A conceptual framework for performance assessment in primary health care

As health systems strive to achieve improvements in quality, equity and efficiency, systems of performance assessment are increasingly being introduced. To function effectively as tools for internal quality improvement, they need to be aligned with staff and organisational objectives, foster insight into practice and provide a focus for learning leading to improvement. Adopting such a "coalface" perspective, we developed a conceptual framework to underpin the potential development of a quality system for a large primary health care program. The Framework for Performance Assessment in Primary Health Care (FPA_PHC) is grounded in evaluation theory and explicitly identifies the processes of primary health care articulated by the World Health Organization (WHO). It is based on Donabedian's (1998) now classic "structure", "process", "outcome" model for assessment of quality of care. The FPA_PHC specifies the development of objectives that are focused on patients/families/communities and has four indicator levels relating to stewardship, organisational structures and processes, processes of care and intermediate outcomes. Equity can be assessed by asking of processes of care and intermediate outcomes: "is it the same for everyone?" The indicators can be mapped to higher order system performance frameworks such as the National Health Performance Framework. The FPA_PHC has been adopted for the National Quality and Performance System for Divisions of General Practice and its application in this and a second setting are described.