Conceptual models of health care have evolved over the past four decades. Beginning in 1966 with Donbedian's now classic work on assessing the quality of health care, most such models of care have incorporated common elements of structure, process and outcome [2
]. Guided by this framework, there have been a number of efforts to deconstruct the components of primary care over succeeding decades. The US Institute of Medicine both developed and refined definitions of primary care [3
]. Its framework has been used as a template to plan primary care reform and as a base in the development of instruments used to evaluate the quality of primary care delivery [4
Despite its merit, Starfield [1
] highlighted the failure of the Institute of Medicine's framework to recognize the characteristics of varied health service organizations. Her conceptual framework linked structure, process and outcome through core dimensions of capacity, performance and health status. Capacity involved elements such as personnel and facilities, the organization of services, financing and governance. She saw performance as being represented by four unique features of primary care service delivery (first-contact care, longitudinality, comprehensiveness and co-ordination of care) as well as five essential, but not unique features, e.g. medical record format and three derivative features, e.g. cultural competence.
Like Starfield, Campbell and colleagues [6
] acknowledge the importance of differentiating between individual and population perspectives of quality. Their succinct conceptual model viewed individual perspectives of quality as oriented towards two dimensions, access and effectiveness, with effectiveness having subdimensions of clinical and interpersonal care. They viewed population perspectives of quality being measured primarily by equity and efficiency.
Subsequent frameworks have begun to identify the importance of structural or organizational features. Both Sibthorpe [7
] in Australia and Watson et al.
] in Canada have highlighted the wide range of organizational contributions from governments to support primary care. These provisions, such as fiscal, material and health human resources [8
], affect the ability of primary care providers to deliver services from practice settings. These themes were continued in a recent primary care framework published by the Organization for Economic Co-operation Development (OECD) [9
]. Although acknowledging core dimensions of quality, access and expenditure, the group illuminated the importance of broader dimensions of macro- and micro-efficiency and health care system design, policy and context. The consensus group found structural measures to be insufficient to assess safety and effectiveness, and hence excluded them from its final measurement framework. The OECD Health Quality Indicators project stressed the need for a framework that reflects the complexity of primary care to guide the selection of indicators [10
Although many of these frameworks acknowledge the importance of major structural components of the primary care system, only recently have important contextual influences recognized by Donabedian been seriously explored. Lamarche et al.
] concluded a comprehensive evaluation of the influence of organizational models on primary care outcomes by suggesting that differences in output are fundamentally related to dimensions such as vision and the practice's environment context. This conclusion resonates with recent findings that features such as team size and financial incentives [12
] may have independent effects on quality of care.
There is evidence that organizational factors partly explain major variations in demanded diagnostic tests [13
], referrals to specialized services [14
] and the frequency and timing of follow-up visits [15
]. Investigators have explored the possible interrelations among medical practices, primary care outcomes and organizational structure [16
], mode of remuneration [16
], group style and peer pressure [17
], organizational culture [18
] and team cohesiveness [19
Recent efforts to explain practice variations have tried to integrate multiple levels of analysis by considering individual and situational factors. Organizational science offers relevant concepts and definitions to facilitate this type of analysis. Contemporary definitions of ‘organizations’ have evolved from a closed-system perspective portraying them as isolated systems with no interaction with their environment [20
] to an open-system perspective in which they are viewed as a system of interdependent activities ‘linking shifting coalitions of participants embedded in wider material-resource and institutional environments’ [21
]. This open-system perspective encapsulates three distinct levels of analysis: sociopsychological (the behaviors of individuals), organizational structure (the structural features that characterize the organization) and ecological (the organization viewed as an entity operating in a larger system of relations). Such definitions and perspectives can enrich our understanding of primary health care models. This paper's central premise is that new concepts in organizational theory have much to offer in the understanding of systemic drivers towards quality primary care.