Service Quality

Improving the quality of care involves three interlinked concepts: quality planning, quality control, and quality improvement: ¹⁵²⁴²⁵

• Quality planning Includes aims, processes, and goals needed to create an environment for continuous improvement. includes aims, processes, and goals needed to create an environment for continuous improvement.

• Quality control Entails monitoring established processes to ensure their functionality. entails monitoring established processes to ensure their functionality.

• Quality improvement the action of every person working to implement iterative, measurable changes, to make health services more effective, safe, and people-centred. is every person working to implement iterative, measurable changes to make health services more effective, safe, and people-centred.

This action provides guidance on the steps countries can take to make health services more effective, safe, and people-centred via careful planning and iterative, measurable changes. ⁸²⁵²⁶It contains the following sub-actions:

• Sub-action 1. Create an enabling health system environment 

• Sub-action 2. Implement tools, interventions, & processes to reduce harm and improve the effectiveness of clinical care

• Sub-action 3. Engage and empower patients, families, & communities 

Sub-action 1. Create an enabling health systems environment 

An enabling health system environment includes the supportive conditions (i.e. payment systems, funding flows), governance processes, legislative environment, and culture that creates quality in a health system. Establishing an enabling environment creates concrete accountability and liability for the delivery of quality health services at the national, district, and facility levels and develops a shared understanding of quality across the health system. ¹⁰¹⁵¹⁶

Key activities  

National and sub-national levels

• Establish a national commitment to quality. ¹⁵²⁵²⁶
  • See page 13 of the WHO’s planning guide for quality health services for step-by-step guidance. 
• Develop a national strategic direction on quality and , and update the national quality policy, strategy, or plan at least every five years. ¹⁵²⁵²⁶
  • See pages 14-17 of the WHO’s planning guide for quality health services for step-by-step guidance. Also, see Annex 2 of the guide for a list of questions to consider when planning for quality in a health system. 
• Select and prioritise a set of quality interventions, including ^15252627
  • Interventions to create an enabling systems environment (i.e. registration and licensing, external evaluation and accreditation, clinical governance, public reporting and benchmarking, training and supervision of the health workforce)
  • Interventions to reduce harm (i.e. safety protocols and checklists, quality improvement protocols and checklists, systems for adverse event reporting)
  • Interventions to improve the clinical effectiveness of care (i.e. standardised clinical forms and decision support tools, context-appropriate clinical standards, pathways and protocols, clinical audits and mortality reviews) 
  • Interventions to engage patients, families, and communities (i.e. tools, services for health literacy and self-care, formalised community engagement mechanisms)
• Develop a pragmatic quality measurement framework. ²⁶
  • See page 17 of the WHO’s planning guide for quality health services for step-by-step guidance. 
• Develop an operational plan and resourcing strategy to ensure the national direction on quality is translated into action. Some of the critical resource considerations include: ¹⁵²⁵²⁶
  • Time:  Clinicians who spend time in training; records departments; and discussing standards, measurements, and action plans can not spend that time in clinics.
  • Data, information, and guidance:  Clinical and management staff need access to standards, practical guidance on tested quality improvement methods, and examples of results, which must be gathered and developed for local use.
  • Funding: The cost of staff time and how to best use it are critical resource questions at all times. Direct costs of quality improvement programs include quality support staff, training, data collection, and access to information.
  • See pages 17-18 of the WHO’s planning guide for quality health services for step-by-step guidance.
• Establish a quality directorate, department, or unit to move forward with the development and operationalization of the national direction on quality. ²⁵
  • This directorate should intentionally work across different health sector institutions and stakeholders outside the government (such as health professional associations) to achieve buy-in as well as to gain additional resources for developing and implementing regulations. ²⁸
  • The directorate should also coordinate quality systems with national or local government to ensure valid standards, reliable assessments, consumer involvement, demonstrable improvement, transparency, and public access to quality criteria, procedures, and results. ²⁴
• Establish well-designed health information and monitoring and evaluation (M&E) systems that routinely collect and publish data on quality health systems at the national, subnational, and local levels. Also, utilise external assessment, such as peer review and accreditation. ¹⁵²⁵²⁶
  • See action #3 in the adjustment to population health needs module for a list of activities that countries can take to strengthen their M&E systems; and a list of relevant case studies, tools, and resources.
• Cultivate a culture of learning on quality across the health system, and embrace a continuous process of improvement. ¹⁵²⁵²⁶
  • Implementers’ and governments’ do not always line up—the process of institutionalising quality management infrastructure can take as many as 5-8 years, though individuals might change more quickly. “In using external technical assistance to set up quality systems, attention should be given to ensuring that transferred know-how becomes fully institutionalised.” ²⁴
  • See pages 14-15 of the WHO’s handbook for national quality policy and strategy for additional guidance.

District level

• Commit to delivering on national quality goals and priorities. ²⁶
  • See page 24 of the WHO’s planning guide for quality health services for step-by-step guidance. 
• Develop district-level quality structures and operational plans, and update them based on learnings from health facilities and the new or emerging national strategic direction on quality (if relevant). ²⁶
  • See pages 25-26 of the WHO’s planning guide for quality health services for step-by-step guidance.
• Orient health facilities to district- and national-level quality goals and priorities. ²⁶
  • See pages 25-26 of the WHO’s planning guide for quality health services for step-by-step guidance.
• Fulfil facility needs for reaching selected aims, and ensure functioning support systems for quality health services. ²⁶
  • See page 29 of the WHO’s planning guide for quality health services for step-by-step guidance.
• Maintain engagement with the national government on quality health services. ²⁶
  • See pages 26-29 of the WHO’s planning guide for quality health services for step-by-step guidance. 
• Foster a positive environment for quality health service delivery, and adapt quality interventions to district-level contexts. ²⁶
  • See pages 30-32 of the WHO’s planning guide for quality health services for step-by-step guidance.

Facility level

• Commit to district aims, and identify clear facility improvement aims. ²⁶
  • See pages 40-41 of the WHO’s planning guide for quality health services for step-by-step guidance. 
• Establish, organise, and support multidisciplinary quality improvement teams, and prepare for action. ²⁶
  • See pages 41 of the WHO’s planning guide for quality health services for step-by-step guidance. 
• Conduct a situational analysis or baseline assessment to understand the current ‘state of quality’ in the facility and to identify gaps.  A key step in improving service quality is evaluating how the facility currently delivers services or processes as well as how much value these services provide to patients. There are a variety of tools and techniques that can be used to evaluate the quality of care at the facility level:
  • Health facility assessments (i.e. Service Provision Assessments, Harmonised Health Facility Assessments, Service Availability and Readiness Assessments, etc.)
  • Individual-level surveys (i.e. PROMs questionnaire, patient satisfaction surveys, provider satisfaction surveys) 
  • Other facility-specific assessments (i.e. setting and monitoring progress toward internal quality improvement targets) 
  • See pages 42 of the WHO’s planning guide for quality health services for step-by-step guidance. 
• Adopt standards of care. ²⁶
  • See pages 42 of the WHO’s planning guide for quality health services for step-by-step guidance. 
• Identify and prepare for quality improvement activities by developing an action plan. ²⁶
  • See pages 43 of the WHO’s planning guide for quality health services for step-by-step guidance. 
• Undertake continuous measurement of . ²⁶
  • See pages 44 of the WHO’s planning guide for quality health services for step-by-step guidance. 
• Focus on continuous improvement—identify what works and does not work, and refine action plans over time. 
  • Build pathways to improvement through supportive supervision, performance monitoring and measurement, and continuing professional development. To avoid duplication and fragmentation, performance monitoring that occurs at the facility level should be aligned with national and subnational monitoring and evaluation efforts. ^15262930
  • Collect and use performance data to make decisions and improve the quality of services.  To ensure that services and processes align with population health needs and context, continuously collect accurate, timely, and reliable population health data as a part of quality processes. These data should, in turn, support local decision-making processes to ensure that services and processes align with the local population’s needs and preferences and achieve desired health outcomes. Approaches should prioritise improvements in areas with the greatest quality deficits to ensure health equity and the efficient use of resources. ⁹²⁶
  • Cultivate a culture of learning. facilities should be designed and managed using systems to identify, react to, and learn from safety incidents and quality gaps. Successful systems require facilities fostering a culture of safety, reporting on errors and near misses, learning from their mistakes, and tracking progress towards safety- and quality-related goals. ⁹²⁶
  • See pages 45-46 of the WHO’s planning guide for quality health services for step-by-step guidance. 

Related elements

• Governance
• Financing
• Information & technology
• Management of services

Relevant tools & resources

• Davey et al., 2022: How to embed quality improvement into medical training 
• The Global Fund, 2022: Compendium of resources on the quality assurance of essential health products 
• WHO, 2022: Global competency framework for universal health coverage 
• WHO, 2022: Caring for those who care: guide for the development and implementation of occupational health and safety programmes for health workers 
• WHO, 2022: Compendium of resources on quality of care 
• WHO, 2021: Building better together: Roadmap to guide implementation of the Global Strategic Directions for Nursing and Midwifery in the WHO European Region
• WHO, 2021: WHO Global Benchmarking Tool (GBT) for evaluation of national regulatory systems
• The National Center for Complex Health & Social Needs and IHI, 2020: Measuring Complexity: Moving Toward Standardized Quality Measures for the Field of Complex Care
• CHCS, 2021: Assessing the Impact of Complex Care Models: Opportunities to Fill in the Gaps
• WHO, 2020: Quality health services: a planning guide
• WHO, 2020: Operational framework for primary health care - see operational lever on systems for improving quality of care (page 58)
• WHO, 2018: Technical series on PHC - Quality in PHC
• WHO, 2018: Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care
• WHO, World Bank, and OECD, 2019: Delivering quality health services: a global imperative for universal health coverage
• WHO, 2016: Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level
• USAID and CHIP, 2012: Creating strong incentives for high-quality health care in low- and middle-income countries 
• Institute for Healthcare Improvement: Improvement Capability Self-Assessment Tool

Sub-action 2. Implement tools, interventions, and processes to reduce harm and improve the effectiveness of clinical care 

The presence of quality standards and safety protocols in a facility is often not sufficient to achieve quality gains. Studies show that providers in LMICs often do less than half of the recommended evidence-based care actions, and incorrect diagnosis is a major challenge. These quality gaps are due, in part, to insufficient capacity within the PHC workforce. ¹⁰ Here, we describe various activities countries can implement to increase the capacity of staff to provide better services as well as to increase their motivation to improve.

Key activities

National and sub-national levels 

• Reform pre-service education and training. Pre-service education is the first opportunity for providers to receive training that will influence technical quality. However, stagnant medical curricula have resulted in mismatched provider competencies and patient needs, which can lead to quality gaps at the point of care. ¹⁵
  • Include ‘principles of quality' in the pre-and in-service training of the PHC workforce as well as in continuous professional development. ¹⁵²⁶
  • Read more about strategies to reform medical education and curricula in the Workforce and Service Availability and Readiness modules.
• Develop and support the implementation of quality and evidence-based standards at the point of care. Developing clinical standards is often an early step in the national quality policy development process. ^15233132
  • Develop and implement community-based models of care that address multiple dimensions of quality. Design patient care protocols and clinical pathways that emphasise the core dimensions of quality (timeliness, , , safety, people-centeredness, integration, and equity). 
  • See pages 16-17 of the WHO’s technical series on the quality of care and the organisation of services module for additional guidance. 
• Build structures to ensure that staff receive compensation in a timely and reliable manner and are therefore available and motivated to provide quality services. Such structures may include training for local staff in financial management and accountability systems, such as recordkeeping, to ensure that facilities are using funds for their intended purpose. ²⁷³¹
• Implement integrated care pathways, referral protocols, team-based care models, and other that make it easier for providers to proactively and competently manage patient care. ²⁷³¹
• Use population health management approaches to balance provider caseload and increase timeliness and efficiency of care. When providers are overburdened by patient demand, they may not have adequate time to devote to each patient. This challenge can be avoided during empanelment. When planners determine the appropriate size for each panel, they should strongly consider provider burden and the number of available providers. ³³
  • See the empanelment deep dive in the population health management module for more information on what empanelment is and how to implement it.
• Use monetary or non-monetary incentives to improve the motivation, availability, and competencies of staff, such as pensions, insurance, travel, child care, and community support or engagement efforts, among others. Depending on the context, incentives may also be managed at the facility level. ³⁴³⁵³⁶
  • See the WHO’s review of incentive and remuneration strategies and the Service Availability and Readiness and Purchasing and Payment Systems modules for additional guidance. 
• Ensure that staff have the tools, medicines, and supplies they need to deliver quality services using robust supply chain management, supportive policies, and flexible financing. ^15233132
  • Develop and support the implementation of health product and policy standards.
  • Develop and support the implementation of administrative controls to safeguard the health of patients and staff during everyday patient care (i.e. standard precautions that apply to all patient care).
  • Conduct medicines regulation, which includes pharmacovigilance and post-marketing surveillance of medicines and supplies. 

Local and/or facility level

• Provide ongoing training and continuing professional development opportunities, such as continuing medical education programs and peer-to-peer learning. ²³³¹³²
  • Learn more about training and professional development opportunities in the service availability and readiness module.
• Use protocol-based approaches and decision-making tools to make it easier for clinicians to readily access reliable, evidence-based content at the point of care. ^15233132UpToDate is one such clinical resource that can give providers the informational tools they need to improve care. 
  • See pages 16-17 of the WHO’s technical series on the quality of care and the service availability and readiness module for additional guidance. 
• Implement systems for performance monitoring and data-driven decision-making. To ensure adherence to safety and quality standards in practice, promote a continuous culture of quality improvement, and equip providers with the requisite training and resources needed to deliver high-quality services. Staff supervision is one form of applied, individual-level performance measurement and management that can improve and help staff to deliver more effective services. ^15233132
  • Learn more about systems for quality improvement in the management of services module.
• Use team-based models of care to balance provider caseload and increase the timeliness and efficiency of care. If there is an adequate supply of human resources, shifting responsibilities to other staff members may help enable providers to spend more time with patients. How responsibilities are divided between the health workforce depends on their training and competence and should always be planned with optimization of roles in mind. It is crucial to ensure that providers have the relevant competencies to carry out their responsibilities when optimising roles and scopes of practice and that they are part of larger multidisciplinary teams that are structured to meet population health needs. ^15233132
  • Learn more about team-based models of care in the organisation of services module.

Supporting elements

• Policies and leadership
• Multisectoral approach
• Financing
• Inputs
• Management of services and population health
• Service availability & readiness 
• Primary care Primary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” functions

Relevant tools & resources

• Ariadne Labs, 2022: Better Evidence Project
• Davey et al., 2022: How to embed quality improvement into medical training 
• The Global Fund, 2022: Compendium of resources on the quality assurance of essential health products 
• WHO, 2022: Compendium of resources on quality of care 
• WHO, 2022: Compendium of resources on safer primary care 
• WHO, 2022: Global competency framework for universal health coverage 
• CHCS, 2021: Assessing the Impact of Complex Care Models: Opportunities to Fill in the Gaps
• The Journal of Precision Medicine, 2021: Maximise healthcare performance by reducing unwarranted variations
• WHO, 2021: Building better together: Roadmap to guide implementation of the Global Strategic Directions for Nursing and Midwifery in the WHO European Region
• WHO, 2021: Global Patient Safety Safety refers to the practice of following procedures and guidelines in the delivery of PHC services in order to avoid harm to the people for whom care is intended.  Action Plan 2021-2030
• WHO, 2021: WHO Global Benchmarking Tool (GBT) for evaluation of national regulatory systems
• The National Center for Complex Health & Social Needs and IHI, 2020: Measuring Complexity: Moving Toward Standardized Quality Measures for the Field of Complex Care
• WHO, 2020: Quality health services: a planning guide
• WHO, 2020: Operational framework for primary health care - see operational lever on systems for improving quality of care (page 58)
• Healthcare Financial Management Association, 2019: Reducing clinical variation to drive success in value-based care (part 1) and (part 2)
• WHO, World Bank, and OECD, 2019: Delivering quality health services: a global imperative for universal health coverage
  • See table 5.1 (page 66): illustrative quality interventions for an enabling system environment for list of evidence-based interventions for creating an enabling system environment
• Relias, 2018: 4 steps to successfully reducing clinical variation
• WHO, 2018: Technical series on PHC - Quality in PHC
• IHI, 2017: IHI Framework for Improving Joy in Work
• JLN, 2017: The Joint Learning Network has developed a resource on financing and payment models based on country implementation experience as well as a manual and online course on costing health services for provider payment. 
• WHO, 2011: Patient safety curriculum guide: multi-professional edition 
• Frenk et al., 2010: Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

Sub-action 3. Engage and empower patients, families, and communities

Meaningful community engagement helps to build and strengthen people’s trust in the health system and to solicit feedback that can be used for quality improvement efforts. It is also a critical way to hold health systems accountable for the delivery of —a core element of service quality. Global evidence suggests that community engagement and empowerment mechanisms can promote better care, enhanced patient experience, more effective healthcare utilisation, reduced costs, and improved health outcomes. ²³³⁷

Key activities 

National and sub-national levels

• Generate enabling conditions for community engagement and empowerment.
  • Create fundamental shifts in governance and accountability arrangements. For example, governments might embed values important for community engagement and empowerment, such as transparency, equity, and inclusiveness, into existing governance structures and processes. 
    • See pages 22-23 of the WHO’s community engagement framework for additional guidance. 
    • Adopt policies that promote multisectoral and intersectoral action for health, such as Health in All Policies. 
      • See the multisectoral approach module for additional guidance. 
• Establish a shared vision, mission, or purpose. Focus leadership efforts on cultivating a shared vision, mission, and sense of purpose across the health system. For example, seek to design models of care that promote this shared vision of quality health services, and involve patients, families, and community members in this process.  
  • See page 23 of the WHO’s community engagement framework and the policy & leadership module for additional guidance. 

All levels 

• Generate enabling conditions for community engagement and empowerment.
  • Resources: Invest in and manage resources to promote the engagement and empowerment of communities. For example, redesign spaces and implement technologies to support participatory processes and collaboration. 
    • See page 23 of the WHO’s community engagement framework and the action ‘improve the way health facilities are designed and managed’ for additional guidance. 
  • A prepared and supported workforce:  Equip health workers with the “soft skills” needed to meaningfully engage with communities, such as value-based decision making, self-awareness, empathy, and . 
    • See page 23 of the WHO’s community engagement framework and the service availability and readiness module for additional guidance.
  • People-centred accountability arrangements:  At the facility level, community engagement mechanisms can provide patients with the means to hold providers accountable for the delivery of services that meet their needs and preferences. Supply-side accountability mechanisms can also help to reinforce service quality and reward providers or care teams for the services that are high-quality and in line with local priorities. ¹⁰³⁰ In addition, successful care models are accountable to patient needs and health outcomes. Accountability can occur at many levels in the health system: ^38394041
    • At the national level, policymakers and planners can reinforce accountability by implementing empanelment schemes and other mechanisms to promote PHC as the first point of contact and equity in access to quality services.
    • At the regional level, referral centres can accept accountability and responsibility for the health outcomes of patients in their catchment areas.
    • At the local level, care teams can take responsibility for the active management of the health of their patient panel, using prompt referrals and proactive outreach.
• Build capacity for community engagement and empowerment.
  • The WHO’s community engagement framework identifies four capacities necessary to ensure effective implementation of health services and programmes. Effective implementation means that health services and programs align with the local context and that communities are involved in the design, implementation, and improvement of these services and programmes. These capacities include: ^15263742
    • Capacities for shared assessment and analysis of the situation. 
      • Link M&E frameworks to community and health service feedback mechanisms to ensure that community input informs the design and implementation of health interventions, services, and programmes.
      • Routinely measure and publicly report on the quality of health services from the patient perspective, including measures of patient experience and patient-reported outcomes.
  • Capacities to design context-specific approaches for shared agenda-setting and planning and for defining roles and responsibilities. 
    • Involve communities in the planning and implementation process in meaningful ways. For example, countries should engage and empower communities to 
      • Contribute to the development of national health plans (including the strategic direction on quality) as well as their operationalization at the subnational level.
      • Collaborate and engage with health professionals and providers through feedback and formal community engagement mechanisms to discuss clinical performance and contribute to the design of improvement activities.
    • Engage communities in the design, organisation, and delivery of services early and often, such as by involving citizen representatives in national and local priority setting exercises.
  • See pages 20-21 of the WHO’s technical series on the quality of care and pages 23-24 of the community engagement framework for people-centred, and resilient health services for additional guidance.
• Implement strategies to increase .
  • Enhance health literacy among the population. ^25424344
    • Develop policies and plans on health literacy promotion including operational plans and funding strategies to sustain and implement health literacy programmes across the health system. 
    • Establish well-designed surveillance and risk communication platforms that routinely collect and disseminate health information from and to local communities.
    • Collaborate across sectors for mutual successes, and meet obligations to provide people with accurate, up-to-date information that is unbiased by undue influence from outside the health sector.
    • Capacitate PHC centres and care teams to provide relevant and accessible information to patients and to engage them as equal partners in their care.
    • See pages 31 and 42 of the WHO’s report on engaging patients, carers, and communities for delivery and the health literacy section of the population health management module for additional guidance.
• Use shared decision-making in clinical settings. ⁴²
  • See pages 5 and 18 of the WHO’s report on engaging patients, carers, and communities for integrated health services delivery for additional guidance. 
• Build peer support and expert patient groups. 
  • See pages 7 and 23 of the WHO’s report on engaging patients, carers, and communities for integrated health services delivery for additional guidance. 
• Support patients, families, and communities to participate in self-management and self-care. 
  • See pages 7-8 and 23-25 of the WHO’s report on engaging patients, carers, and communities for integrated health services delivery for additional guidance. 
  • See the self-care section of the population health management module for additional guidance. 

Supporting elements

• Multisectoral approach
• Population health management
• Workforce
• Primary care Primary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” functions

Relevant tools & resources

• AHRQ, 2022: What is patient experience?
• WHO, 2017: WHO community engagement framework for quality, people-centred, and resilient health services 
• The Institute of Economic Affairs, 2016: Participatory Budgeting, Community Score Card and Citizen Report Card Toolkit
• WHO, 2016: Technical series on safer PHC - patient engagement
• US Department of Veteran Affairs, 2012: Patient safety assessment tool 
• AHRQ: Health literacy improvement tools, professional education and training, and publications
• CDC: Health literacy homepage 
• The World Bank: Rapid Feedback: The Role of Community Scorecards in Improving Service Delivery

Integrated models that offer a more comprehensive set of services to patients (including diagnostic, pharmaceutical, behavioural, and rehabilitative services) can help to increase the efficiency and timeliness of primary health care. In communities where it is difficult to access routine and reliable care, integrated care models delivering comprehensive care during a single care interaction may be an especially effective way to improve service quality, especially for patients with complex conditions. ⁴⁵⁴⁶ It is important to make sure the model chosen is patient-centred in order to sustain improvements to the quality of care.

Key activities

All levels

The WHO’s framework on integrated, people-centred health services outlines five interdependent strategies that countries can take to make services more integrated and person-centred. 

• Create an enabling environment that brings together all stakeholders necessary to undertake system-wide change.
  • See page 9 of the WHO’s framework and the sub-action on creating an enabling environment above or more information. 
• Bolster participatory governance and promote mutual accountability. 
  • See page 6 of the WHO’s framework and the policy & leadership module for additional guidance. 
• Empower and engage people and communities. 
  • Co-design services with patients. To ensure they are acceptable to patients, seek to understand how well services are functioning from the perspective of the patient, including whether or not the services meet the patients’ need for . Co-design is one approach that facilities can use to centre patients’ voices and experiences in this design process. ⁴⁷⁴⁸
  • Routinely measure and publicly report on the quality of health services from the patient perspective, including measures of patient experience and patient-reported outcomes. ¹⁵⁴²
  • See page 5 of the WHO’s framework for the sub-action on engaging patients, families, and communities under action 1 for more information.
• Promote models of care that prioritise primary care, community-based services, and the co-production of health.
  • Implement integrated care management programs.  Integrated care management is a team-based, patient-centred approach to managing patient care. It is designed to improve patient care and reduce the unnecessary utilisation of services through three core activities: ²⁹⁴⁹
    • Proactive coordination with other health care providers and the social sector.  Care teams initiate, monitor, and follow up on patient referrals and visits to other specialists and sectors. Read more about coordination principles and practices here. 
    • Effective clinical management. Care teams deliver clinically effective care, or care that is evidence-based, person-centred, and high-value.
    • Proactive outreach. Teams are proactive in their care of patients and often engage patients in health promotion and disease prevention activities. 
  • Improve the integration of public health and primary care. A WHO Policy brief has identified five broad actions that countries around the world have taken to enhance the integration of primary care and public health. These actions are not meant to be mutually exclusive and can incorporate interventions from more than one action. ⁵⁰
    • Coordinating for individuals. Interventions can include the coordination of clinical and community services and the establishment of “one-stop-shop” centres, where clinical and community services are brought together at one site.  
    • Applying a population perspective to clinical practice. Interventions can involve using population-based information and analytical tools (risk assessments, clinical epidemiology) to enhance clinical management. 
    • Identifying and addressing community health problems. Interventions can include conducting community health assessments and using clinical encounters and shared data (EHRs) to build community-wide databases and to identify and address underlying community health problems.
    • Strengthening health promotion and disease prevention. Interventions can include the provision of health education to patients and the involvement of patients in the design and implementation of new services or processes at the local level. 
    • Collaborating around policy, training, and research. Interventions can include cross-sectoral education, training, and research. 
• Coordinate services around the needs and demands of people within and across sectors. 
  • See page 8 of the WHO’s framework and the organisation of services and primary care functions modules for more information.

Relevant tools & resources

• The Picker Institute and Harvard Medical School, 2022: The eight principles of person-centred care 
• WHO, 2021: Community-based mental health services using a rights-based approach
• WHO and UNICEF, 2020: Community-based health care, including outreach and campaigns, in the context of the COVID-19 pandemic
• AMA, 2019: Advancing Health Equity: A Guide to Language, Narrative and Concepts
• AHRQ, 2017: Guide to Improving Patient Safety Safety refers to the practice of following procedures and guidelines in the delivery of PHC services in order to avoid harm to the people for whom care is intended.  in Primary Care Settings by Engaging Patients and Families
• WHO, 2016: Framework on integrated people-centred health services
• IHI, 2008: Partnering with Patients and Families to Design a Patient- and Family-Centred Health Care System: Recommendations and Promising Practices
• IHI, 2006: Patient and Family-Centred Care Organisational Self-Assessment Tool

Improving the physical design of health facilities and the way services are delivered can facilitate improved access; improve the waiting experience, privacy, and physician/staff-patient communication; reduce patient anxiety; and reduce the risk of infection. ²⁹⁵¹The changes/design choices countries make should be: 

• Person-centred and equity-promoting

• Simple and easy to use for both patients and providers

• Appropriately tailored to the internet connectivity and literacy of a given context and adaptable to anticipate any changes in service delivery

• Supported by sufficient resources (staff, information and communication technology)

Assuming that facilities have sufficient resources and autonomy to make changes to the design of the facility, they may undertake the following sub-actions to improve service quality: ²⁹ 

• Sub-action 1. Streamline workflows & reduce waste

• Sub-action 2. Rearrange or expand facility operational hours

• Sub-action 3. Implement or improve appointment systems

• Sub-action 4. Reduce waste times 

Sub-action 1. Streamline workflows & reduce waste

Some studies estimate that up to 40% of clinical office work is redundant or unnecessary. While there is limited data on overhead costs in LMICs, some studies suggest an ideal rate of 35% for primary care facilities. ²⁹⁵³ When used effectively, various technologies and quality improvement methods can help to reduce waste, cut back on administrative burdens, and increase the timeliness and efficiency of care. In addition, changes to the interior space of a facility can help to improve patient experience, team culture, and person-centeredness of care.

Key activities

• Use information and communication technologies to reduce administrative burden and make care safe and efficient. Various technologies can help to reduce waste and increase the efficiency of care, including the use of clinical communication and collaboration solutions like secure text messaging and the use of EHRs to manage patient care, maintain more accurate and complete patient records, and ensure safer transitions of care. ²⁹⁵⁴⁵⁵
• Use lean methodologies to streamline workflow. Quality improvement the action of every person working to implement iterative, measurable changes, to make health services more effective, safe, and people-centred. practices like continuous flow and just-in-time processing can help to improve efficiency. More information on these techniques can be found here. ⁵³
• Implement shared medical appointments or block appointments. Shared medical appointments can decrease wait times and optimise provider time by pairing a group of patients with similar health needs with a single provider. Shared medical appointments have been used extensively for maternal and newborn health and evidence is emerging of success for the management of non-communicable diseases as well. ⁵⁶⁵⁷
• Optimise the interior space of facilities: Three quick and cost-effective techniques that facilities can use to optimise the physical space of their practice include developing team stations, creating an engaging environment, and incorporating uplifting designs to alleviate patient anxiety. ⁵²
• Ensure strong communication and appropriate transfer of knowledge during any transition in ambulatory care. Transitions may include handoffs between different providers within a care team, handoffs between shifts, or transitions between facilities or to higher levels of care. 

Sub-action 2. Rearrange or expand facility operational hours

To ensure that services are timely, patients must be able to visit health facilities at times and on days that are convenient to them and do not require substantial sacrifice in work or childcare. Because expanded days and hours of service may require more human resources, stakeholders must consider how they can reorganise the health system to accommodate these changes. 

Key activities 

Because increased hours may reduce the density of patients throughout the day, fewer providers may be scheduled on each shift, allowing them to be scheduled later (or earlier). This rescheduling may require pilot testing and observation of patient flow to optimise, and it is important to ensure that all services are staggered as well so patients still have access to comprehensive care. 

• Stagger shifts. Because increased hours may reduce the density of patients throughout the day, fewer providers may be scheduled on each shift, allowing them to be scheduled later (or earlier). This rescheduling may require pilot testing and observation of patient flow to optimise, and it is important to ensure that all services are staggered as well so patients still have access to comprehensive care. 
• Integrate services. Facilities may currently use designated days for services such as antenatal care or antiretroviral therapy. Instead, facilities should ensure that patients can receive a comprehensive range of services at any time to optimise appointment time and minimise return visits. See action #5 (make care more integrated and person-centred) for additional activities related to care integration.
• Increase staff or expand service delivery hours. Both of these considerations involve substantial financial inputs from the health system for the compensation of additional staff or extended hours. Stakeholders should consider whether they have the resources necessary to implement these changes. However, facility managers must ensure that staff receive adequate incentives and support to reduce provider burnout and maintain motivation. If staff is asked to work inconvenient hours, health systems may choose to consider additional incentives. 
• Introduce on-call telephone systems. In areas where patients have access to phones or computers, facilities may choose to have providers available to provide remote consultations during non-clinic hours. Unless there is substantial telemedicine technology in place, these consultations may be limited to acute or emergency care. 

Sub-action 3. Implement or improve appointment systems 

Appointment systems can improve access to services at the point of care. These systems need not be complex and should be easy to use for both patients and providers, appropriately tailored to the internet connectivity and literacy in a given context, and adaptable to anticipate any changes in service delivery. These systems, if supported by a sufficient workforce, can improve waiting times and the person-centeredness of service delivery.

Key activities

• Use in-person or community-based appointment systems. In areas where some or all of the population lacks access to the internet or phones, appointments can be scheduled through in-person visits to the clinic. If the clinic is not conveniently located, appointment systems should be made available in the community. For instance, CHWs may make referrals or help schedule appointments during routine population outreach activities. Novel, community-based appointment systems are especially needed in settings of fragility, conflict, and vulnerability. 
• Use appointments made via SMS or telephone and linked with an appointment tracking system (paper or electronic). In areas where patients have reliable access to telephones, appointments may be scheduled by calling or texting the facility. However, there must be an organised system for recording appointment availability for the clinic staff answering phones. Additionally, in low-literacy settings, texting cannot be the only system for requesting appointments.
• Use electronic portals. Electronic portals may be an efficient option if patients have reliable access to computers or mobile devices and the internet.  Additionally, systems must be in place to ensure that these portals remain up to date, and alternative means of scheduling should be available if any portion of the patient panel does not have access to the internet.
• Maintain ad-hoc appointments. Even with efficient appointment systems, facility managers should ensure that patients can access care for urgent needs, possibly by reserving specific days or times for walk-in visits or same-day appointments. 

Sub-action 4. Reduce wait times

• Introduce group visits. Are there patients whose needs are fairly standardised (certain chronic care conditions, antenatal care) who could receive care in a group context? What sort of logistics would need to be in place to organise these visits? How would this change be effectively communicated to patients? 
• Use multidisciplinary care coordination. Are there any services that are currently being provided by doctors that can be effectively provided by nurses or CHWs who are in greater supply? What kind of training (if any) would these providers need to be able to provide a wider range of services? Can any of these services be provided outside of the facility? Are there systems in place to simplify the process of patient registration and referral, such as patient registries and referral management systems?
• Make care more proactive and accessible. Bringing care “to the patient,” using telemedicine appointments or home visits, can help to make care more timely, particularly among patients who face geographic or financial barriers to care or during a time of crisis. Does the patient have a condition that can be managed via phone or a home or community visit? What form of communication would be most efficient for patients and providers (text message, video conference, email, home visits)? Which providers would be responsible for telemedicine or home visits, and how would their workflow need to change to accommodate this responsibility?

Related elements

• Information & technology
• Physical infrastructure
• Management of services and population health 
• Access 
• Primary care Primary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” functions

Relevant tools & resources

• PHCPI, 2021: Telehealth services and community-based care modules 
• I-PASS Patient Safety Safety refers to the practice of following procedures and guidelines in the delivery of PHC services in order to avoid harm to the people for whom care is intended.  Institute: Multiple tools and methodologies 
• The Joint Commission: Tools for high-quality patient hand-offs 
• James et al., 2015: Inefficiency in Primary Care: Common Causes and Potential Solutions
   

Services are evidence-based 

Effective are based on the best available scientific research. ⁶⁸⁶⁸⁶⁹ In practice, evidence-based care includes systematic patient assessments; correct diagnoses; and the provision of appropriate treatments, counselling, and referrals. ¹⁰ Even if a service or process is evidence-based, however, it may not necessarily be effective in the local context. For example, if a local facility does not have the resources and staff needed to implement a service or process change, it may limit the of the intervention. Services and processes should be highly tailored to the local context to maximise resources and impact. ¹⁰⁷⁰ PHC centres and care teams can take advantage of quality improvement methods to identify problems and suggest and test solutions in their context.   

Additional guidance on tailoring solutions to the local context can be found in the local priority setting section of the Population Health Management module. Quality improvement the action of every person working to implement iterative, measurable changes, to make health services more effective, safe, and people-centred. methods and interventions are discussed in the management of services module and the sub-action on creating an enabling systems environment for quality. 

Services are appropriate

Care should adhere to clinical standards. ⁶⁸⁶⁹ that explicitly defines what is required to achieve improved health for a given service, including how providers should act and the reasonable degree of care a patient should expect to receive based on their specific health needs. ⁷¹⁷² To achieve this, minimum standards will need to be established and enforced wherever is delivered, with neither the overuse nor underuse of the best available techniques. For example, everyone who is likely to benefit from a vaccine should receive one, and not every child with a cold should receive antibiotics. ⁶⁸⁶⁹⁷³ 

While less formal than a , the use of practice guidelines can also promote more effective care. A practice guideline is meant to be an adaptable set of evidence-based recommendations. Providers can consult practice guidelines to help them make decisions about how to manage care for specific clinical conditions, including what screening, diagnostic, or therapeutic actions to use. ⁷⁴

In addition, detailed information on promoting a culture of quality improvement and mechanisms to support such a culture at the national and local levels can be found in Policy and Leadership, Adjustment to Population Health Needs, and Management of Services modules. Content related to building the skills and motivation of facility leaders and staff can be found in Workforce, Service Availability and Readiness, and Management of Services. 

Services are consistent

Effective care minimises the variability or inconsistent care practices that can occur in all aspects of service delivery. Consistent care practices are also a key dimension of safe, efficient care. To improve patient safety, clinical productivity, and patient outcomes, countries should aim to reduce: ^75767778

• Operational variability, which refers to the differences in care provided by primary care providers and staff. It can often be traced back to a single activity or inactivity in the care delivery process. Several strategies can help to reduce operational variability, including the implementation of standard processes, procedures, and checklists and the automation of certain routine tasks and pathways (e.g. computerised order entry). 
• Knowledge variability, which refers to differences in expertise among primary care providers and staff. Knowledge variability is more difficult to identify and assess because it is based on an individual’s education and experience level as well as their bandwidth to stay up to date with the most current knowledge and information. Various clinical decision support tools, such as UpToDate, can help to bridge this know-do gap and reduce knowledge variability. The use of electronic medical records can also help. 

Additional strategies for reducing variability are discussed in this module’s sub-action on reducing harm and improving the clinical effectiveness of care. 

Services are acceptable

If services are not acceptable to the local population, their effectiveness may be limited. To be effective, services must be trusted and valued by the patients they are designed to serve, taking into account factors such as the . Research shows that positive user experience (dignity, privacy, respect) can improve patients’ confidence and trust in the health system. In addition, such positive experiences are linked to better technical quality of care. To ensure positive user experiences, PCPs should treat all patients with dignity, autonomy, and respect and clearly communicate about the services and processes that impact the patient’s care. ¹⁰

To be acceptable, services must be person-centred, and relationships between patients and providers must be mutually respectful and trusting. The VSP 2.0 conceptualises people-centeredness, including dimensions of patient-provider respect and trust as separate but related to effectiveness. Detailed information on person-centred care can be found in the Primary Care Functions module. 

See the “take action” section for tangible next steps countries can take to make care more effective. The following actions may be especially relevant:

• Action 1. Cultivate a system-wide commitment to quality
• Action 2. Strengthen accountability between patients and providers
• Action 3. Capacitate providers to deliver better quality services

According to the WHO, “patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum.” ⁷⁹ Patient safety can be operationalised as safe practices being routinely followed in the delivery of care as well as in facilities more broadly. requires certain inputs but also depends upon provider training in safe practices and a facility culture that promotes learning and safety.

Safety Safety refers to the practice of following procedures and guidelines in the delivery of PHC services in order to avoid harm to the people for whom care is intended.  is a broad topic, particularly because what comprises PHC differs substantially between contexts, and data on primary care safety in low- and middle-income countries are scarce. ⁸⁰ However, to be considered “safe,” care should cultivate trust between patients and providers and minimise harm. ⁸¹⁰⁵⁵

Care is appropriate and minimizes harm

Safe care means that providers and services deliver appropriate care (see Effectiveness Effectiveness refers to care that is evidenced-based and adheres to established standards and the extent to which a specific intervention, procedure, regimen or service does what it is intended to do for a specified population when deployed in everyday circumstances. section) and minimise harm. In practice, safety may be understood through several care processes or moments of care.

Medicines and supplies safety

A qualitative study of primary care doctors and nurses found that most providers associated safety with medicines and supplies. ⁸¹ While medicine and supplies safety is only one component of ambulatory care safety, it is perhaps the most pervasive in the primary care literature. There are many considerations related to medicines' safety. 

• Prescribing practices:  Are providers prescribing appropriate medications to patients, for a sufficient amount of time and cost? Do providers have access to and adhere to the most current prescribing practices? The WHO estimates that more than half of medications are prescribed, dispensed, or sold inappropriately. ⁸² The WHO offers many resources on the rational use of medicines, including 12 interventions that countries can implement here.
• Medication reconciliation: Do providers know what medications patients are taking? During medication reconciliation, providers can compare the medications that a patient is taking to the medications they are supposed to be taking and make adjustments as necessary. ¹⁶ This reconciliation is particularly relevant if patients are being prescribed medications outside of primary care settings. Coordination Coordinated care includes organizing the different elements of patient care throughout the course of treatment and across various sites of care to ensure appropriate follow-up treatment, minimize the risk of error, and prevent complications. Coordination of care happens across levels of care as well as across time, and often requires proactive outreach on the part of health care teams as well as informational continuity. of care between primary care providers and specialists can help improve medication reconciliation. Many resources on medication reconciliation can be found on WHO’s Patient Safety Safety refers to the practice of following procedures and guidelines in the delivery of PHC services in order to avoid harm to the people for whom care is intended.  and the Institute for Healthcare Improvement websites.  Additionally, the United States Agency for Healthcare Research and Quality has a set of innovations and tools to improve medication reconciliation. 
• Polypharmacy: Are patients taking too many medications? This may be particularly relevant for elderly patients or patients with chronic conditions and may be a concern for microbial resistance. Assessments of polypharmacy can take place during medication reconciliation. 
• Adherence: Are patients taking the medicines that they are prescribed and at the correct frequency?  The WHO estimates that around half of patients take their medications incorrectly. ⁸²  Primary care Primary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” providers play an important role in medication adherence. Medication adherence is an individual decision that is informed by multiple factors including lifestyle considerations, side effects, poor provider communication, and lack of involvement in medical decision-making. ⁸³ Particularly when primary care providers and patients have longitudinal, trusting relationships, providers can work with patients to understand and solve challenges related to adherence. Discussions about adherence can also be conducted by community-based providers during home visits or community-based care. ⁸⁴ 
• Falsified medicines: Are medications what they are supposed to be? Falsified medicines are a safety concern worldwide, particularly in countries where there are no robust quality surveillance systems to ensure that medications meet regulations. ⁸⁵ This challenge is made even more acute by the often laborious and costly methods used to evaluate medication falsification.  

The WHO has developed a set of resources on Medication Without Harm that addresses many of these medication-related concerns. Many resources are also available from Universities Allied for Essential Medicines. Additionally, the resource Medicines in Health Systems provides a robust overview of the role of medications in achieving Universal Health Coverage.  

Supplies safety refers to the presence and appropriate use of supplies. These include but are not limited to the presence of all necessary equipment for ambulatory care, safe use of supplies to ensure safe blood donation, and safe use of supplies to promote infection control. Resources related to these elements of safety include:

• Blood donor selection
• Screening donated blood for infections
• Towards 100% voluntary blood donation
• Ventilation for infection control

Diagnostic safety

Graber et al (2002) proposed a three-part framework for considering diagnostic errors: 1) errors of uncertainty, 2) errors caused by system factors, and 3) errors of thinking and reasoning. ¹⁶¹⁷ While these categories have significant overlap and should not be considered exhaustive, they provide a useful framework for considering the types of interventions that can be used to address each. 

• Errors of uncertainty may be particularly relevant in diagnoses in which patients refuse testing, there are limitations in medical knowledge, or there is an unusual disease presentation. ¹⁶ These errors may be challenging to systematically address, but as the errors arise, providers should be sure to discuss and debrief them (promoting a culture of learning from mistakes is discussed within Safety Safety refers to the practice of following procedures and guidelines in the delivery of PHC services in order to avoid harm to the people for whom care is intended.  Systems).
• System factor errors are related to problems within the health facility or larger health system. For instance, system errors may occur due to poor communication between staff, delays due to provider absenteeism, or lack of availability of diagnostic equipment. Like errors of uncertainty, these errors should be debriefed with the relevant stakeholders, and tools such as process flow mapping or root cause analysis may be particularly relevant for identifying the drivers of these errors. 
• Errors of thinking and reasoning have significant overlaps with competence. Diagnostic errors related to thinking and reasoning may be of particular concern during the redistribution of roles and responsibilities among providers or if providers are not given appropriate training. Strategies for addressing competence are discussed in the  module, but a few options include strengthening pre-service and in-service education, enhanced supervision, and the use of decision-making tools. ¹⁶¹⁷

Administrative and process safety 

Many administrative and process errors can occur in primary care. While “administrative and process” safety is a broad term; here, we refer to it as the use of administrative controls to safeguard the health of patients and staff during everyday patient care. Such controls may include: ⁵⁵⁸⁶⁸⁷ 

• Policies and procedures to ensure service quality, including compliance with standards of care and effective use of resources
• Workplace or community initiatives to improve awareness of safety requirements and standards of care, such as education campaigns and in-service training
• Systems for monitoring compliance with quality and safety standards
• Systems for monitoring, evaluating, and providing feedback on the performance of healthcare staff, services, or processes 

A failure to follow such controls may result in or be a result of poor information management or a breakdown in communication between staff, patients, and other actors. Some common examples of administrative and process errors include: ⁵⁵

• Patient record errors. Staff incorrectly or poorly document patient information, due to a lack of education, a lack of motivation, or a breakdown in the information architecture. For example, care teams record patient data in different places in the electronic or paper-based health record or neglect to input timely, accurate information. 
• Poor management of diagnostic test requests and results. Staff mismanages patient test results. For example, staff miss a test result or misdiagnose the results due to a lack of knowledge and training. In addition, staff may fail to inform a patient and their care team about test results or update the patient’s chart.
• Poor transitions of care. Patient information is poorly communicated or coordinated between and within levels of care. Communication failures can occur during patient transition both from the primary care into the hospital setting and vice versa. For example, speciality providers may not have access to patient health records due to data privacy laws, or primary care providers do not have access to patient discharge summaries from the emergency room unless patients hand them a written copy. 

For a more detailed list of common administrative and process errors and common reasons for these errors, see the WHO’s report on administrative errors, a part of their technical series on safer primary care. 

Procedural safety

While major surgeries are likely not occurring in primary care settings, smaller procedures are common. Like diagnosis, procedural safety has significant overlaps with provider competence. Enhanced pre-service and in-service education can contribute to safer procedures. 

The WHO Safe Surgery Checklist and Implementation Guide have been used extensively in low, middle, and high-income settings to prevent harm during surgeries. The WHO also has global guidelines on the prevention of surgical site infection. Similarly, the WHO Safe Childbirth Checklist is a valuable resource to ensure adherence to safe childbirth practices.

Care cultivates respect, trust, and communication between patients and care teams

Respect, trust, compassion, and communication in patient care 

Respect and trust between patients and providers help to ensure fair treatment and safer primary care. While sometimes overlooked, patient respect for providers is a critical part of the experiential quality of care and is often influenced by patient perceptions of provider attitudes, competence, and caring behaviours. ⁸⁸

is one of the most important tools for building trust. ⁸⁹ Furthermore, compassion has important links to the quality of care. For example, studies have shown that compassion and the touch of a trusted other can help to alleviate another person's experience of pain and to improve stress-related disease. ⁹⁰

The VSP 2.0 conceptualises patient-provider respect and trust as separate but related to safety. More detailed information on person-centred care can be found in the Person-Centeredness section of the primary care functions module. 

Respect, trust, compassion, and communication in day-to-day facility operations 

Primary care Primary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” facilities should be designed and managed with systems in place to identify, react to, and learn from safety incidents. To do so, facilities must foster a culture of safety, report on errors and near misses, learn from their mistakes, and track progress towards safety-related goals. 

Facilities will be better suited to adapt to safe practices if they can quickly and easily learn from mistakes or errors within the facility. This is often referred to as a “learning organisation.” One study in the United States found that care teams with strong leadership often reported more errors in practice. The authors further investigated these counterintuitive findings and determined that well-led teams foster an environment in which reporting and learning from mistakes are welcomed and encouraged. This prompted the authors to identify qualities of teams and leaders that facilitate organisational learning: ⁹¹

• A safe learning environment where voices are valued. Even in instances where it may seem obvious, facility leaders should be sure to communicate that all voices are welcomed and valued and all providers—regardless of cadre—are invited and encouraged to share concerns. 
• A compelling vision for what needs to be improved. Leaders should employ clear systems for recording and sharing visions between stakeholders, including providers and community members 
• Team-based learning infrastructure, in which small groups can contribute lessons and expertise. For instance, if a facility experiences an adverse event, there should be systems in place to allow providers to come together and discuss implications, lessons, and improvement strategies.  

A conceptual model for learning organisations has identified three “building blocks” for such organisations. These include 1) a supportive learning environment, 2) concrete learning processes and practices, and 3) leadership behaviour that provides reinforcement. The researchers found that these three elements were controlled by different mechanisms, and high performance in one does not predict high performance in others. A corresponding “Learning Organization Survey,” intended to assess an organisation’s learning capability, maps competencies across these three dimensions. The survey is meant to be used at the organisational unit level. This may correspond to a facility department or to a whole facility depending on the size and number of facilities. It characterises a supportive learning environment as one that prioritises psychological safety, appreciation of differences, openness to new ideas, and time for reflection. Concrete learning processes and practices include experimentation, information collection and analysis, education and training, and information transfer to other networks. Finally, the model emphasises the importance of having leaders who prioritise dialogue around problem identification and adaptation. ⁹²

Respect, trust, and communication during transitions of care

Ensuring strong communication and appropriate transfer of knowledge during any kind of transition in ambulatory care can help reduce errors and improve safety. Transitions may include handoffs between different cadres of providers within a care team, handoffs between shifts, or transitions between facilities or to higher levels of care. 

The Joint Commission has developed an infographic on the eight elements necessary for high-quality handoffs. One of these elements includes standardised communication tools, such as I-PASS. I-PASS is a mnemonic for the important components of informational transfer in a handoff: illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by the receiver. ⁹³ Implementation of I-PASS includes a two-hour workshop, a role-playing session, a computer module, a faculty development program, direct observation tools for evaluation and feedback, and process-change campaign materials. A prospective intervention study of I-PASS in the United States found a 23% reduction in the medical-error rate before and after the intervention. 

See the “take action” section for tangible next steps countries can take to make care safer:

• Action 1. Cultivate a system-wide commitment to quality
• Action 2. Strengthen accountability between patients and provider 
• Action 3. Capacitate providers to deliver better quality services

refers to the ability of the health system to provide primary care services to patients when they need them, with acceptable and reasonable wait times, and at days and times that are convenient to them. Timeliness Timeliness refers to the ability of the health system to provide PHC services to patients when they need them with acceptable and reasonable wait times and at days and times that are convenient to them.   includes two elements:

• First, patients should be able to physically access care with acceptable and reasonable waiting times. 
• Second, hours and days of facility operation should allow patients to find a time to visit facilities without sacrificing other obligations and duties such as work or childcare and to access care for emergent needs, including on nights and weekends.

Timely care minimises waiting times and delays, helping to improve patient satisfaction and reduce utilisation of emergency- or hospital-based services that may result in higher costs for the patient and health system. ²³ For example, untimely patient flow and notification systems can lead to delays in preventive care (or other services), and in turn, increase the patient’s risk for developing chronic diseases that cause more mortality, morbidity, and costs for the health system. ⁹⁴⁹⁵⁹⁶ Timely care also promotes health equity and improved health outcomes for all segments of the population. ⁹⁷ For example, timely use of appropriate medications and treatment protocols during emergencies is an important dimension of patient safety and clinical effectiveness. 

Care is convenient and efficient

In order to receive appropriate care, patients must be able to access facilities in a way that does not burden them. The following factors are potential barriers to convenient patient access.

Inconvenient operational hours

Facility hours may be a barrier to care for individuals who work or have regular obligations. Inconvenience is most often a barrier when facilities do not offer evening or weekend hours. Inconvenient hours of operation can also contribute to long waiting times, short consultations, and provider burnout. 

A systematic review of public and private healthcare facilities in LMIC found that across multiple settings, waiting times, operational hours, and availability of staff were more favourable in private clinics compared to public ones. ¹⁹

Inefficient appointment systems

Appointment systems—coupled with effective use of resources and high-quality care—may be an effective starting point for ensuring timely access to care. A 2016 review of primary care experiences in six Latin American countries found substantial gaps in performance regarding waiting times and appointment systems: one-fifth of respondents skipped an appointment due to problems with scheduling, one-third had to wait more than five days for an appointment, and 39% could not schedule an appointment by phone. ⁹⁸

Long wait times 

Long wait times may be attributable to diverse causes including staff shortages, inefficient or absent appointment systems, limited operational hours, and ineffective facility management regarding human resources or patient flow. Facility managers may choose to conduct activities such as process flow mapping (discussed in greater detail in the Management of services module) in order to assess how and why patients are experiencing long waiting times.

Poor follow-up &/or outreach

Poor follow-up or outreach with patients may be a barrier to timeliness, particularly among patients who live far from a facility. Providers may choose to follow-up with patients via telephone or home visits to improve timeliness (discussed in greater detail in the population health management and information & technology modules and action #4: make care more integrated and person-centred.)

Fragmentation in transitions of care

Poor communication or coordination between primary care and higher levels of care (and vice versa) can lead to delays in patient care. Within a facility, poor communication and transitions of care can lead to prolonged stays and overutilization of services. Patients who face language and cultural barriers are especially vulnerable to poorly managed transitions. There are various strategies that facilities and providers can use to improve transitions of care, including discharge planning, use of standardised referral guidelines, and secure health information exchange.

For a more detailed list of transitions of care and common challenges and recommendations to improve, see the WHO’s report on transitions of care, a part of their technical series on safer primary care. 

Care is geographically and financially accessible 

In addition, patients’ ability to access timely services is strongly influenced by where they live and what services they can afford. These patients may face substantial external costs if they miss work or require alternative child care in order to access services, which can, in turn, lead to catastrophic health expenditure. ⁹⁹ In addition, patients who live far from the facility and have limited transportation options are more likely to face barriers to timely care. 

The VSP 2.0 conceptualises geographic access and financial access as separate but related to timeliness. More detailed information on geographic and financial access to care can be found in the Access module.

See the “take action” section for tangible next steps countries can take to make care more timely:

• Action 4. Make care more integrated and person-centred 
• Action 5. Improve facility design and workflow 

in its simplest form can be understood as a ratio of inputs versus outputs, or the success with which health system resources are transformed into valued outputs (e.g. patient consultations) or improved patient outcomes. At the primary care level, efficiency means primary care providers or PHC facilities are able to attain their desired objectives with the available resources, minimise waste, and maximise capacities to deliver care to those who need it most. (100-102, 104)

Despite this straightforward input-output model, efficiency is the result of many interrelated processes in the health system.(12,100–103) For example, system-level characteristics like good governance can promote the efficient transformation of resources into valued outputs like patient consultations or outcomes like equity or responsiveness. There are two types of efficiency important for service quality:(100–102,104)

• Technical efficiency (or doing the things right), which refers to the ability of the health sector to attain the highest level of output given a set of inputs. At the point of care, it refers to how resources are used during service provision.
• Allocative efficiency (or doing the right things), whereby the health sector provides the highest value health services available. ‘Highest-value’ means that resources are allocated so as to maximise the welfare of society. Such decisions should be informed by the needs, values, and preferences of the populations they are designed to serve, preferably via a participatory, deliberative priority-setting process.  

Efficient health services maximise technical and allocative efficiency and exhibit the following common attributes:

Care makes the best use of time and money 

Inefficient care wastes considerable time and money for health systems and communities worldwide.(8) It is estimated that up to one-fifth of health expenditure makes little or no contribution to improving people’s health.(23,105) At the point of care, inefficient care may involve the provision of duplicate services, unnecessary referrals to speciality or hospital services, and avoidable hospital admissions (potentially due to delays in evidence-based, preventive care).(8)

On the contrary, efficient care avoids the waste of resources, including medicines and supplies and the energy and expertise of staff. For example, providers should use standardised care processes and patient health records (electronic or paper-based) to track a patient’s care carefully, avoid repetition, and iterate on their care plan in a way that makes the best use of resources.(8) For example, providers might consider switching patients to generic medications to cut costs for the patient. In addition, to make the most use of time and expertise, providers should work together as a cohesive team. (8,21)

Care minimises waste & variability 

Relatedly, care teams should deliver services in such a way that minimises harm and resource waste. However, much of this work begins upstream. To promote efficient care, health systems and facility managers should take strides to ensure rational use of medicines and supplies (i.e. medicines regulation—see sub-action on creating an enabling a systems environment); optimise human resource mix; reduce corruption, and strengthen the use of information technology infrastructure (i.e. electronic health records). (8) As with any intervention, it is important to use quality improvement methods, culture change, continuing education and professional development, and provider incentives to sustain this shift to a more efficient practice. (21)

Minimising the variability of care is also an important strategy to minimise harm (discussed in the effectiveness deep dive). Additional guidance on reducing waste and streamlining facility operations is discussed in this module’s action on improving the way facilities are designed and managed. 

Care is proactive 

When care is proactive, there are fewer inputs necessary to get the same health outputs, helping to reduce inefficiencies in care. For example, diagnosing hypertension early can produce good health with medications rather than diagnosing the complications of hypertension, which may require expensive interventions like dialysis. Outreach strategies (discussed in Population Health Management and the COVID-19 strategy on community-based care) are one-way providers and facilities can promote more proactive care. 

Care models that foster linkages between public health and PHC also help to promote more proactive, efficient care.(10,40,41,106,107)  Services or processes that allow for the prevention and early detection of disease, such as evidence-based screenings and public-health surveillance and outreach, can help to cut costs and improve the health and well-being of the population.(107) More on health promotion and disease prevention activities that can be employed in facilities can be found in the following resources:

• Population health management: proactive population outreach
• Maintaining access to routine and essential services: community-based care
• Surveillance The ongoing and systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of service delivery and public health. , response, and management: risk communication, testing and contact tracing, and case management and transmission control

For more information on the potential causes of inefficiencies in primary care, explore this practice-based research project.

 means organising the health system around the comprehensive needs of people rather than around individual diseases. People-centeredness involves engaging with people, families, and communities as equal partners in promoting and maintaining their health—including through communication, trust, and respect for preferences as well as through ongoing education and support so that they can participate in health care decisions.(108)

People-centred services put patient needs and values front and centre. While expectations and approaches to people-centred care vary between countries, it generally means ²³

• Services meet communities’ unique needs and preferences. To meet patients’ needs, countries must successfully engage patients, families, and communities in all aspects of design, planning, governance, and delivery of .(23,108,109) See the sub-action for engaging patients, families, and communities for additional guidance. 
• Services are delivered with compassion and respect. Compassion Compassion is the emotional response to another person’s suffering and the authentic desire to take action to relieve their pain or suffering in some way. has important links to the quality of care. For example, studies have shown that compassion and the touch of a trusted other can help to alleviate another person's experience of pain and to improve stress-related disease. (23,90)
• Services promote patient activation, health literacy, and self-care. Engaging and empowering people to participate in their own care is essential to improving health outcomes, increasing patient satisfaction, reducing costs, and improving the clinician experience. is one of the most important approaches to achieving this engagement:  patients and providers work together to make decisions and select treatments and care plans.(23,110)

The VSP 2.0 conceptualises people-centredness, including dimensions of patient-provider respect and trust as separate, but related to service quality. Learn more

High-quality services are integrated and person-centred; in integrated and person-centred care, primary care providers or care teams coordinate care around patients’ needs and engage patients as equal partners in healthcare. ^38394041

The VSP 2.0 conceptualises coordination, including dimensions of integration, as separate but related to service quality.

Strategies to promote people-centred, integrated care are also discussed in the sub-action on promoting people-centred, delivery. 

High-quality services are equitable, meaning patients, families, and communities receive the same treatment regardless of personal characteristics such as gender, race, ethnicity, geographical location, and socioeconomic status. In reality, gaps in quality service delivery impact disadvantaged populations the most. Thus, to achieve the goal of high-quality services for all, it will be important to prioritise interventions that translate to better outcomes for these populations.(111)

Visit the WHO’s webpage on health equity to learn more about health equity and its determinants.
 

• A clinical practice guideline A clinical practice guideline is meant to be a more flexible set of evidence-based recommendations than a standard of care. Providers can consult practice guidelines to help them make decisions about how to manage care for specific clinical conditions, including what screening, diagnostic, or therapeutic actions to use. is meant to be a more flexible set of evidence-based recommendations than a standard of care. Providers can consult practice guidelines to help them make decisions about how to manage care for specific clinical conditions, including what screening, diagnostic, or therapeutic actions to use. ⁷⁴
• Compassion Compassion is the emotional response to another person’s suffering and the authentic desire to take action to relieve their pain or suffering in some way. is the emotional response to another person’s suffering and the authentic desire to take action to relieve their pain or suffering in some way. ⁹⁰
• Comprehensiveness Comprehensiveness refers to the provision of holistic and appropriate care across a broad spectrum of health problems, age ranges, and treatment modalities. Comprehensive care should address a wide range of preventive, promotive, chronic, behavioural, and rehabilitative services and include an assessment of a patient’s risks, needs, and preferences at the primary care level. refers to the provision of holistic and appropriate care across a broad spectrum of health problems, age ranges, and treatment modalities. Comprehensive care should address a wide range of preventive, promotive, chronic, behavioural, and rehabilitative services and include an assessment of a patient’s risks, needs, and preferences at the primary care level. 
• Effectiveness Effectiveness refers to care that is evidenced-based and adheres to established standards and the extent to which a specific intervention, procedure, regimen or service does what it is intended to do for a specified population when deployed in everyday circumstances. refers to care that is evidenced-based and adheres to established standards and the extent to which a specific intervention, procedure, regimen or service does what it is intended to do for a specified population when deployed in everyday circumstances.
• Efficiency Efficiency refers to the ability of a health system to attain its desired objectives with the available resources, while minimising waste and maximising capacities to deliver care to those who need it.  refers to the ability of a health system to attain its desired objectives with the available resources, while minimising waste and maximising capacities to deliver care to those who need it.
• Equity in health Equity in health refers to “the absence of systematic or potentially remediable differences in health status, access to health care and health-enhancing environments, and treatment in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically within and across countries.” refers to “the absence of systematic or potentially remediable differences in health status, access to health care and health-enhancing environments, and treatment in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically within and across countries.” ¹³
• Extrinsic motivation Extrinsic motivation refers to motivation that is incentivized by anything other than personal drive and commitment. Extrinsic motivation may be related to monetary or non-monetary individual incentives or environmental incentives. Individual monetary incentives may include salary, pensions, insurance, travel, child care, heat, retention allowances, subsidised meals, subsidised clothing, and subsidised accommodation. refers to motivation that is incentivized by anything other than personal drive and commitment. Extrinsic motivation Extrinsic motivation refers to motivation that is incentivized by anything other than personal drive and commitment. Extrinsic motivation may be related to monetary or non-monetary individual incentives or environmental incentives. Individual monetary incentives may include salary, pensions, insurance, travel, child care, heat, retention allowances, subsidised meals, subsidised clothing, and subsidised accommodation. may be related to monetary or non-monetary individual incentives or environmental incentives. Individual monetary incentives may include salary, pensions, insurance, travel, child care, heat, retention allowances, subsidised meals, subsidised clothing, and subsidised accommodation. ³⁴
• The first level of care The first level of care is “the entry point into the health care system at the interface between services and community; when the first level of care satisfies several quality criteria, it is called primary care.”  is “the entry point into the health care system at the interface between services and community; when the first level of care satisfies several quality criteria, it is called primary care.” ¹⁵
• Health care services Health care services refer to any intervention, procedure, regimen, or process that health workers use to respond to the needs and demands of their patient population. Depending on the context, services may be provided by public or private providers. refer to any intervention, procedure, regimen, or process that PCPs use to respond to the needs and demands of their patient population.
• Health in All Policies is “an approach to public policies across sectors that systematically takes into account the implications for health and health systems of decisions, seeks collaborations, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It emphasises the effect of public policies on health determinants and aims to improve the accountability of policy-makers for the effects on health of all levels of policymaking.” ¹³
• Integrated health services Health services that are managed and delivered so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector and according to their needs throughout the life course. refers to “the management and delivery of health services so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation, and palliative care services through the different functions, activities, and sites of care within the health system.” ¹³
• Intrinsic motivation Intrinsic motivation is a feeling of accomplishment driven by organisational goals and the impact of one’s work on patients and communities.  is a feeling of accomplishment driven by organisational goals and the impact of one’s work on patients and communities. 
• Outcomes Outcomes are the effects of the provision and experience of care on processes of care and on patients’ health. are the effects of the provision and experience of care on processes of care and on patients’ health.
• Patient cycle times Patient cycle times, or the office visit cycle time, is the amount of time in minutes that a patient spends at an office visit. The cycle begins at the time of arrival and ends when the patient leaves the office. , or the office visit cycle time, is the amount of time in minutes that a patient spends at an office visit. The cycle begins at the time of arrival and ends when the patient leaves the office.
• Patient engagement Patient engagement is a partnership between patients and their care team. It combines patient activation with interventions to promote positive health behaviours, such as obtaining preventive care or engaging in regular physical exercise. The focus on activation and engagement rather than compliance recognizes that patients manage their own health most of the time and need to be able to make informed decisions about their own health.
    is a partnership between patients and their care team. It combines patient activation with interventions to promote positive health behaviours, such as obtaining preventive care or engaging in regular physical exercise. The focus on activation and engagement rather than compliance recognizes that patients manage their own health most of the time and need to be able to make informed decisions about their own health.
• People-centred care People-centred care is “an approach to care that consciously adopts the perspectives of individuals, carers, families, and communities as participants in and beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways. People-centred care also requires that people have the education and support they need to make decisions and participate in their own care.” is “an approach to care that consciously adopts the perspectives of individuals, carers, families, and communities as participants in and beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways. People-centred care People-centred care is “an approach to care that consciously adopts the perspectives of individuals, carers, families, and communities as participants in and beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways. People-centred care also requires that people have the education and support they need to make decisions and participate in their own care.” also requires that people have the education and support they need to make decisions and participate in their own care.” ¹³
• Primary care Primary care is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” is “a key process in the health system that supports first-contact, accessible, continuous, comprehensive, and coordinated patient-focused care.” ¹⁵
• Primary health care Primary health care (PHC) is “a whole-of-society approach to health that aims to maximise the level and distribution of health and well-being through three components:  (a) primary care and essential public health functions as the core of integrated health services; (b) multisectoral policy and action; and (c) empowered people and communities.” (PHC) is “a whole-of-society approach to health that aims to maximise the level and distribution of health and well-being through three components:  (a) primary care and essential public health functions as the core of integrated health services; (b) multisectoral policy and action; and (c) empowered people and communities.” ¹⁵
• PHC services PHC services refer to any intervention, procedure, regimen, or process that providers use to respond to the needs and demands of their patient population at the primary care level. Because of PHC’s community-facing orientation, services can be provided virtually or face-to-face in homes, communities, or PHC centres. Depending on the context, services may be provided by public or private providers. refer to any intervention, procedure, regimen, or process that providers use to respond to the needs and demands of their patient population at the primary care level.(15) Because of PHC’s community-facing orientation, services can be provided virtually or face-to-face in homes, communities, or PHC centres. Depending on the context, services may be provided by public or private providers. ⁶⁷⁸
• Provider availability Provider availability is defined as the presence of a trained provider at a facility or in the community when expected to provide the services as defined by his or her job description. is defined as the presence of a trained provider at a facility or in the community when expected to provide the services as defined by his or her job description.
• Provider competence Provider competence entails having and demonstrating the knowledge, skills, abilities, and traits to successfully and effectively deliver high-quality services. entails having and demonstrating the knowledge, skills, abilities, and traits to successfully and effectively deliver high-quality services.
• Provider motivation Provider motivation “...in the work context can be defined as an individual’s degree of willingness to exert and maintain an effort towards organisational goals.” Motivation captures intrinsic and extrinsic characteristics that affect the behaviour and performance of providers in a health system.  “...in the work context can be defined as an individual’s degree of willingness to exert and maintain an effort towards organisational goals.”(112) Motivation captures intrinsic () and extrinsic () characteristics that affect the behaviour and performance of providers in a health system. 
• Safety Safety refers to the practice of following procedures and guidelines in the delivery of PHC services in order to avoid harm to the people for whom care is intended.  refers to the practice of following procedures and guidelines in the delivery of PHC services PHC services refer to any intervention, procedure, regimen, or process that providers use to respond to the needs and demands of their patient population at the primary care level. Because of PHC’s community-facing orientation, services can be provided virtually or face-to-face in homes, communities, or PHC centres. Depending on the context, services may be provided by public or private providers. in order to avoid harm to the people for whom care is intended. 
• A service delivery platform refers to the level of a health system at which interventions can be appropriately, effectively, and efficiently delivered.
• Shared decision making “is an interactive process in which patients, their families and carers, in collaboration with their health provider(s), choose the next action(s) in their care path following an informed analysis of possible options, their values, and preferences.”(113)
• Social determinants of health Social determinants of health “...are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems.” “...are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems.”(114)
• A standard of care A standard of care is a guideline that explicitly defines what is required to achieve high-quality care for a given service, including how providers should act and the reasonable degree of care a patient should expect to receive based on their specific health needs. is a guideline that explicitly defines what is required to achieve high-quality care for a given service, including how providers should act and the reasonable degree of care a patient should expect to receive based on their specific health needs. ⁷¹⁷²
• Timeliness Timeliness refers to the ability of the health system to provide PHC services to patients when they need them with acceptable and reasonable wait times and at days and times that are convenient to them.   refers to the ability of the health system to provide PHC services PHC services refer to any intervention, procedure, regimen, or process that providers use to respond to the needs and demands of their patient population at the primary care level. Because of PHC’s community-facing orientation, services can be provided virtually or face-to-face in homes, communities, or PHC centres. Depending on the context, services may be provided by public or private providers. to patients when they need them with acceptable and reasonable wait times and at days and times that are convenient to them.