Providing high-quality care in primary care settings: how to make trade-offs.
OBJECTIVE
To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care.


METHODS
Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices.


METHODS
Three regions of Quebec.


METHODS
Health care professionals and staff of 5 PC practices.


METHODS
Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed.


RESULTS
The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters.


CONCLUSIONS
Irrespective of their models, PC practices' pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care.
Professor in the Research Centre of the Centre hospitalier de l'université de Montréal and in the Department of Family and Emergency Medicine at the University of Montreal in Quebec. marie-dominique.beaulieu@umontreal.ca.
Marie-Dominique
MD
Beaulieu
Researcher in the Département des Sciences de la santé communautaire at the University of Sherbrooke in Quebec.
Robert
R
Geneau
Research Coordinator at the Research Centre of the Centre hospitalier de l'université de Montréal.
Claudio
C
Del Grande
Professor in the École Nationale d'administration publique in Montreal.
Jean-Louis
JL
Denis
Professeur adjoint de clinique in the Department of Family and Emergency Medicine at the University of Montreal.
Eveline
E
Hudon
Professor in the Department of Family Medicine at McGill University in Montreal.
Jeannie L
JL
Haggerty
Médecin conseil at the Agence de santé et des services sociaux of the Mauricie-Centre du Québec in Trois-Rivieres.
Lucie
L
Bonin
Professeur adjoint de clinique in the Department of Family and Emergency Medicine at the University of Montreal.
Réjean
R
Duplain
Professor in the Faculté des sciences infirmières at the University of Montreal.
Johanne
J
Goudreau
Professor in the Department of Family Medicine at the University of Ottawa in Ontario.
William
W
Hogg
D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D011320:Primary Health Care / Q000458:organization & administration*; D036301:Qualitative Research; D011787:Quality of Health Care / Q000458:organization & administration*; D011792:Quebec; D011795:Surveys and Questionnaires