Tools to remove barriers to quality improvement in primary care

22 Aug 2019 | Primary Care
Tagged quality improvement Primary Care tools removing barriers

Quality improvement (QI) is the use of systematic tools and methods to improve health care outcomes and experiences of care. You need knowledge and skills in improvement science if you are to undertake robust improvement work.

Several popular QI tools and methods have been around for a long time and are widely used across the different methodologies such as process mapping and statistical process control. While process mapping is user-friendly and easy to learn and do, other tools such as statistical process control require a whole different skillset and level of expertise.

Liberating Structures is a set of tools designed to be simple and effective to apply by frontline staff. There are 33 micro-structures, based on complexity science. One of the structures is the theory of inventive problem-solving (TRIZ). TRIZ uses ‘creative destruction’ to help teams acknowledge and let go of the things that are holding them back from achieving their goals. It is a fun way to tackle challenging or taboo topics and give everyone a voice.

RNZCGP Quality Symposium 2018 – TRIZ workshop

At the RNZCGP Quality Symposium 2018, 132 primary care quality enthusiasts participated in the Health Quality & Safety Commission’s TRIZ workshop on increasing success-removing barriers to primary care improvement initiatives.

The participants, who included general practitioners, practice managers, nurses, other symposium speakers and representatives from PHOs and government organisations, were asked:

  • how do we ensure quality improvement doesn’t happen in general practice?
  • how many of the things that have been identified are we currently doing or are currently occurring?
  • what can we stop doing? What do we need to do to make a list item stop? What could we do instead?

The workshop materials were collected at the end of the session and the results were themed using NVivo qualitative software. Teams gave their consent for the Commission to share the data generated.

How do we ensure quality improvement doesn’t happen in general practice?

Answers from the groups included:

  • no resources (no time, funding, staff or anyone who is capable)
  • make QI difficult to do
  • have a poor culture
  • lots of competing priorities
  • undermine and undervalue QI
  • have no teamwork, no leadership and no collaboration
  • do not communicate.
How many of the things identified are we currently doing or are currently occurring?

Groups approached this question differently; some groups agreed on the top barriers to improvement and other groups’ individual members ticked off everything they thought was currently occurring in primary care.

The biggest barriers reported to be hindering primary care QI were:

  • the lack of time
  • lack of perceived value of QI
  • working in silos
  • lack of incentives and other resources for quality improvement
  • several other factors reflecting capability and culture. 
What can we stop doing? What do we need to do to make a list item stop? What could we do instead?

The third part of the TRIZ workshop asked the groups to identify what needed to be stopped to enable success. The concept of 15% Solutions was introduced.

15% Solutions is another Liberating Structure based on the work of Gareth Morgan.[1] It is founded on the idea that everyone only has control of 15 percent of their work but that 15 percent may be different for everyone (including managers). If everyone works on their 15 percent, the collective impact could bring about significant change. 15% Solutions is about what is possible for participants to do now, without any additional resources or authority. Finishing the workshop with 15% Solutions gave a positive conclusion and showed people they have the power to act.

Participants identified factors often called the ‘soft factors’ or non-technical elements of QI which are related to people and within their control. Collaboration was the most commonly selected solution followed by communication, a culture of QI and using QI processes.

Some of the commonly identified barriers, such as financial and time barriers, did not figure highly in the list of identified solutions. Although these factors are identified as things that need to be attended to, participants may have considered them as outside their control.


Symposium participants identified lack of time and the perceived value of QI, closely followed by resources, capability and culture as barriers to QI that are currently present in the New Zealand primary care sector. The barrier of time to undertake QI is supported in the primary care literature and is linked to resourcing, and funding issues and mechanisms.[2,3,4]

Perceived lack of value of QI, which was the second highest identified barrier occurring in general practice could be grouped under QI culture along with no leadership or champion, culture of blame, resistance to change and the lack of meeting with, and listening to, each other. Culture has many definitions but is commonly defined as ‘the shared ways of thinking, feeling and behaving’ or ‘the way things are done around here’.[5]

Changing behaviour is at the crux of all improvement efforts and in the end it all boils down to someone starting change, the ‘one lone nut’, which may be what was identified in the group’s 15% Solutions.

At the Commission, we have been fortunate to work alongside many of those ‘lone nuts’ in the Whakakotahi primary care programme and you can see their work here. There are many other examples of primary care improvement work around the country to draw inspiration from. We encourage you all to venture into ‘lone nut’ territory as you may find that you are not ‘lone’ for very long at all and are instead are part of a growing group of enthusiasts.


  1. Morgan G, Zohar A. 1995. Achieving quantum change: Incrementally. Schulich School of Business Working Paper, York University.
  2. de Wet C, Bowie P, O’Donnell C. 2018. ‘The big buzz’: a qualitative study of how safe care is perceived, understood and improved in general practice. BMC Family Practice 19(1): 83.
  3. Kiran T, Ramji N, Derocher MB, et al. 2018. Ten tips for advancing a culture of improvement in primary care. BMJ Qual Saf bmjqs-2018-008451.
  4. Ogrin R, Aylen T, Rice T, et al. 2019. Engagement of primary care practice in Australia: learnings from a diabetes care project. Australian journal of primary health (25)1.
  5. Mannion R, Davies H. 2018. Understanding organisational culture for healthcare quality improvement. BMJ 363: k4907. P 2.

Appendix 1 Data tables

Table 1: How do we ensure that quality improvement (QI) does not happen in general practice?

Number of post-it notes
1. Resources: No time + Funding + Staffing + Capability + Dedicated resource 64 + 22 + 17 + 27 + 14 = 131
2. QI Processes: Make QI difficult to do + Data collection and analysis 43 + 19 = 62
3. Culture: Blame/poor culture 56
4. Competing priorities + lack of incentives 33 + 19 = 52
5. No teamwork or collaboration, work in silo’s 41
6. Devalue QI 26
7. No leadership or QI champions 17
8. No communication 16

Table 2: How many of the things identified in the first question are currently occurring?

Number of ticks
1. Lack of time 19
2. Lack of perceived value  10
3. Silos 7
4. Lack of incentives 6
5. Funding 5
6. Staff training in QI 5
7. Poor planning and process 4
8. No leadership or dedicated champion 4
9. Culture of blame 3
10. No dedicated IT data extraction, analysis and support 3
11. Resistance to change 3
12. No continuity of care 2
13. Don’t meet or listen 2
14. Learned helplessness 1

Table 3: What can we stop doing? What do we need to do to make a list item stop? What could we do instead?

Number of post-it notes
1. Collaboration 9
2. Communication 4
3. QI culture 4
4. QI process 3
5. Funding 2
6. Systems 2
7. Time 2
8. Rewards 1
9. Empowerment 1


Authors: Jane Cullen, quality improvement advisor, Health Quality & Safety Commission and Associate Professor Sue Wells.

Last updated 22/08/2019