Intended for healthcare professionals

Education And Debate Improving the quality of health care

Research methods used in developing and applying quality indicators in primary care

BMJ 2003; 326 doi: (Published 12 April 2003) Cite this as: BMJ 2003;326:816
  1. S M Campbell, research fellow (,
  2. J Braspenning, senior researcherb,
  3. A Hutchinson, professor in public healthc,
  4. M N Marshall, professor of general practicea
  1. a National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL
  2. b UMC St Radboud, WOK, Centre for Quality of Care Research, (229), Postbus 9101, 6500 HB Nijmegen, Netherlands
  3. c University of Sheffield, Section of Public Health, Sheffield, S1 4DA
  1. Correspondence to: S Campbell

    Before we can take steps to improve the quality of health care, we need to define what quality care means. This article describes how to make best use of available evidence and reach a consensus on quality indicators

    Quality improvement is part of the daily routine for healthcare professionals and a statutory obligation in many countries. Quality can be improved without measuring it—for example, by guiding care prospectively in the consultation using clinical guidelines.1 It is also possible to assess quality without quantitative measures, by using approaches such as peer review, videoing consultations, and patient interviews. Measurement, however, plays an important part in improvement.2 We discuss the methods available for developing and applying quality indicators in primary care.

    Summary points

    Most quality indicators are used in hospital practice but they are increasingly being developed for primary care

    The information required to develop quality indicators can be derived by systematic or non-systematic methods

    Non-systematic methods are quick and simple but the resulting indicators may be less credible than those developed by using systematic methods

    Systematic methods can be based directly on scientific evidence or clinical guidelines or combine evidence and professional opinion

    All measures should be tested for acceptability, feasibility, reliability, sensitivity to change, and validity

    What are quality indicators?

    Indicators are explicitly defined and measurable items referring to the structures, processes, or outcomes of care.3 Indicators are operationalised by using review criteria and standards, but they are not the same thing; indicators are also different from guidelines (box 1). Care rarely meets absolute standards,5 and standards have to be set according to local context and patient circumstances. 6 7

    Activity indicators measure how frequently an event happens, such as the rate of influenza immunisation. In contrast, quality indicators infer a judgment about the quality of care provided,6 and performance indicators8 …

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