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Follow 10 Tips to Improve Primary Care Quality

By Christopher Cheney  
   July 23, 2019

Advice for effective quality improvement includes devoting time and resources, gauging patient experience, and taking a persistent approach.

At primary care practices, clinician-led quality improvement efforts not only boost the value of patient care but also elevate meaning in providing care, according to a recent journal article.

Primary care quality in the United States compares poorly to other industrialized countries on several measures, including timeliness of appointments when patients are sick as well as access to care on weekends and holidays. In addition, nearly half of physicians are experiencing symptoms of burnout, which can be eased through quality improvement (QI).

Quality improvement benefits primary care practices and their patients, Canadian clinicians wrote this month in the journal BMJ Quality and Safety. "Primary care professionals in North America are trained to provide excellent care to the patient in front of them. Few have been trained to measure and improve the care they provide to a population of patients. Fewer still are familiar with improvement science or QI tools."

The clinicians generated 10 tips to help guide QI efforts at primary care practices:

1. Time and resources: Enlist a dedicated cadre of clinicians and other staff members to lead QI work, including redistribution of clinical income to pay for physicians to lead the effort. Training should also be provided to QI team members.

2. Intrinsic motivation: QI efforts should capitalize on the natural desire among caregivers to improve clinical care such as clinician passion for teaching and developing expertise.

3. Patient experience: A patient experience survey can play a pivotal role in driving QI efforts. At their primary care practice, the BMJ Quality and Safety clinicians garnered a 20% response rate to the patient experience survey administered at their Toronto, Canada-based primary care practice. "Patient feedback has helped us identify and prioritize improvement opportunities," they wrote.

4. Early win: One way to promote QI success is to identify an early win. The BMJ Quality and Safety clinicians initially focused on boosting cancer screening rates for cervical, breast, and colorectal cancer.

5. Flexibility: Leaders of a successful QI effort are open to learning and adjusting course when necessary. In addition to ramping up cancer screening at the start of their QI initiative, the Toronto-based primary care practice also sought to improve influenza immunization among patients over 65, but positive results were difficult to achieve. Interventions to increase flu shots at clinics such as mass media campaigns were eventually dropped so resources could be diverted to more promising areas.

6. Persistence: Some priorities such as timely access to care require sustained commitment even if there are daunting obstacles such as resistance from some staff members.

7. Patient engagement: The Toronto QI team generated several gains based on involvement of patients in the improvement work, including increased access on evenings, weekends, and holidays. For example, patient surveys revealed the need to promote awareness about the availability of urgent care.

8. Openness to criticism and imperfection: QI teams should be transparent about their efforts and open to critiques. "Our QI leaders have tried to welcome criticism, suppress our own defensive reactions, and have made changes to how we collect, analyze or present data based on staff feedback," the clinicians wrote.

9. Ongoing improvement: Successful QI initiatives feature a strategy aimed at ongoing improvement rather than time-limited projects. "Concerted efforts to enable change may be time-limited, but the commitment to monitor and sustain improvement in a core set of performance indicators should be ongoing," the clinicians wrote.

10. Embed QI organizationally: To help ensure success, a primary care practice's leadership team should be heavily invested in QI efforts. The chief of the Toronto-based practice made sure QI was consistently included on the medical staff's meeting agenda and featured in the organization's strategic plan.

Applying quality improvement tips

Although these QI tips were developed at a Canadian-based primary care practice, they are widely applicable to practices in the United States, the lead author of the BMJ Quality and Safety article told HealthLeaders.

"All of the tips are suited to U.S. primary care. I think the payment and measurement context are different, so galvanizing intrinsic motivation and measures that are meaningful to the local practice may be more challenging," said Tara Kiran, MD, MSc, a physician in the Department of Family and Community Medicine at St. Michael's Hospital, Toronto, Canada.

Involving patients in QI efforts is crucial, she said. "This was a turning point for us. Clinicians want to improve the health and lives of our patients—we want to provide them with excellent care. Sometimes though, we aren't aware that what we are doing is not meeting patient needs. Hearing praise, concerns, and potential solutions directly from patients is helpful to motivate care teams to improve."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Primary care quality in the United States compares poorly to other industrialized countries on several measures.

In primary care, successful quality improvement initiatives capitalize on the intrinsic commitment of medical staff to provide high-value care.

Involving patients in quality improvement can reveal unexpected opportunities.

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