Conditions and barriers for quality improvement work

Eva Arvidsson, Sofia Dahlin, Anders Anell

Keywords: Primary health care, General practice, Quality improvement, Audit & feedback, Quality indicators, Reimbursement, Incentive


High quality primary care is expected to be the basis of many health care systems. Expectations on primary care are rising as societies age and the burden of chronic disease grows. To stimulate adherence to guidelines and quality improvement, audit and feedback to professionals is often used. Even with carefully designed audit and feedback practices, barriers related to contextual conditions may prevent quality improvement efforts. The purpose of this study was to explore how professionals and health centre managers in Swedish primary care experience existing forms of audit and feedback, and conditions and barriers for quality improvement, and to explore views on the future use of clinical performance data for quality improvement.


We used an explorative qualitative design. Focus groups were conducted with health centre managers,
physicians and other health professionals at seven health centres. The interviews were analysed using qualitative content analysis.


The main part of the audit and feedback was “external”, from the regional purchasers and funders, and focused on non-clinical measures such as revenues, utilisation of resources, and the volume of production. The participants did not perceive that this audit and feedback practices contributed to improved quality in general. This, along with lack of time for quality improvement and lack of autonomy were considered barriers to quality improvement at the health centres.


Professionals and health centre managers did not experience audit and feedback practices and existing conditions in Swedish primary care as supportive of quality improvement work. From a professional perspective, audit and feedback with a focus on clinical measures, as well as autonomy for professionals, are necessary to create motivation and space for quality improvement work. Such initiatives also need to be supported by quality improvement efforts at the system (macro) level, which favour transformation to a primary care based system.