The Quality Book of Tools is a comprehensive book of practice management and clinical care indicators for improving quality in primary care, family practice settings in Ontario, Canada. This Quality Book of Tools 2010 was developed following an international review and modified Delphi process in 2008-2009 and is the revised version of the 2003-2005 Quality in Family Practice Tool. It is available as a hard copy book and in an open source, web-based version. It is designed for family practices in Ontario but could be useful to primary care settings throughout Canada and internationally.

This Quality Book of Tools includes a conceptual framework of categories and values depicted in the Quality Flower, a yellow and purple sunflower chosen as a metaphor for the Book of Tools.

Just as a sunflower follows the sun throughout the day and grows vigorously under its rays, but withers without water and sunshine, Quality in primary care requires attention, nurturing and support to flourish. The future of the sunflower lies in its centre, just as the practice team’s commitment to continuous quality improvement is at the heart of Quality. The petals of the sunflower represent the categories of indicators of quality in a family practice setting. Eight categories have been identified in this 1st Edition Quality Book of Tools, and in the future more may be added as primary care evolves and quality improvements develop further. (The sunflower’s yellow petals represent as-yet unidentified categories.) Purple was chosen as the colour of Quality because it is a complex and unique hue that stands alone, representing the complex nature of quality and the challenge of including continuous improvement in the normal rhythm of everyday work. However, with time and experience, the inherent value and rewards of incorporating Quality into day-to-day activities become ever clearer.

The five values integral to developing a sustainable quality-improvement culture in primary care in Ontario, in no particular order, are:

  • A culture of continuous quality improvement (CQI) that is never-ending and included in usual daily activity. The Plan-Do-Study-Act (PDSA) cycles for testing a change can be used to apply CQI.
  • A process of self-reflection that allows the family practice to undertake actions needed to assess its current standing in terms of best practices.
  • Making such assessments in a voluntary, non-threatening manner.
  • The inclusion of patient/consumer involvement.
  • Interdisciplinary team development and functioning.

The five values surround the Quality flower, which has eight petals representing the eight categories that incorporate the common elements of family practice activities. These eight categories also align with the established aims of the Institute of Medicine: Crossing the Quality Chasm and the Ontario Health Quality Council’s Reporting Framework: Attributes of a High Performing Health System1,2(Table 1). The eight Categories are in no particular order and are labelled for convenience:

  1. Patient-Centred
  2. Equitable
  3. Timely and Accessible
  4. Safe
  5. Effective Clinical Practice
  6. Efficient
  7. Integrated and Continuous
  8. Appropriate Practice Resources

The eight Categories have 34 Sub-Categories, which group similar Indicators together. The Sub-Categories have 70 Indicators, which can be separated into 43 practice management and 27 clinical indicators. The indicators have been systematically designed to identify the common elements of family practice performance that can be assessed to improve the quality of care. Even so, the list of indicators is not exhaustive and may not include all of the elements that are important and relevant for individual practices. Each indicator has Criteria that can be counted or measured in order to assess quality of performance of an indicator. Criteria are discrete, definable, measurable and explicit. There are three types of criteria:

Essential – required to demonstrate best practice
Desirable – required to demonstrate additional quality

(*Assumptions about indicators are based on the nature of these indicators and the regulations that qualify them)

It is expected that most family practices will first meet the requirements for the legal and essential criteria, and then strive to meet the desirable criteria.

Best-practice guidelines and the associated audit requirements are extremely complex and require external and internal resources which are not universally available in family practices in Ontario at time of writing. Although these guidelines reflect best practice, few practices meet all the criteria outlined in the Quality Book of Tools for monitoring quality performance. Best practice will need to evolve and be updated over time. The indicators and criteria in the book are not intended to be considered standard of practice in Ontario. They are intended as a guide only, and, in the spirit of continuous quality improvement (CQI) and rapid cycle change, to assist practices to make choices. Some indicators may take priority over others, but over time all the indicators in a family practice would be incorporated and be part of an ongoing quality improvement program.

The Quality Tool is a web-based instrument. Each indicator has a section called Further Information that lists relevant web links, which can be accessed directly from the electronic version. The up to date links have been collected in a resource database that can be found at http://quality.resources.machealth.ca. Each criterion is qualified by the Interpretation which explains the expected performance measurement activities that must be completed to meet the requirements of the criterion. These Further Information links connect to helpful on-line resources in Ontario or elsewhere (for example, government sites, professional organizations’ sites and best-practice guidelines as of 2010, such as the Cochrane Library review, and so on). The authors are not responsible for and do not necessarily endorse the content on the linked websites.

  • Criteria Symbols

    Legal and Safety – required by law*

    Essential – required to demonstrate best practice

    Desirable – required to demonstrate additional quality

    (*Assumptions about indicators are based on the nature of these indicators and the regulations that qualify them)