranging series of reforms aimed at improving the quality of the NHS through modernisation and renewal. This report from theNuffield Trust combines comparative quantitative information with political analysis to present an overview of quality since 1997. The authors of this paper acknowledge that quality has improved overall, but report that it is not as clear whether this improvement reflects the resources invested. Three questions are asked – Are the improvements in quality over the past decade as good as could have reasonably been expected? How much of the improvement can be attributed to deliberate reforms? Has a reliable capacity for improvement been embedded in the NHS? The authors call for an English national quality programme, for which a blueprint is provided.

Leatherman S, Sutherland K and Dixon J. The Quest forQuality; Refining theNHS Reforms; a Policy Analysis and Chartbook. London: The Nuffield Trust, 2008. www.nuffieldtrust.org.uk/publications/detail.asp?id=0&PRid=389

Reducing inappropriate medication in the elderly

This US study assessed trends in the use of inappro-priate medication by primary care patients aged 65 years or above. A four-year project was delivered to 99 practices, all members of a research network, using a common electronic medical record. Quarterly reports on inappropriate medication use were sent to each practice, with interventions such as on-site visits and network meetings to review performance put in place. The results showed that the use of inappropriate and rarely appropriate medication in the elderly popu-lation decreased over the time of the study.

Wessell AM, Nietert PJ, Jenkins RG, Nemeth LS and Ornstein SM. Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices. American Journal of Geriatric Pharmacotherapy 2008;6:21–7.

Universality, equity and quality of care in the NHS

As part of a series of analysis papers ‘NHS at 60’, the author of this paper examines the difficulties faced by the NHS in ensuring equity of access to quality health care. The author notes that little information about the quality of care was published before 1997, beyond statistical data. Developments in monitoring and reporting of the NHS quality agenda are outlined and commented upon.

Delamothe T. Universality, equity, and quality of care. BMJ 2008;336:1278–81.

Workshops to increase knowledge of asthma management

This paper reports a randomised trial, conducted to assess the effectiveness of locally adapted practice guide-lines about paediatric asthma management delivered to general practitioners (GPs) in interactive workshops. Twenty-nine practices took part, using the Australian asthma-management guidelines adapted to suit the local population. The authors found that the GPs taking part in the workshops felt more confident in the man-agement of an acute attack of asthma, and in ongoing management, leading to the conclusion that the work-shop method of disseminating guidance was linked with improved knowledge and confidence.

Liaw ST, Sulaiman ND, Barton CA et al. An interactive workshop plus locally adapted guidelines can improve general practitioners’ asthma management and know-ledge: a cluster randomised trial in the Australian setting. BMC Family Practice 2008;20(9):22.


  1. Muir Gray, JA. Where’s the chief knowledge officer? BMJ 1998;317:832–40.

Peer Review

Commissioned; not externally Peer Reviewed.