1. Impact of quality on day-to-day efforts of PHC
Effective care: meets standards and guidelines
4 dimensions
Training
Knowledge
Skills
Practice
4 core dimensions of primary health care
Access
Comprehensiveness
Continuity of care
Coordinated care
As clinicians how we practice and how we manage our facilities impacts on quality of services delivered. We may define quality care as patients receiving effective evidence-based care which are in the CPGs. In order to deliver quality care, we need to ensure all members of the primary health care team treating patients are:
professional trained and continue their professional development
so that they understand the facts
and have the capacity to perform specific procedures
and implement knowledge and skills
If we want to ensure the core dimensions of PHC are achieved, we need to be transparent and involve the community as well as the hospitals that we refer to in our Quality measurements, so that we have good patient and population health outcomes. This is even more relevant when we are now facing the rising burden of non-communicable diseases.
We need to nurture the quality culture by having the enabling environment in our facility, use of incentives, technology so that the processes of Quality performance measurements does not overwhelm us.

2. Quality in PHC Cannot be taken in isolation: System approach
Use of frameworks
PHCPI
IHI
Insurance-driven improvement in health care quality
Standard baseline level of quality across system
Motivating providers
Generating demand
Not static: shifting goal posts
Measures depends on system goals and functions
When we want to improve the quality of PHC services, we need to take the system approach. How we deliver services is dependent on system inputs and the entire health system should be coordinated to ensure equitable access to quality services. Your health system goals (whether health outcomes, financial protection, equity, efficiency, sustainability) and the context of your health system functions (financing, supply side, demand, protocols & pathways, accountability mechanisms) will determine which services you will focus on for quality improvement. There are already many framewoks available to help you take this system approach.
Why use frameworks?
Articulates knowledge and priorities on how how quality is defined
Guides measurement, what to measure and what not to measure
Common language for improvement
Another point to remember is that quality is a journey, improvement cycle and we need to review our strategy and measures. There are many measurement tools and the indicators that you choose will depend on your country’s health system goals.

3. Country pathway System Assessment of Quality (Frameworks)
Identify gaps
(Toolkit)
Alignment
Policies & strategies
Information infra
Processes & tools
Managing & linking data
Using data for decision making
Measuring the Performance of Primary Health Care toolkit
bit.ly/2KfOkcv
Not zero baseline – policy, regulations (licensing, drugs, devices, CPD), accreditation, HTA, CPGs, QI, audits, patient safety
Assess measurement system – In Malaysia’s case we reviewed our QAP after 25 years, it has taken us 5 years to review our strategic plan and we are engaging stakeholders to develop a national policy for quality in health care.
Identify gaps in quality measurement by applying measurement tools:
Measuring the Performance of Primary Health Care toolkit (bit.ly/2KfOkcv)
Technical quality - effectiveness of care
Experiential quality - client satisfaction vs patient experience
Community engagement
We found that our measurement was unbalanced with an overemphasis on effectiveness of prevention and cure and there was a need for indicators addressing safety and patient centeredness and quality of long term care. It was of limited use in private sector.
We had too many indicators: from 700 to 150 to 72 indicators suitable for PBF
For alignment, we attempted to (1) start with broad goals of the health system and create/track indicators to measures (2) Measure variability across the indicators and equity
(3) Add timeliness as service quality (versus access) (4) Measures beyond clinical intermediate outcomes (ex. Diabetes control) to outcomes (ex. prevent complications)
(5) Set priority conditions (highest burden, cost) for improvement (with MOH) and NIA to reflect goals (6) Create “global measures” across disciplines within each cell e.g. all surgeries measures infection