We identified seven themes that described views related to the existing systems for A&F and QI at the HCs: 1. Multiple forms of A&F with different purposes and designs, 2. Focus on revenues, costs and efficiency measures from regional managers and owners, 3. More limited attention to clinical quality, 4. Motivation from comparison and transparency, 5. More structured approaches needed for complex change, 6. Focus on avoiding quality degradation rather than quality improvement, and 7. Perceived barriers for QI. The last theme consisted of three categories: 7a. Criticism of measures – and hopes for better ones, 7b. Lack of time, and 7c. Responsible but not in control. A presentation of the content of each theme and selected informative quotes follow below.
1. Multiple forms of audit and feedback with different purposes and designs
Participating HCs were exposed to multiple forms of A&F. We identified four different types of stakeholders with different stated purposes and varying designs in terms of their A&F: 1) the regional managers in their role as purchasers and funders, 2) the owners of the HCs, 3) the regional pharmaceutical committees and the Swedish strategic programme against antibiotic resistance (Strama) groups, and 4) the PC research and development (R&D) unit (in one of the two regions).
Except for general dialogue and information exchange they all had different aims, used different measurements and had different targets, see Table 1.
Characteristics of different stakeholders’ A&F
Stakeholder and role
Regional managers (Purchasers and funding agents)
Owners of the HCs (public or private)
The regional pharmaceutical committees and Strama groups
The primary care R&D unit
Control compliance to contractual obligations
Monitor revenues, expenditures and general performance
Monitor prescriptions at the HCs and
Facilitate learning and innovation through local improvement activities
Often face-to-face, sometimes by video link, but sometimes sending out data reports only
Sometimes face- to-face meetings, but usually sending out data reports only
Often face-to-face meetings or video meetings, but sometimes sending out data reports only
Audit reports in combination with face-to-face meetings
Participants from HC
Usually limited to HC managers and key staff selected by the HC manager
HC managers (who distribute information to the staff)
HC managers and key staff at the HCs
HC managers and key staff at the HCs
Measures and targets
Facilities, staffing, opening hours and collaboration agreements with a focus on non-clinical measures.
Quality of care measures often linked to financial P4P incentives.
Expenditures, utilisation of services (e.g. diagnostic procedures) and other non-clinical measures. Process measures linked to financial incentives (e.g. number of visits and waiting times).
Mainly clinical measures linked to treatment guidelines, evidence-based national targets and regional recommendations on drug use, including restrictive use of antibiotics.
A combination of mainly clinical measures compiled by the R&D unit, reflecting quality of care for different patient groups. Discussion and reflection rather than goals.
We have contractual follow-up by the reginal purchasers. Actually, I sent it in last weekend. Previously, they sent us feedback and asked us to comment on it. It can be different types of data. It can be clinical data, but it can also be about accessibility or staffing. Anything is possible. It can be for example [treatment with] anticoagulants. [And then they ask us to] tell them what we think about our results. Last time it was about patient safety. (HC B, manager)
Some feedback about finances, how we are doing on prescriptions, diagnostic procedures and laboratory tests. Then we also get feedback on how we are doing on medication reviews of patients taking more than 10 drugs, how many we have done, and the cost of drugs for diabetes, asthma, and COPD and what else is it …?
(HC A, manager)
There has been a lot of feedback on [how we prescribe] antibiotics. Strama have been very much out visiting … to check that we follow the guidelines.
(HC C, Medical officer)
We have had a follow-up every year from the R&D unit and it has been valuable
(VC E, manager)
We do not have the energy or tools to set aside time to find out how many patients have heart failure or atrial fibrillation and [how many of them have] this treatment in that dose….
(HC G, manager)
2. Focus on revenues, expenditures and production volume from owners and regional purchasers
The participants talked about "clinical quality” i.e. the quality of different procedures such as diagnostics, treatment and rehabilitation of patient groups with different diseases or needs, and distinguished this from data and measures regarding revenues, costs, utilisation of services, access to care and patient satisfaction. Both the regional purchasers, and in particular the owners, regularly delivered data to the HCs linked to revenues, production volume and utilisation measures, e.g. registration of diagnoses (influencing revenues), number of visits, and expenditures related to diagnostic procedures and drug prescriptions.
The owners provide us with statistics every month and these are a mixture of different types of statistics. But these are not clinical [measures], it is more about consumption of various… of care, laboratory tests, x-ray, right? (HC C, manager)
One HC manager said that the owners clarified their mission for the HCs through the financial goals.
The demands of balanced financial results across HCs from owners were perceived as a driving force to use data, but this demand was rarely described as a positive driver.
We monitor the numbers of laboratory tests, x-rays and other diagnostic procedures, and pathology every month and report it to the staff. Recently we felt that we had to find a different way to report it, so for a period so we have calculated each doctor's production costs the amount of Swedish Krona. But now we feel, and they also feel, that this is not right. Everybody has a different number of visits. (HC E, manager)
Several participants, both HC managers and staff, felt that the payment system in its current form forced them to do tasks that did not add value for patients, in order to gain sufficient funding for HC activities that did create value for patients in the following step. Examples of such tasks connected to funding were home visits to patients who did not need them, carrying out QI projects in areas or ways that were not considered necessary, and several administrative tasks.
It has become a bit strange in this control system we have that controls our financial situation and what we do. We can do some things just to get funding to be able to use the money for our patients in the next step, for example registration of diagnoses for the ACG system. We do put resources into it to be able to get better quality for our patients, but it is a detour, so to speak. It can be quite frustrating sometimes! (HC A, manager)
Many HC managers found it their informal duty to act as a "filter" between employees and regular reports from regional purchasers and in owners. They studied the data, assessed the results and then brought up some of them with the employees
All the figures are sent to us and when we see that something is happening, then we act. We can't just report everything every month to everyone, but we follow a lot. (HC E, manager)
3. More limited attention to clinical quality
Clinical quality, i.e. measures that reflected the actual care of patients and diseases, was followed up only to a small extent by regional purchasers and owners, with the exception of a few measures linked to P4P, e.g. use of antibiotics. In contrast, the R&D unit, the pharmaceutical committee and Strama brought data on clinical quality when they visited the HCs. The visualisation of clinical results, and comparison with others, together with a dialogue around current measurements were perceived as valuable and inspirational for QI. The participants particularly appreciated visits by senior colleagues with experience from work at health centres.
Then he showed how the different colleagues worked and it led to a very creative discussion between us colleagues.
(HC F, Employee))
Nurses at many HCs followed quality on diabetes care through the National Diabetes register (NDR) which they found useful but sometimes time-consuming, since they had to register in both the EMRs and the quality register.
The HCs had to retrieve additional data on clinical quality from the EMRs themselves. For example, at one HC, data on heart failure was previously studied by a GP trainee, and the HC kept following this from time to time but not regularly. Some HC managers presented plans on initiating regular follow-ups on more topics. A few said that they looked forward to using the EMR-generated “Primary Care Quality” system to monitor clinical quality.
4. Motivation from comparison and transparency
Working with measurements and data was described as a meaningful task, particularly by HC managers at some HCs.
We can get data out of the EMRs and then think and calculate, but I am the one who does it. Everything takes time and I think… I think it's fun to do it too. Create Excel charts and tables and comparisons, but it takes time, all of that. (HC H, medical officer)
A common method of using data for QI was to simply visualise it and compare with other HCs, especially for clinical data and data on utilisation of laboratory tests and diagnostic procedures.
As soon as you raise a problem area, it suddenly just gets better. You do not have to make any changes, just raise the subject and something happens in the group and then the data becomes better. We have seen it so many times. (HC E, manager)
For prescriptions of antibiotics and other drugs, the same method was used but with data and comparisons for each individual doctor. First, the results were discussed in a group. Then, each GP was handed a list of their patients with the expectation that each GP should “act and change their habits” accordingly.
We focus on some topic, discuss, think about how we can improve and then we receive some statistics that are individual. And then we handle the statistics on an individual level. That's how we work. (HC D, Employee)
The participants described both positive and negative feelings concerning sharing data that identified them as individual team members, and about comparing this personal data with each other openly. Doctors were used to discussing differences of opinion, e.g. concerning the use of laboratory tests or drug prescriptions. They explained that they did not criticise or judge each other. Instead, there was an understanding of "necessary variation" linked to patient needs. However, some nurses said that they were not comfortable with this method.
So we measured it and then we asked if “you [the nurses] are prepared to, every day before you go home, record for yourself how many calls you have made and write it on the board. You don't even need to write your name.” No, they weren't prepared for that. (HC G, manager)
A similar method was also used for more complex problems that required collaboration and team work. In these cases, the individual feedback could be one step in the process of QI. For example, one HC tried to address the issue of frequent visitors. In this case it was decided that one GP would interview selected patients to better understand the causes of frequent visits. This information was later used by giving each GP a list of their own frequent visitors to try to improve the quality of care for their patients. Data from the National Diabetes Register (47) was used in a similar way.
In NDR, for example, we usually report twice a year at workplace meetings so that everyone can see the results. And where the goals are not fulfilled, the reports end up at each doctor's desk for action, or active thinking. Sometimes there can be good reasons for why goals are not reached or why the doctor has chosen not to achieve them. It is not just presenting data but expecting reflection and preferably action. (HC E, manager)
5. More structured approaches needed for complex change
For major improvement projects, requiring organisational changes, the participants described a more structured approach, i.e. using more or less formal Plan-Do-Study-Act (PDSA) cycles.
Some participants described how working according to the traditional PDSA method included forming an improvement team, setting goals, analysing problems, extracting data, analysing data, and considering possible changes. Subsequently the teams tested changes, measured again, evaluated outcomes and finally they proceeded to “run another lap”.
If I show a figure where someone prescribes a lot of a particular drug it will drop pretty automatically. What is difficult to get action on is if we have to change something bigger. For example, when we want the asthma nurse (instead of the doctor) to take all asthma patients who have no other disease. Then maybe more time is needed for her and we have to plan. It requires more structure and organisational changes. Then it can be more difficult to get action. There might not be enough time for that either. (HC H, medical officer)
The HC could also use a simplified version of the PDSA method.
In our QI projects here at the HC, we are much more direct. We sit down, but sometimes maybe only for 15 minutes and then somebody gets up, grabs a pen and goes to the flip board. Let’s ask 10 patients who are leaving, can you make sure that the forms will be in place? We will meet again in two weeks. Then we’re done with analysing and move on. We don't really have the time to follow all that methodology and I don't really know what is best, but we have made a choice. (HC G, manager)
Some participants also described how coaching and project management from an external party could facilitate the QI process. However, coaching needed to be according to the conditions of the HCs and should focus on results rather than the method.
6. Focus on avoiding quality degradation rather than improvement
Many QI projects across participating HCs were described as trying to “adapt to reality” and as avoiding quality degradation rather than accomplishing quality improvements. One explanatory factor referred to was a lack of resources including a shortage of GPs and other health professionals. The staff searched for opportunities to increase efficiency by balancing needs in different groups. For patients with chronic diseases, the improvement projects were about prioritising those with greater needs, e.g. by improving continuity of care and extending teamwork around patients. Improvements to drug treatment in chronic care were common, partly because they were connected to P4P funding. For patients with non-severe acute diseases, like minor infections and smaller injuries, participants described QI projects on improving telephone accessibility and implementing new digital technologies, such as digital triage systems, in order to ration the utilisation of GPs.
At all HCs, the staff also tried to increase capacity by involving all professions in direct patient work. This included making all professions a possible "first-line contact", e.g. by enabling patients to go directly to physiotherapists, psychologists or psychosocial teams without a GP referral. HCs also arranged for nurses to take over the diagnostics and treatment of some patients from the GPs, e.g. those with minor infections. Similarly, all professions were involved in the treatment and follow-up of patients with chronic disease.
At several HCs, data was extracted to track any adverse effects for other patient groups than those targeted in improvement projects. For example, one HC planned to follow up what happened to patients whose care was rationed. The HC had been criticised by regional purchasers for making patients with acute minor problems wait, and they thought that “proving” that 1–2 weeks waiting did not cause harm might lead to acceptance of their policy and prioritisation.
It is possible to produce statistics and reports on which patients had to wait more than a week. We plan to do this to see if there is something we have missed there. If there was actually someone who should have come earlier or if waiting doesn’t matter. If waiting doesn’t cause harm we don't think it matters much [that patients with acute minor problems wait]. Was there someone who had to wait two weeks before they got their appointment and if so, was this OK? Was it completely OK or was it in any sense harmful that they had to wait so long? If it wasn't harmful or the patient might even have been well before they came in and there were no other consequences of waiting, then it might be good to be able to show this. (HC H, Medical officer)
At another HC the idea was to monitor clinical quality using “Primary Care Quality” to ensure that clinical quality did not deteriorate due to shortage of staff after an improvement project was carried out. The HC was about to lose half of their GPs the following year, and a new working method was introduced in which nurses rather than GPs saw patients to a greater extent than before.
7. Barriers to QI
7a. Criticism of measures – and hopes for better ones
The participants were critical about the dominance of A&F based on measures reflecting revenues, expenditures and the volume of care.
The data that we usually receive on physiotherapy concerns accessibility, which has been followed traditionally. Not much else. […] How many visits did the physiotherapist have? There is no evaluation on quality or treatment. There's nothing like that really. That's what we're missing. (HC E, Employee)
Also measures of accessibility such as the number of patients who got an appointment within three or five days, a measure the regional purchasers found important, were often described as “pointless”.
A pointless measure is offering everyone an appointment within five days. Who came up with that? After all, it is totally insane since we have tax-financed health care and laws on priority setting. The law says that we should prioritise those with the greatest need for care… I think this type of measurement creates so much frustration in primary care when there are much more important measures (HC G, manager)
The participants’ main wish was for more measures reflecting clinical quality, including patient outcomes. They wanted additional measures representing the patients’ perspective on care, and measures that reflected quality in PC from a broader perspective.
They (regional purchasers) asked us how many complaints we had had. Not how many medical incidents or mistakes. [We] thought about that … What are complaints? So, well…. (HC B, manager)
Many participants also said that “real quality” could not be measured. Hence, they had to accept ”proxies” that could give a hint about quality even if this was not the whole truth.
Some things you can put into numbers. Other things are assessed more using soft data. It may not be as easy to measure. … It might be possible to measure, but you cannot compare numbers like one, two, three, four as for hard data. It's more subjective. (HC E, manager)
7b. Responsible but not in control
Funding of HCs had to cover both direct and indirect expenditures related to salaries, prescribed medication, laboratory analyses, and diagnostic procedures. Sometimes QI could increase expenditures for the HC. For example, one HC had worked on optimising drug treatment for diabetes, which resulted in better blood pressure and blood sugar levels for their patients, but also more expensive medicines, which in turn led to higher costs for HCs who had to pay for prescribed drugs.
It is a high price financially, but maybe in 10 years the patients will gain something, we don’t know. (HC G, manager)
Total expenditure at the HCs, which the HC managers were held accountable for, was partly out of the managers’ direct control. For registered patients, HCs had to pay for visits and drug prescriptions for their patients arranged by other PC providers.
[We had] very bad metrics for a certain drug. A doctor in town prescribed all of it. But it was registered on, and paid for, by us, because the patients were registered with us, but did not come to us. (HC F, Employee)
A main problem, brought up by many participants, was the large and growing pressure for more PC services, described as a “mission impossible”. This included trying to adapt to the demands and needs of all current patients while at the same time constantly being assigned new tasks, like requests for prompt follow-ups of patients discharged from the hospital, or taking over responsibility for patient groups that used to be taken care of by hospital-based specialists, usually without extra funding.
Then it is also true that the assignment we have been given, we didn´t define it ourselves, but we got an assignment that was determined by some third party. And then the resources that we get to fulfil this assignment, we might not get them. But the assignment doesn’t change but stays the same anyway. We take care of 13,000 patients. Whether we have staff or not we are supposed to fulfil the assignment. It is like saying that a ship needs 35 crew members with different skills, and then there is only half of the crew, but the ship should sail anyway, the crew should do all these jobs. Somewhere this equation doesn’t add up. (HC F, Employee)
The HCs reported that they could not refuse tasks or registration of new patients, even if there was a shortage of GPs and other health professionals.
Unrealistic requirements from the regional purchasers and owners related to access to care for minor problems was also seen as a big problem. Several participants experienced a conflict between what they thought was good quality and these requirements.
The main goal of politicians is that accessibility should be so damned good. So if it is 25 persons who need to see a doctor one day, yes, then it should be 25. What is it then that we have to cut down on? Well, the clinical quality, the quality of communication (HC F, Employee)
A solution considered necessary in order to create good quality at the HCs by both professionals and HC managers was prioritising and rationing, i.e. to remove tasks to balance with the available resources. But this was not possible for single HCs and had to include changes in contracts for all HCs in the region.
For several complex problems, QI focusing on individual HCs was deemed insufficient. To initiate change and improvements, other health care providers needed to be involved as well. This meant that QI needed to be initiated and governed from the meso level, and had to include both hospital and primary care. One example referred to by participants was patients with mental health problems. Here the HCs wanted to work on improvement together with psychiatric care providers.
Similarly, some participants suggested that systematic QI should also be conducted at the national level. One example given was to create improved conditions for good continuity in PC by strengthening the overall capacity and number of GPs. Solutions to the current shortage of GPs were largely perceived to be found at the macro level. Thus, improvements at the HC level were not perceived to be enough, but systematic improvements on the macro level were required.
The management in different regions does not have the ability to make sure that the doctors want to work in primary care and to make a correct analysis of what the reason is [for lack of GPs], so they could find the cause and then remedy it. They are not willing to do that (HC F, Employee)
7c. Lack of time
Most of the participants described a desire to improve daily work at the HC, but it was difficult to find time for QI projects since they had to fill their days with patient appointments. The lack of time also made it difficult to obtain and assess data. Many HC managers said that they simply had no time to do it themselves. The HC administrators who could have helped them were also often occupied with other tasks such as meeting regional requirements that the doctor's dictated notes should be typed up within 48 hours, or the HC would lose some of its funding.
Participants at HCs that had performed a few QI projects pointed out that it was difficult to follow and improve quality in several fields at the same time, or to work as systematically as they wanted. Many emphasised that they did not just need time for the QI projects themselves, but also time to think about what they needed to improve.
We must have enough health professionals. Because we are too few and work is too stressful, we can’t think of quality and QI projects. I think that doctors should have some time for reflection as well because it is also a part of our job to think about what we do and how we are doing it. When we are this few, maybe we need it even more. (HC C, medical officer)
The current situation was perceived to cause frustration but was also described as a distinct motivator behind QI. QI projects could try to find ways to improve overbooked schedules for GPs or to reduce expectations on GPs to prescribe medication or order tests without seeing the patients.