Department of Family Medicine, University of Ljubljana, Slovenia
Received date: 14 May 2012; Accepted date: 20 November 2012
Every patient who visits his or her general practitioner (GP) or primary care team first and foremost seeks to banish the fears connected with their disease, gain the doctor’s help to cure or at least improve their con-dition, and return to their home environment or workplace. People place immeasurable trust in medi-cal staff and, in a modern society, various factors contribute to quality of care provided though this personal relationship between patient and physician or nurse. These include the assessors and supervisors who use various criteria to test the quality and safety of medical treatment.
The basis of a comprehensive and systematic ap-proach to establishing quality in business, organisa-tional and highly specialised lines of work was introduced to health care through the business world. Arguably, it is because these approaches are insuf-ficiently adapted to health care that their translation to this setting causes problems in practice. Just as in the business world, quality in health care is perceived as enabling greater competitiveness at both the local and national levels. Some countries even adopt national strategies on quality and safety in health care partly for this reason.
International certification or accreditation, based on standardised evaluations, is also issued in health care. Of these, the ISO (International Organization for Standardization) 9001:2008, NIAHO (National Inte-grated Accreditation for Healthcare Organizations), JCI (Joint Commission International) and ISO 15189: 2007 are the best known and most widely used. By meeting the requirements defined in these standards, internationally adopted principles of quality medical care can be achieved in domains including safety, timeliness, effectiveness, efficiency and patient focus.
Last year, the practice where I have been working as a GP for a number of years was also involved in the process of obtaining the ISO 9001:2008 certificate and, in 2012, it was awarded this certificate as part of the Ljubljana Health Centre. Throughout the quality veri-fication process I felt that the quality evaluation should be modified for primary health care. As an example, the parameters included in the PHAMEU international study (Primary Health Care Activity Monitor for Europe) under the ‘Quality’ section would be much more appropriate.
The PHAMEU project covered 27 European Union (EU) member states, one EU candidate country (Tur-key), and three members of the European Free Trade Association (EFTA: Iceland, Norway and Switzerland). This project paid special attention at the primary care level to the quality of preventive actions, the quality of organisation and chronic illness management, the quality of drug prescriptions, the quality of diagnostics and treatment, and the organisation of maternal and child health care. Of course, part of the project focuses on the equipment available at the practices, the avail-ability of medical staff, accessibility and complaint systems, which are the basic components of assessing established standards.
Many elements of current certification procedures are sound, but a practice, even if well equipped with state-of-the art equipment, can nonetheless exhibit poor quality in managing chronic illnesses or preven-tion, and chaotic drug prescribing, for example ex-cessive antibiotic prescribing. Another criterion used in the PHAMEU project worthy of highlighting is ‘avoidable hospitalisation’. For example, if cancer is detected at an early stage, mutilating surgery may be prevented and treatment lengths shortened, reducing patients’ suffering. If management of a patient with chronic obstructive pulmonary disease (COPD) is of good quality, hospitalisation and unnecessary costs may be reduced.
Another set of quality criteria, those measured by the QUALICOPC international study (Quality and Costs of Primary Care in Europe), are also much more useful for physicians, nurses and patients involved in primary health care. In addition to other quality criteria, this project also takes into account the possi-bility of a migrant or foreigner entering the healthcare system. Today the following question is more than appropriate: ‘You need an interpreter when talking to the doctor in this practice, is one available or not?’ It also includes elements of error prevention (wrong medicine, wrong test Results, and excessive repetition of tests).
In case readers feel that my dissatisfaction with established standards such as the ISO is excessive, I would like to stress that the modern concept of quality encompasses more than the measurement of effective-ness, equipment availability, information flow, com-plaints, and so on, and also includes creativity and the ability to adapt the changing healthcare environment.
In conclusion, I would like to touch upon the ability of primary care to adapt, respond in a timely way, and plan appropriately for future change. We know that primary health care internationally, especially in terms of organisation and financing, is in a period of crisis that may continue for another decade. These turbu-lent times are reflected in a number of issues such as lack of staff, which is particularly critical in rural areas, pressure from the unemployed, who more often seek psychological assistance from their GPs, greater need for health care during ecological disasters, the unreas-onably high prices of medicines, and so on. Many are unsure how primary health care will cope in these turbulent times.
Unfortunately, we are not asked about how we plan our activities during a time of crisis. A moment of crisis is the wrong time to start learning about the adaptability of health care, because this would mean that it is already too late. However, it is appropriate to be even more aware of the importance of knowledge and creativity and the absurdity of excessive bureauc-racy for superfluous issues, which is just as common in health care as in other industries. The human factor is of key importance in the response to a crisis. How is the ability to adapt or the appropriateness of crisis planning included in the certification processes? Will we come out of the crisis wiser?
Success in emerging from the current crisis may prove to be the most important evidence that our work in primary health care has been effective.
Not commissioned; internally Peer Reviewed.