Performance indicators for general practice

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7013.1167c (Published 28 October 1995) Cite this as: BMJ 1995;311:1167
  1. Frances Mair, Research fellow
  1. University of Kansas Medical Center, Department of Family Medicine/Telemedicine, 8630 Halsey, Lenexa, KS 66215, USA

    Emphasis is changing from quality assurance to continuous quality improvement

    EDITOR,--Performance indicators have long been used in the United States as a tool of quality assurance programmes and are now being promoted in Britain.1 The emphasis of quality assurance on identifying “problems” and the “bad apples” in medicine is, however, now being viewed in the United States as counter productive. Unsurprisingly, it is difficult for a negatively oriented process to engender the enthusiasm and capture the support of health care professionals. That is not to say that standards are not required, but in the United States the emphasis is changing from quality assurance to continuous quality improvement.

    The Joint Commission on Accreditation of Healthcare Organisations has used performance indicators as part of its quality assurance programme and will continue to do so, but it is placing increasing emphasis on continuous quality improvement.2 Many general practitioners must fear that performance indicators as introduced by family health services authorities will be used punitively to identify deficiencies and exert control. Continuous quality improvement aims not to blame but, instead, to seek the root causes of a failure in process that can be improved.3 Important tenets of continuous quality improvement are that efforts for improvement are internally driven, not an external mandate; that it focuses on systems first and individuals second; that it recognises that error free care cannot be guaranteed but instead emphasises that the quality of care can always be continuously improved; and that the commitment of leaders is necessary.2

    Quality of care should be assessed and monitored and efforts made to improve standards. Nevertheless, the imposition of performance indicators by family health services authorities without consultation and negotiation is unlikely to be as beneficial as a well planned quality improvement programme that aims to get each primary health care team continually to improve the quality of care provided. As with many things that are imposed, people will try to find ways of cheating the system and of going through the motions of monitoring and evaluation while not really believing in them.

    Performance indicators can certainly be useful, but they should be only one of many tools used in a much wider programme that seeks to improve quality of care. It is also vital that any such project be proactive and a collaborative effort between management and all those in the front line of the provision of health care.


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