Occasional Paper 10 - The Royal New Zealand College of General ...

The Royal New Zealand 

College of General Practitioners 

RNZCGP Annual 

Quality Symposium 

1–2 February 2008 

Summary of Proceedings 

Quality Assurance, Quality Improvement and 

Quality Frameworks in general practice and 

primary care

Prepared by: 

Maureen Gillon (National Director Quality) 

Reviewed by Board of Quality: 

John Wellingham (Chair) 

Kenneth Tong 

Chris Fawcett 

Harry Pert 

Jim Vause (Te Akoranga a Maui) 

Published by The Royal New Zealand College of General Practitioners, New Zealand, 2008. 

ISBN: 978-0-9582772-4-2 

© The Royal New Zealand College of General Practitioners, New Zealand, 2008. 

The Royal New Zealand College of General Practitioners owns the copyright of this work and has exclusive rights in accordance with 

the Copyright Act 1994. 

In particular, prior written permission must be obtained from the Royal New Zealand College of General Practitioners for others 

(including business entities) to: 

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as defined by the Copyright Act 1994.

Contents 

Introduction ....................................................................................................................................................................... 4 

Contributors: .......................................................................................................................................................... 5 

Summary of Proceedings: Overview ................................................................................................................................ 6 

Day 1 – Quality Measurement ............................................................................................................................... 6 

Day 2 – Quality Improvement ................................................................................................................................ 9 

Results ............................................................................................................................................................................. 12 

Masterclass .......................................................................................................................................................... 12 

Pat Snedden, Chair, MOH Quality Improvement Committee – key messages .................................................. 13 

Key points: Development of a quality environment for primary care in New Zealand ...................................... 13 

Conclusion – The way forward ............................................................................................................................ 18 

References ....................................................................................................................................................................... 19 

© THE ROYAL NEW ZEALAND COLLEGE OF GENERAL PRACTITIONERS / Summary of Proceedings 2008 3

Introduction 

New Zealand is a recognised world leader in quality in general practice through, its approach to supporting quality and 

safety in general practices through the Cornerstone programme where practices measure their quality of care against 

Aiming for Excellence, both based on internationally accepted best practice. 

There are emerging issues in quality that require attention within the primary care quality networks, such as introduction 

of clinical indicators through the Performance Management Programme which will impact on practice systems 

and processes. The Annual RNZCGP Quality Symposium was a good starting point for the discussion. 

The symposium introduced the third edition of Aiming for Excellence, which provides an important contribution to 

existing frameworks to guide improvements in quality and safety in general practice primary care. 

Day 1 – Masterclass 

Professor Martin Roland (UK) CBE conducted a master-class on day one of the Symposium. He is an expert commentator 

on the quality of international health systems, clinical governance and the UK Quality Outcomes Framework 

(QOF). His session covered what’s new in quality measurement and improvement and a comprehensive overview and 

discussion of the QOF. 

Bio: 

Martin Roland, Professor of General Practice at the University and Director of the National Primary Care Research 

and Development Centre (NPCRDC) is the founding director of the NIHR School for Primary Care Research, a 

collaboration between the five leading departments of primary care in England. He is Head of the School of 

Community Based Medicine within the Faculty of Medical and Human Sciences in Manchester. The School comprises 

of three research groups: Primary Care, Psychiatry, and Biostatistics, Informatics and Health Economics. 

His previous areas of research include back pain, hospital referrals, out of hours care, and nurse practitioners in 

general practice. Professor Roland is also founding Director of the new National Institute for Health Research 

(NIHR) School for Primary Care Research, a funded collaboration established in 2006 between the academic 

departments of primary care at Manchester, Oxford, Cambridge, Bristol and Birmingham. 

Martin is an elected Fellow of the Academy of Medical Sciences with 25 years experience of working in general 

practice, most recently in the University’s practice at Rusholme Health Centre in central Manchester. 

Day 2 

Day two focused on What’s working, Why and How to make progress with quality improvement initiatives. Local 

experts highlighted the relevance of international quality frameworks and how existing processes in New Zealand 

contribute to a culture of improvement in primary care. 

4 © THE ROYAL NEW ZEALAND COLLEGE OF GENERAL PRACTITIONERS / Summary of Proceedings 2008

The workshop established how interdependency of current initiatives that impact on general practice could produce a 

course of action that will contribute to a collective outcome through shared understanding and a coordinated quality agenda. 

Contributors: 

The Royal New Zealand College of General Practitioners, Jonathan Fox (President), Karen Thomas (CEO), and its 

Board of Quality (John Wellingham (Chair), Chris Fawcett, Harry Pert, Kenneth Tong, Jim Vause, and Maureen Gillon, 

acknowledge and thank those who contributed to the success of the symposium. In particular, Martin Roland (UK) and 

Pat Snedden provided valuable and thoughtful comments and facilitation throughout the two days. 

Thanks are due to: 

Tangata Whenua, Ngati Whatua 

Martin Roland (UK) 

Pat Snedden (MOH Quality Improvement Committee) 

Tane Taylor (RNZCGP Te Akoranga a Maui 

Dee Mangin (Otago University) 

Les Toop (Otago University) 

Jim Primrose (MOH) 

Verna Smith (ACC) 

Sue Dovey (RNZCGP) 

Andrew Holmes (MOH) 

Stephen Lillis (Board of Assessment) 

Denise Ward (Pinnacle) 

Chris Boberg (ProCare) 

Stephanie Pope (Te Wana) 

Stephen Buetow (Faculty of Medical and Health Sciences) 

Tim Malloy (Rural) 

Margie Apa (MOH) 

David Galler (Sector Quality Direction) 

Judi Strid (HDC) 

Jocelyn Tracey (Phocus) 

Michael Lamont (PHO Alliance) 

Jane Ayling (NZNO Practice Nurses) 

Kevin Hague (DHBs) 

The College would also like to thank those who facilitated the small group sessions during the two days and acknowledge 

participants for giving up time to attend. It was good to see the strength of the Quality network, with 140 participants 

from every level of primary care. The stimulating and challenging conversation throughout the symposium 

highlights a continuing passion to drive a high quality primary care sector and there is a keen interest in continuing to 

develop the quality agenda in New Zealand. 

Note: the material in the overview is extracted from Martin Roland’s preparatory work. 


Summary of Proceedings: Overview 

Day 1 – Quality Measurement 

Themes: 

1. Why measure quality of care – How can it be defined? 

2. The characteristics of a good indicator 

3. Should quality assessment focus on process or outcome? 

4. Should indicators be evidence based? 

5. What are some of the problems in measuring quality? 

6. Frameworks: How to develop a set of quality indicators 

7. Debate: “Pay for performance is the answer to quality improvement”. 

Day one covered why quality needs to be measured and how it should be defined. The learning objective was to 

ensure participants would be able to describe the main reasons for measuring quality and develop an understanding 

of current international trends in quality measurement. As a conceptual framework, Donabedian’s structure, process 

and outcome were used to describe the relationship between frameworks, quality of care and why different stakeholders 

might have different perspectives on quality. 

Why measure quality? 

• As a basis for quality improvement 

• Comparisons can stimulate and motivate change 

• As part of pay for performance schemes e.g. QOF 

• As part of regulation e.g. of minimum standards 

• To assist with purchasing e.g. contracts which include minimum quality standards 

• To identify areas of need for future investment 

• To inform service users 

• Understand international trends in quality assessment 


Frameworks of quality 

Defining quality can be difficult because of different perspectives. Patients and carers, clinicians and managers have 

different needs and expectations about which aspects of quality should be measured. ‘How can quality be measured’, 

often starts with a discussion of ‘What is quality’. A number of authors have described frameworks, including 

Donabedian 1 , O’Leary and O’Leary 2 and Maxwell 3 . Participants explored the conceptual framework described by 

Campbell et al 4 , and included notions of safety 5 . Group discussions explored the scope and adequacy of existing 

quality frameworks, identified aspects of care for which quality can’t be measured, and ways of measuring quality 

which might make care worse. 

Frameworks of quality must provide clear direction for what to measure and what is relevant to measure. The group 

explored the difference between indicators, guidelines, standards and targets, the characteristics of good indicators 

and how evidence is incorporated into quality measurement. 

There has been considerable debate about the pros and cons of using process and outcome as measures of quality. 

However, it is important that the aspect of care being measured be under the control of the person/organisation whose 

care is being judged. In general practice, process measures are often better indicators of quality of care if the purpose 

of measurement is to influence the behaviour of those providing care. Processes are common, under the control of 

health professionals, and may be rapidly altered. Outcome measures are rare and may follow a change in process by 

up to 10 years. The group discussed whether process or outcome indicators were more useful, what aspects of care 

are important to measure and what can be controlled. 

Important considerations: 

1. Measuring quality can have drawbacks, with negative or unintended consequences as well as those that are 

intended: 

• Long lists of ‘primary care indicators’ that only indicate the level of activity that has taken place, not the 

quality with which that care has been given. Activity is sometimes synonymous with quality, but by no 

means always 

• Inspection of sets of quality indicators often highlights what is not being measured 

• Problems in comparing performance between areas with different populations 

• Perverse behaviours, which may be induced by incentives, associated with quality measurement 

2. Understand why there is a need to measure (macro or micro level) services and considerations before proceeding: 

• What indicators already exist? 

• What is the evidence for use? 

• What data is already available? 

• Is there a need to develop your own indicators? 

3. To measure quality of care in a range of different circumstances some general principles apply. 

• Be clear about why you want to measure quality 

• Consider the service and aspects of care you want to assess 

• Are they important to measure? 


• If you use existing indicators, is there evidence for aspects of care that you want to measure If so, how will 

you access it to develop your quality indicators? 

• Decide what lengths to go to in order to collect data on quality of care 

A sample of quality frameworks (Table 1) provided examples in New Zealand and the UK QOF. 6 Each identified 

strengths and weaknesses of the different frameworks and the approaches taken to development. 

Debate: “Pay for performance is the answer to quality improvement” 

The UK Quality Outcomes Framework (QOF) contract, based on 146 outcome indicators, links income to performance. The 

model has been challenged for changing general practice from an internal framework of professionalism to an external 

framework that embraces a market model of healthcare with performance 7 . Based on their paper, Les Toop and Dee Mangin 

were invited to take the negative view and provided a view of the New Zealand context and the argument against a QOF 

framework being applied in New Zealand. Verna Smith (ACC), who is completing a Ph.D on Pay for Performance, took the 

affirmative perspective, along with Jim Vause, from the College’s Board of Quality, who agreed to participate. 

The debate provided clarity on the complex issue of Pay for Performance and highlighted the complex issues around 

quality measurement and monitoring discussed during the day. The real value was the argument for and against quality 

measurement in a Payment for Performance model. Policy, funder and general practice perspectives stressed the need 

for careful consideration of the impact before progressing and for all parties to move forward together on the issue. 

Table 1: Examples of frameworks: 

Standards National Programmes Local Programmes – PHOs Outcomes measurement 

RNZCGP Aiming for Cornerstone Pinnacle Q9 

Excellence 

HCA Te Wana standards Te Wana ProAc 

H&DC Health Sector HDC Complaints process ProExcellence 

Standards 

H&DC Code of Rights 

Ministry of Health 

International programmes 

DHBs PHO Performance 

Management Programme 

QOF (UK) 


Day 2 – Quality Improvement 

Themes: 

1. Are indicators useful? What are the internationally transferable concepts? Frameworks: QOF and Aiming for 

Excellence – what are the benefits if any? 

2. So your results look bad: what to do next? 

3. Aiming for Excellence version 3 

4. Forum – Exploring the interdependency of quality initiatives that impact on general practice 

5. What’s in it for me? 

6. Martin Roland – reflections from the two days 

Quality Improvement 

Building on the lessons from day one, day two focused on quality measurement, and its application by a range of 

organisations for the purpose of measurement and improvement. In particular, how the UK health system uses measurement 

for incentivisation, its limitations and relevance for New Zealand. 

Martin Roland led the second day with a presentation on the Quality and Outcomes Framework, covering development 

and how it was used to negotiate the UK GP contract. The framework focuses mainly on chronic disease management, 

with little on the clinical care of acute medical problems, or on communication between doctors and patients. 

It represents a major gap in the overall assessment of quality of care in general practice. He noted that NZ 

should consider the impact of a QOF type framework and identify important principles relevant to its own setting, as 

adoption of another framework may not apply or be relevant. The way forward should be a well considered pathway, 

to ensure important aspects toward improvement in the NZ setting are measured. 

Frameworks are important, and that each is unique. The group discussed the impact of QOF on NZ initiatives such as 

the PHO Performance Management Programme and the other frameworks such as the College’s Aiming for Excellence. 

There are important lessons for NZ general practice and the health sector, for example: 

• Should the NZ College reconsider its structure for the Aiming for Excellence framework? 

• What are the pros and cons of including clinical outcome indicators in Aiming for Excellence? 

• What would a framework for NZ look like and how would we select/develop clinical indicators? 

Room for improvement? What do you do next? 

“So you’ve measured your chosen aspect of care, and there appear to be problems in your care.” 

The group was taken beyond the theory to the practical application of quality through people, processes and tools. 

Measuring quality using quality indicators is only the first step to improving quality. There is no single method of 


improvement and sustained improvement is more likely to be successful if multiple approaches that align with professional 

values are used. Practical approaches to quality improvement that are aligned to performance evaluation are 

key features of any improvement system. 

The group was asked to explore commonly used strategies and processes for quality improvement, their relative 

strengths and weaknesses, and identify which ones they would implement. In particular: 

• Which indicators, what they measure, and in particular any problems with recording 

• Standards – Who decides? What is good, bad or useful, and on what basis? 

• How robust is the data/information? 

• Clinical or organisational audit, including significant events 

• Feedback of results of audits on quality of care 

• Quality circles, assessment by peers 

• Release of information on quality of care to professionals or to the public 

• Educational events: lectures, seminars and courses 

• Opinion leaders to promote change and quality improvement 

• Financial or employment penalties 

Applying theory to practice in the NZ setting 

The symposium identified how much of the theory is reflected in NZ general practice through strategies such as 

Cornerstone or other similar quality improvement processes. An understanding of the strengths and weaknesses of 

such programmes in achieving success were discussed and which ones should be enhanced and which ones used 

less. A number of innovations or opportunities were identified where examples of teamwork were crucial in making 

progress. The Pinnacle experience of assisting their practices to prepare for Cornerstone General Practice Accreditation 

was provided as an example of a ‘win-win’ approach. 

Aiming for Excellence version 3 is an example of leadership to guide capability in NZ general practices. An overview of 

development was provided. Martin Roland provided an independent opinion and messages for the future. He noted 

that Aiming for Excellence is a model that the UK considers good practice and is now looking to NZ for further advice. 

Forum – different perspectives 

The purpose of the forum at the close of day two was two-fold: to understand the perspective of sector organisations, 

their role in quality and how they link measurement with improvement in their own organisations. Each provided clear 

guidance about a primary health care quality with its complexity of people, professionals, and systems, but there was 

clear agreement that; “…We have already come a long way, we are taking responsibility for leading quality in the health 

sector, and there is a sense of hope…” 

10 © THE ROYAL NEW ZEALAND COLLEGE OF GENERAL PRACTITIONERS / Summary of Proceedings 2008

Main points: 

• There is a need to identify linkages and interdependency of quality initiatives that impact on general practice at 

a national and regional level. 

• There is a willingness to ensure that actions contribute to collectively improving outcomes for patients and 

developing effective methods of keeping them out of secondary care through utilisation of primary care resources. 

• Fostering a learning environment to reduce harm and the level of complaints is essential. A culture of preventing 

harm and learning from mistakes must be a feature of primary health care. 

• The importance of defining, standardising and linking measurement with improvement processes, that provider 

assurance of a high performing primary health care sector. 

• ‘The quality of the experience’ is an emerging theme and likely to be a challenge with diverse communities and 

expectations. How will general practice teams respond? 

Further discussion needed: 

• Quality frameworks, Clinical indicators, Safety, monitoring and feedback systems – NZ has most general practices 

participating in PHOs but there is no evidence that it adds value to quality in general practice, what would 

improve effectiveness and how would we know. 

• Pay for performance, target setting – does it make a difference? 

• How can we continue to learn from international experiences – opportunities and lessons? 


Results 

1. Masterclass 

Martin Roland’s one day Masterclass contributed to a better understanding of the link between quality measurement 

and its components, quality improvement and processes, and the positive or negative impact of 

incentivisation. 

The group identified and discussed limitations of measurement only and its reductionist aspect; that quality indicators 

only measure what can be measured. They were concerned that measurement alone may exclude more important 

aspects of care and encourage minimalist approaches to the delivery of care. 

There are existing lessons that result from the impact of a measurement only approach: 

• A ‘piecemeal’ approach to providing care at the expense of holistic care 

• Organisational/sector focus on measured aspects of care to the detriment of other areas 

• Decisions being made from poor quality data or that which is difficult to access 

• Differences between providers may be difficult to interpret 

• Quality measurement can be expensive (e.g. if review of individual patient records is needed) 

• May encourage a blame culture and reduce professional motivation to improve 

• May lead to short-term, rather than longer term strategic planning 

• May introduce perverse incentives to gain or manipulate data 

Measurement must sit within an established framework that justifies why data is being collected and has agreement 

of those involved. There are no magic bullets for quality improvement but the first steps toward quality 

improvement rely on the drivers having the right motivation. Professionalism is identified as an important driver – 

‘doing the right thing right’, and measuring quality should always be for the right reason – why, who for, and the 

spirit of intent. 

Secondly the capacity to measure technical processes raised the question of fairness. Current structures are complex 

with many players including, large organisations with good capacity and small businesses with little capacity. Fairness 

and equity issues were raised as a caution to applying generic expectations. 

Finally there is agreement that there is a need for greater dependability in the health sector but, remaining to be solved, 

Who pays and What are they paying for? There was a strong message that paying for professionalism is more acceptable 

than paying for performance. 


2. Pat Snedden, Chair, MOH Quality Improvement Committee – key messages 

The College is grateful to Pat Snedden, chair of the Ministry of Health’s Quality Improvement Committee, who 

provided valuable comment and reflection during the symposium. Its role is to provide leadership on quality in the 

NZ Health sector. 

Main points: 

• The QIC interest in primary health care is front line quality and the quality of the experience. Primary care has 

been exempt from the attention that secondary care has received and recent concerns from NZ and Australia 

highlight the need for attention. (NZ Health and Disability Commissioner – complaints system, ACC – harm 

panel for serious and sentinel events) 

• There is a need to establish a Quality Agenda and Framework for NZ Healthcare. The area of focus needs to be 

on how to share information, and what information is needed to make progress. 

• QIC believes people most at risk should get what they need and more analysis on inequalities is essential. It will 

need to establish how to engage with communities to determine what should be measured and wish to develop 

a continuing relationship. 

• A relationship between QIC and the primary care sector is essential. QIC is responsible for providing oversight 

to ensure the sector improves the patient journey and includes consumer participation in decision making, 

keep people out of secondary care and manage primary care more effectively. It is interested in working with 

the collective interests and establishing rules of engagement in dialogue that includes respect for all views but 

also the ability to challenge if needed. 

• Management of healthcare incidents is acknowledged as a problem area. QIC is interested in the overall management 

of sentinel events and wish to begin an informed public debate that will identify a process to deal with 

sentinel events and serious safety issues. Those who have been hurt will be recognised and professional 

innovation will be highlighted. There is a commitment to honest dialogue. 

“The QIC Goal for 2008 – how can we bring our mutual excellence to citizens of Aotearoa?” 

* Mr Snedden is also chair of the Auckland District Health Board. 

3. Key points: Development of a quality environment 

for primary care in New Zealand 

1. High level quality – culture of sector, what do we want the sector to do and why 

There is a growing NZ quality network that is beginning to form in the primary care sector. This group is taking greater 

interest, ownership and leadership of quality and there are now established relationships developing that are having 

an impact on sector quality – professional organisations, funders, service providers, teams, patients and communities. 

Sector quality will be successful if clinical governance relies on doctors being not only arbiter of quality but an essential 

participant in the process. All primary care clinicians should have access to all the information required to best manage 

patients; access to records, to secondary care management if appropriate, medication history, to diagnostics that help 


assess the nature and severity of complaints and access to specialist services to advise and assist in management of 

care in the community. 

System issues must focus on quality improvement interventions that address patient conditions. The essence of the 

primary health care strategy is to make connections and be more connected. This means there must be a robust 

integrity of the system in which primary care operates alongside other services, (whether health or other agencies), 

that impact on wellbeing such as housing or work and income. Does primary care have the infrastructure, information and 

connections to best help patients? 

Participants were asked to remember that the system is there for patients that access primary care for proactive or 

reactive reasons. Proactive reasons might include nutrition advice, screening, vaccinations, referral to WINZ, Housing 

NZ etc. Reactive reasons might include ‘unwellness’. If it is the latter, what is it that patients need and value? What does 

primary care do for them now; how might that be improved? 

For both parties, building a relationship would be a good start. Do we know and trust each other? 

There are obvious workforce issues, not just numbers but stability of the workforce, after hours, training and recruitment. 

Secondly, a range of diagnostic and information based tools exist that assist clinicians to provide care for patients. 

Access to those resources varies around the country – this is an increasing challenge for quality in primary care. 

2. Frameworks of quality in NZ 

Leadership on quality in the New Zealand Health Sector by a number of organisations has already provided the 

beginning of an infrastructure for a quality framework. The forum reinforced the need to maintain and support local 

quality frameworks and foundation programmes. Their contribution to improvement and transparency in primary health 

care quality is now apparent. 

The forum also acknowledged the value of national quality frameworks as an important benchmark for local quality 

programmes and their potential for improving patient outcomes. These frameworks are complementary and the principle 

of alignment and collaboration where possible, was encouraged. 

The use of quality frameworks can be inspirational when they incentivise teamwork and reflection on clinical 

practices – quality committed teams make improvements and streamline redundant systems, processes, paperwork, 

duplication; so they can focus on improving patient outcomes. 

Existing quality frameworks have provided leadership by applying clinical governance approaches, and clear 

guidance for their use, particularly for establishing goals and setting targets. Examples provided by presenters 

noted that the ‘spirit of intent’ has strongly influenced ownership through principles, governance structures and 

buy in from those involved. 

3. Significant tools for quality 

Quality tools should be defined by the owners and users and be fit for their purpose. They should identify the gap 

between current practice and ‘best practice’ and be able to influence and reinforce change. 

• Quality toolkits are useful; practices don’t want to reinvent the wheel. More assistance through greater access 

to a wide range of existing resources is required. Cost and time was identified as major barrier for some 


• Define the owner – there was agreement that a shared vision and agenda will have an impact on which quality 

tools and methods are used in the sector 

• Measures – what should be measured? Development and use of indicators is dependent on the context and 

environment 

• Improvement – change depends on effective clinical leadership and governance, the culture of the sector, local 

networks, national and frameworks and supporting resources 

• Enhanced teams – the diversity of teams is changing in primary care and provides more scope to work differently 

with individuals and across populations 

• Practices – the building should provide the range of services and activities that support a quality learning 

environment – space, culture of teamwork, range of health professionals, protected time, an IT infrastructure, 

PMS, guidelines integrated with PMS systems, linkages to other primary and secondary services, diagnostics, 

PDSA cycles of activity for monitoring 

• Patient focused – tracking the patient journey – the electronic patient record is identified as the key to improvement 

4. Pay for performance 

Pay for performance should be carefully established with principles and parameters within an established framework 

agreed to by the sector. An appropriate balance of incentives (financial, contractual, professional) is essential. There 

are different perspectives that make it important to develop rules before it is established. 

Pay for performance is not straightforward but the group was clear that payment should not be on the basis of data 

collection. It should be linked to service improvement; savings made, efficiencies in services and effective outcomes 

for patients. The group was not supportive of the approach taken by the UK where individual performance was resourced 

instead of systems. Although the group supported pay for professionalism as an essential element to ensure health 

professionals are properly resourced, performance must also be responsive to local needs. 

5. Mechanisms for driving quality 

Pre-requisites for quality – there are a range of mechanisms that the sector may identify. This should be in conjunction 

with QIC e.g. professional standards, clinical governance, continuity/integration of care between primary/secondary. 

The H&DC has a strong interest in safe and high quality systems that are based on ‘learning, not lynching’ – the Code 

of Rights is cited as the best consumer framework and the principles are key. It is a good example of a simple framework 

that can and has been applied across the sector. 

Contracts are a powerful mechanism for driving quality but are dependent on the culture of sector. Contracts should 

note exclusions or inclusion clauses to explain reporting. 

6. Primary Care Health Workforce – professionalism 

Recognition of the value of primary health care teams as a critical success factor in quality is essential. More health 

professionals are working collaboratively and managing patient care as a team so increased clinical training opportu- 


nities and protected teaching or learning opportunities are needed (complexity of evidence, information, IT systems, 

processes, pharmacology, diagnostic tests etc). For this to occur practices must be successful as businesses before 

they can be successful as quality teams: the system must first support the professionals to do the work they need to 

do, and enable them to be clinicians. 

Characteristics of a high quality learning environment: 

• National framework of education 

• Professional framework 

• Research and development 

• Clinical governance 

• Change management 

• Performance management 

• Teams 

• Feedback 

• Analysis of performance 

• Improvement purposes 

7. Make information publicly available 

The UK has been successful in developing publicly available, transparent outcomes information. Patients are able 

to access detailed information about health outcomes in their general practice and compare them with other 

practices. This is highly dependent on information capture, good IT systems, evidence based indicators and a 

willingness to participate. 

In New Zealand H&DC collect information about adverse outcomes, the MOH provide results for the sector. The 

concern from general practice is about the robustness of data and how it will be used. The system relies heavily on 

good quality coordination and support. It is proposed that the PHO Performance Programme might be the precursor 

to a UK style of feedback to sector and patients about performance. 

8. Marketing success 

Patients are not aware of the benefit of quality programmes. Marketing success improves networking opportunities 

and provides an opportunity to showcase and build pride in the sector. Doing this at every level of the system can be 

difficult but building in celebration and including others must be part of the culture. 


Key principles developed by participants 

• Quality must be driven from the front line (bottom up) but supported from the top 

• Formative approaches work best when quality comes from within. An externally driven compliance model 

it will not work 

• Only gather information that is useful to front line clinicians 

• Encourage diversity and team based approaches 

• Encourage communication of experiences – patients and clinicians 

• Allocate responsibility to lead and involve all sectors 

• Streamline and standardize data capture systems and methods to reduce variation and incorporate all 

essential requirements into one Practice Management System so it can be used for quality improvement 

• Prioritise important factors 

• CQI principles should be applied to all processes 

• Identify baseline standards & safety factors e.g. sterilisation, immunisation 

• Support external review by peers as an important part of quality improvement 

• Encourage primary health care teams to value and recognise quality team culture as critical 

• Practices must be successful as businesses before they can be successful as quality teams 

• Quality should be well resourced 

• The use of quality frameworks can be inspirational when they incentivise teamwork 

• National system – National standards or programmes e.g. Cornerstone, Te Wana, must align with the 

Primary Care Strategy 

• Make allowance for local variation – e.g. urban, rural, small. Regional systems – DHB/PHO/MSOs/IPAs, 

have the ability to prioritise enrolled populations 

• Involve everyone! 


Conclusion – The way forward 

The growing leadership and knowledge base forming around primary care quality is apparent and the Quality Symposium 

has provided an opportunity to review emerging issues together. Considerable discussion during the course of 

the two days produced important outcomes, in particular the discussion and principles identified on Pay for Performance 

is testimony to the level of thinking. 

While the obvious workforce and related issues are an underlying problem, there was a clear focus on refinements 

needed to make progress in the health sector. Clear agreement and understanding of the way forward emerged. One, 

that there is agreement that much has been achieved in recent years but there are particular needs for the sector if 

further improvements are to be made. A second is to make progress on a national Quality Improvement Agenda 

There is clear support for a National Quality Framework for primary health care that includes prevention and learning 

approaches to improvement. Recognition that much of the structure is already in place reminds us just how far some 

aspects of the health reforms have changed the way care is offered. In particular, investments in IT initiatives now 

support health practitioners to provide better integration of care through improved information and capacity in practice 

management systems. 

The next step is to improve practice team and primary care capability through development of integrated practice 

environments where learning is paramount. This is an important next step and where the value of previous investment 

is realised through research, education, practice, resources (including people), and quality tools can be utilised to 

contribute to reductions in disparity and improvements in patient outcomes. Learning environments rely on multiple 

interventions that are systematic and sustained. Some of this is achieved through policy, funding and contracting but 

relies heavily on relationships, teams, communication and interdisciplinary collaboration where new ideas can be 

generated and ‘the right’ attitude or culture is important. 


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O’Leary D.S and O’Leary M.R. From quality assurance to quality improvement. The Joint Commission on Accreditation 

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Maxwell R.J. Dimensions of quality revisited: from thought to action. Quality in Health Care. 1992; 1: 171–177. 

4 

Campbell S, Roland M, Buetow S. Defining Quality of Care. Social Science and Medicine. 2000; 51: 1611–1625. 

5 

Dovey S 

6 

UK QOF – Martin Roland, A4E – Kenneth Tong, Pinnacle – Q9 Stephen Lillis, Denise Ward, ProExcellence Chris Boberg, 

Te Wana – Stephanie Pope 

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verdict. British Journal of General Practice. 2007 July; 57(540): 525–527 

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