Something is missing in the conversations of quality measurement and improvement of primary care. There is no question we have a lot of opportunity to improve primary care and solid agreement that good primary care is the foundation of high performing health systems.
The conversations around quality and primary care fall into a trap and once in that trap never seem to escape. The trap is the mistake of making part of a system work well at the expense of the overall system performance.
We see this all the time in practice. We see health care delivery improving efficiency and flow (a.k.a. 'throughput' = number of patients treated per day/hour/minute) without attending to quality and experience of care. We find practices improving access by trashing continuity of care. We see primary care practices put all their improvement energies into one or two diseases and exhausting themselves while leaving the overwhelming majority of patients they serve with the same old care.
Primary care is fundamentally different from the rest of the health care delivery system. More primary care leads to improved outcomes and lower overall costs. More specialty or hospital care leads to increased costs and worse outcomes.
The national paradigm for primary care quality right now is based on detailed tactical aspects of work in practices:
- Add a diabetes educator
- Screen diabetics for depression
- Implement ePrescribing
These are all nice but effective primary care is more than a bucket of tactical improvements. Moreover, focus on the tactical detail may distract us from attending to the overall system. Any one of the interventions listed above may lead to improvement for some patients but a practice could do all of this and more and still fail to provide a solid foundation of primary care. This approach perpetuates the general lack of understanding of the value of primary care.
If we want to achieve overall population health improvements, improve the experience of care and in so doing reduce per capita cost trends, we must understand primary care as an effective system for population health care management.
Complex systems are driven by simple rules. The simple rules driving primary care are:
- Be the first point of access
- Develop relationships over time
- Provide comprehensive services
- Coordinate care
Understanding, measuring, and working with these simple rules helps drive the complex and nuanced work of primary care improvement. Focus on the overall system and support innovation as teams explore the right parts for their local environment.