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Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review
  1. Alessandra Buja1,
  2. Roberto Toffanin2,
  3. Mirko Claus3,
  4. Walter Ricciardi4,
  5. Gianfranco Damiani4,
  6. Vincenzo Baldo1,
  7. Mark H Ebell5
  1. 1 Unit of Hygiene and Public Health, Department of Cardiologic, Vascular, Thoracic Sciences and Public Health, Laboratory of Health Care Services and Health Promotion Evaluation, University of Padova, Padova, Italy
  2. 2 Past Administrative Directorship, ex-ULSS 4, Veneto, Italy
  3. 3 Department of Cardiologic, Vascular, Thoracic Sciences and Public Health, School of Hygiene and Preventive Medicine, University of Padova, Padova, Italy
  4. 4 Department of Public Health, Università Cattolica Sacro Cuore - Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
  5. 5 College of Public Health, University of Georgia, Athens, Greece, USA
  1. Correspondence to Dr Alessandra Buja; alessandra.buja{at}


Objectives Our goal is to conceptualise a clinical governance framework for the effective management of chronic diseases in the primary care setting, which will facilitate a reorganisation of healthcare services that systematically improves their performance.

Setting Primary care.

Participants Chronic Care Model by Wagner et aland Clinical Governance statement by Scally et alwere taken for reference. Each was reviewed, including their various components. We then conceptualised a new framework, merging the relevant aspects of both.

Interventions We conducted an umbrella review of all systematic reviews published by the Cochrane Effective Practice and Organisation of Care Group to identify organisational interventions in primary care with demonstrated evidence of efficacy.

Results All primary healthcare systems should be patient-centred. Interventions for patients and their families should focus on their values; on clinical, professional and institutional integration and finally on accountability to patients, peers and society at large. These interventions should be shaped by an approach to their clinical management that achieves the best clinical governance, which includes quality assurance, risk management, technology assessment, management of patient satisfaction and patient empowerment and engagement. This approach demands the implementation of a system of organisational, functional and professional management based on a population health needs assessment, resource management, evidence-based and patient-oriented research, professional education, team building and information and communication technologies that support the delivery system. All primary care should be embedded in and founded on an active partnership with the society it serves.

Conclusions A framework for clinical governance will promote an integrated effort to bring together all related activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach that sustains the provision of better care for chronic conditions in primary care setting.

  • primary health care
  • chronic disease
  • healthcare
  • health system framework

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Strengths and limitations of this study

  • The study gives a new comprehensive framework to drive an effective management of chronic diseases in the primary care setting.

  • A systematic review was made showing all relevant studies in Cochrane Effective Practice and Organisation of Care Group alongside the dimensions of the framework.

  • We do not report studies illustrating interventions for a specific unique disease even if chronic disease.


The dramatic increase in the burden of chronic diseases in the last 20 years represents a primary concern for health services, and global health system sustainability demands a massive shift to primary care.1–3 As a consequence, the organisation and provision of primary care now faces new challenges (eg, polypharmacy, multimorbidity, fragmentation of care, frequent transitions of care, a need for strong integration and pressure from patients).4 There is currently a growing interest in high-income countries to redesign healthcare organisations, focusing on practices that improve the quality of care and guarantee the equitable, timely and effective management of patients with chronic diseases.5 6 In fact, it is now widely recognised that the care and support needed to live with a long-term condition requires a radical re-design of services, by allowing patients to drive the care planning process and by developing a new management of care for people that is proactive, holistic, preventive and patient-centred as for example defined by the ‘House of Care’ model.7 With these pressures, primary care systems may have difficulty ensuring a coordinated approach, and the lack of clarity concerning their goals has led to divergent approaches, and a slow and often disjointed adoption of changes and improvements.8

Clinical governance is an umbrella for the systematic administration and coordination of different processes having a direct impact on healthcare delivery, including the management of patients with chronic conditions. It encompasses the tools, methods and infrastructure devoted to assuring healthcare delivery, continuously improving the quality of the service and striving towards clinical excellence for patients. Clinical governance was first established in the UK,9 and has been implemented in many different countries.10–13 Until now, it has focused largely on in-hospital care, and met with significant difficulties when transferred to primary care.14 Clinical governance for primary care, focusing on the management of chronic diseases, has specific features and relies on a network of different health professionals working together for their patients’ benefit.15

Our paper aims to conceptualise a clinical governance framework and the tools it needs for the effective management of chronic diseases in the primary care setting, allowing to drive an effective change in healthcare services and thereby systematically improving their quality and safety.


For the purposes of our analysis, we used the Chronic Care Model by Wagner et al 16 and Clinical Governance statement by Scally et al 17 for reference, carefully reviewing each of them and their various components. We then conceptualised a new framework, merging the relevant aspects of both, and also defining and implementing new themes in a way that is relevant for primary care. We ultimately selected five core elements from the original Chronic Care Model (delivery system design, decision support, clinical information systems, self-management support, the community) and six approaches (risk avoidance, coherence, infrastructure, culture, quality methods, poor performance) from the clinical governance framework described by Scally et al based on their relevance to primary care and chronic disease management.

We then devised a framework arranged like a sunflower, where the stem and leaves represent the structural components of the system needed to supply and support the petals. The petals in turn represent the themes or topics that shape direct actions involving patients or caregivers (the bud of the system). The sunflower is rooted in the earth, from where its structural components receive inputs in the form of water and nutrients; in healthcare, inputs from the ‘soil’ enable the provision of primary care, collaboration between service providers and resources from the outside world. The atmosphere in which the sunflower grows informs the views and attitudes that guide the actions of both health professionals and patients.

For each petal (ie, theme or topic), we searched for relevant interventions in the Cochrane Library from 2010 to the end of 2016, in the context of chronic care in the primary care setting. The search strategy used in our umbrella review of the Cochrane Library was based on the MeSH terms: (‘general practice*’ or ‘primary care’) and (‘chronic disease*’ or ‘multimorbidity’), plus one of the following: (1) ‘clinical governance’; (2) ‘quality assurance’ or ‘evidence-based healthcare’; (3) ‘satisfaction, patient’; (4) ‘risk management’; (5) ‘empowerment’ or ‘health literacy’ or ‘engagement’; (6) ‘health technology assessment’ or ‘cost-effectiveness’ or ‘cost-utility’. We also identified all systematic reviews published by the Cochrane Effective Practice and Organisation of Care (EPOC) Group that met our criteria. We included all relevant studies published in the Cochrane Review Database from 2010 to June 2017, and excluded all studies illustrating interventions for a specific disease, or those not involving patients with chronic disease.

Patient and public involvement

The present study does not involve patients or public.


The resulting conceptual framework is shown in figure 1. We define three targets where management strategies could be acted:

  1. The petals consist of the management strategies that directly inform the interventions and clinical practice that acts on and with the patient and their family; primary care delivery happens at the level of the petals level, with the patient at the centre.

  2. The stem represents the underpinning management strategies that support the delivery system, which is the personnel and structures that permit the organisation to support the ‘life of the petals’.

  3. The ground is the environment in which primary care delivery is located, which gives ‘nourishment’ and foundation.

  4. Finally, there is the atmosphere, which represents the management strategies that influence the first three targets.

Figure 1

Framework for primary care management of chronic disease. EBHC, Evidence-based healthcare.

The bud is the centre of the flower

Placing personalised patient-centred care at the heart of the system is an important way to create catalysts for change and encourage service re-organisation, by focusing on patients’ health needs and motivating health system changes.18 We define patient-centred care as care that is based on continuous, healing relationships among health professionals, patients and their families; care that is customised based on the patients’ needs and values19; ensuring that the patient is the source of control; sharing knowledge and information freely and maintaining transparency.

The petals define what and how to act on and with the patients

The petals represent the management strategies that should shape directly the interventions on and with the patients. These dimensions include quality management, perceived quality management, empowerment strategies, risk management and health technology assessment. The Institute of Medicine in the USA (now called National Academy of Medicine) defines quality management as the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.20 It usually has two facets: quality assurance and quality improvement. In chronic disease management, quality assurance concerns the activities and programmes intended to assure or improve the quality of care in a specified medical setting or programme. The concept includes assessing (measuring) the quality of care, identifying problems or shortcomings in the delivery of care, designing activities to overcome these deficiencies and follow-up monitoring to ensure the effectiveness of any corrective action.21 Quality improvement involves the process of attaining a new, higher level of performance or quality.22 Adopting the philosophy of evidence-based medicine in planning the diagnosis, care and follow-up of chronic patients has resulted in a more effective and consistent transfer of the lessons learnt from research into routine practice, helping to reach higher quality standards.23 24 For example, a review showed that, in 5 of 17 good-quality randomised controlled trials, several different interventions were able to improve both adherence to prescribed medicines and clinical outcomes. These interventions frequently included enhancing support from family, peers or allied health professionals such as pharmacists, who often delivered education, counselling or daily treatment support, even if no common features could be identified to explain their success25 (table 1A).

However, while many measures of quality of care in the primary care setting have been validated for specific diseases, little has been done to examine the validity or usefulness of these measures in the context of multimorbidity. To guarantee quality assurance, it is necessary to consider the deliberate and systematic coordination of an organisation’s people, technology, processes and organisational structure in order to add value through innovation, using research to inform practice.26 The systematic coordination and organisation of the primary healthcare team to develop proactive, holistic, preventive and patient-centred models of care has primarily been developed for patients with chronic disease and multimorbidity. A review27 concluded that health-service or patient-oriented interventions designed to improve outcomes in people with multimorbidity in primary care and community settings improved mainly mental health and functional outcomes. Another study28 demonstrated the benefits of applying new technologies (telemonitoring) for community-dwelling patients care with chronic disease and multimorbidity, which significantly reduced healthcare costs, hospital emergency department admissions, hospital length of stay and mortality.

Risk management concerns the systematic identification, assessment and integrated management of current and potential hazards relating to patient care. This is particularly relevant for the care of complex patients with (‘multimorbidity’).28 The creation of a culture that is free of blame and encourages an open examination of errors and failures is key to improving quality and learning.

Clinical incident reporting is a key feature of a risk management system that can improve identification of errors and how we can learn from them. Leape suggests that successful systems provide a safe non-punitive environment, and are simple, timely and inexpensive.29 However, the effectiveness of such systems in promoting adverse event recording is not clear. To evaluate the effects of interventions designed to increase clinical incident reporting in healthcare settings, Parmelli et al in 2012 conducted a review of four trials with several methodological shortcomings. Despite their limitations, two studies showed the effectiveness of the system implementation: one reported an increase in incident reporting rates, while the second showed a sustained improvement after 9 months.30

One review on non-clinical health professional roles found that older people were more likely to receive appropriate medicines with the provision of a pharmacist-led intervention.31 This service provided by pharmacists that involves identifying, preventing and solving medication-related problems, as well as promoting the correct use of medicines and encouraging health promotion and education. Another strategy found to be useful was computerised support for decision-making. The review focused primarily on process outcomes, and provided only limited evidence of whether these interventions resulted in clinical improvement. Another review found that self-monitoring of medicines and patient self-management programmes were generally effective in improving the use of medicines, adherence to prescriptions, reducing adverse events and improving clinical outcomes. It also found a lower mortality rate among people self-managing their antithrombotic therapy.30 The same review revealed numerous other promising interventions to improve adherence and other key outcomes related to medicine usage (table 1B).

Patient satisfaction

Patient satisfaction is fundamental in the case of patients with chronic disease who are likely to be involved in a lasting relationship with healthcare services. It is linked to patients’ expectations of ideal care and their actual experience of care,32 and it is considered by most as a multidimensional construct including multiple domains such as accessibility, organisational characteristics of the system, clinical and communication skills and the doctor-patient relationship, among others. Long waiting lists for non-urgent health procedures are quite common and may affect the health professional-patient relationship, causing distress for patients and their caregivers and distrust of the healthcare system. Improving access by implementing an open access or direct booking for some health problems or referrals has been shown to improve patient satisfaction.33 Home-based interventions for end-of-life care have also been shown to improve both patient and caregivers satisfaction34 (table 1C).

Patient and caregiver engagement refers to a patient-centred and family centred collaborative approach that is tailored to match the fundamental realities of chronic care. Patient and caregiver engagement helps patients discover and develop their inherent capacity to take responsibility for their own life.35 Empowering patients by providing information and increasing their contribution to the planning of services can greatly influence the development of clinical governance on clinical processes and on organisational matters. Contributions from patients will affect the responsiveness and performance of healthcare services, and the process by means of which quality improvement initiatives are identified and prioritised.36 Recent reviews of interventions promoting shared medical decision making, with active involvement of both patients and health professionals, have found moderate evidence of better patient involvement. In addition, decision aids (pamphlets, videos or video-based tools) may improve patient’s knowledge of their care options, so they feel more informed and better able to participate in decision making37 38 (table 1D).

Health technology assessment (HTA) refers to the systematic assessment of the properties and effects of a health technology, addressing the direct and intended effects of the technology, as well as its indirect and unintended consequences. The main aims of HTA are to inform decision-making regarding health technologies (bearing in mind the finite resources available), to drive the introduction of innovations and to identify ineffective or harmful technologies.39 Whether it involves introducing electrostimulators for treating incontinence, or disinvesting in old medical ventilators for long-term domiciliary respiratory support, or a new clinical pathway for diabetes, HTA is a robust method for orienting decision-makers and clinicians towards the best available choices (table 1E).

The atmosphere

The atmosphere dimensions defined at this level shape the interventions given to patients, as petal dimensions, and describe activities between professionals inside the organisation, as well as the relationship with the civil society. Dimensions of the atmosphere include vision and values, integrated care and accountability.

A well-led organisation will monitor whether the vision and values of clinical governance are being clearly and effectively communicated to all members of the staff. This communication gives staff a common and consistent purpose, and clear expectations. A clear vision engenders an open-minded and questioning culture, and ensures that both the ethos and the day-to-day delivery of clinical governance remain an integral part of every clinical service. Apart from health system issues, one of the major barriers to the successful transfer of evidence into locally accepted policies lies in ineffective and unaccountable leaders and managers40 (table 1F).

Integrated care is a concept that brings together the inputs, delivery, management and organisation of services related to patients’ diagnosis, treatment, care, rehabilitation and health promotion. As individuals move across healthcare settings and services, the model of care requires integration and cooperation between a multiplicity of professionals. This integration and cooperation demands a high degree of collaboration between healthcare professionals involved in these services, as well as organisational support. This integration should operate within a primary care system, and through effective communications between specialist and primary care providers, to guarantee better transitions of care for patients with chronic disease. The latter has significant positive effects in reducing hospital readmissions and mortality41–43 (table 1G).

Table 1

Systematic reviews

A robust, comprehensive and transparent accountability, with measurement of performance in healthcare activities can ensure that the system is accountable to society at large, to health professionals and others involved in delivering care and to patients. A fundamental shift is needed from a demand-driven model valuing the volume of the production, to a new model where the providers are accountable for the care outcomes and value that matter to patients and the broader population. Driving accountability for outcomes and value leads to several key benefits: it encourages innovation along entire care pathways, to raise quality and reduce cost; it incentivises collaboration between providers to coordinate care to deliver outcomes; it clarifies for policy-makers what is being achieved by the money being spent and it gives people a stronger voice in their own care and in defining what matters.44 45 Such a system can support effective auditing, which can improve care processes in health districts over the long term.45

The stem defines the means to reach the petals

It is also important to ensure that key underpinning strategies (such as information technology, education and training, research and dissemination) support the delivery system to reach the defined petals dimensions. For example, any service re-organisation should involve building better information communication and technology systems, to enable a better exchange of information throughout a newly rearranged organisation. An effective workforce also needs appropriate technical support, such as access to valid best evidence, to support its clinical decisions. To be useful, the data in information systems must be valid, up-to-date and presented in a way that offers insight. It should also be integrated with the electronic health record, and not provide excessive alerts that lead to ‘alert fatigue’. Finally, it should focus on research that provides evidence of improved patient-oriented outcomes, rather than disease or surrogate markers of improvement.46

Data to highlight differences in patient outcomes, shortfalls in standards, comparisons with other services and time trends are essential. Interconnected electronic health records support clinicians’ efforts to improve outcomes across the full continuum of care, while ensuring accountability, engaging patients in making decisions and managing their care, improving safety and care coordination and avoiding any waste of resources.47 Data are essential to managing performance, normally in relation to two subsets of activities: performance evaluation and performance improvement. Both make use of indicators for assessment purposes, and the latter also to monitor a healthcare organisation’s performance during an improvement process.48 For patients with multiple chronic conditions, it is also necessary to devise team indicators and indicators that encompass all the care provided to a given patient.

Improving the training of healthcare professionals will be important in any effort to re-organise a healthcare system. For example, if more nurses are going to take on the role of case study managers, they will need additional training to build their skill base.49 Ideally, continuing professional education should not be limited to updating professionals’ technical skills, knowledge of new research and improved clinical decision-making. In addition, it should enable all members of the staff to develop skills that allow them to practice to the maximum of their training, and to assure that their skills are aligned with the organisation’s objectives.

The earth defines the ground where primary care is delivered

Community participation should be part of healthcare service planning and evaluation. It is also essential to mobilise community resources to meet the needs of people with long-term conditions, creating a culture and mechanisms that promote safe, good-quality care. It has been suggested that positive outcomes for people with long-term conditions are only achieved when individuals and their families and community partners are informed, motivated and work together.50 Families and individuals are then supported by the broader community, which in turn influences the broader policy environment, and vice versa. In this model, integrated policies span different types of disease and prevention strategies, consistent financing, the development of human resources, legislative frameworks and partnerships.


A framework for clinical governance promotes an integrated effort to bring together all relevant activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach, and thus sustain the provision of better care for patients with chronic disease and multimorbidity.

Quality assurance

There are numerous challenges to providing coordinated and high-quality primary care to patients with chronic disease. For instance, the quality of the management of patients with multiple chronic conditions should be examined, taking the completeness of care into account.51 52 There is often a lengthy gap between the generation of new research-based evidence and the application of this evidence in clinical practice. This is true for clinical management, and for organisational management of patients. Knowledge management is achieved by creating, sharing and applying knowledge, as well as through feeding the valuable lessons learnt and best practices into the ‘corporate memory’ to foster continued organisational learning.51 This broad remit of knowledge management and the sharing of knowledge among organisational fields includes developing values, structures and information technology. It places emphasis on how value can be added: the petals should be revitalised by the atmosphere and ground. Moreover, quality assurance in patients with chronic illness implies using measures to assess the impact of interventions for chronic conditions on a patient’s daily functioning and quality of life. A number of measures from the Medical Outcomes Study have been used in studies of multimorbidity in primary healthcare.53 An advantage of using such measures for patients with multimorbidity lies in that it does not focus on the care provided for specific diseases. Overuse of healthcare has also been assessed by examining hospitalisation rates for ambulatory care sensitive conditions, that is, conditions for which it is believed that well-organised delivery of high-quality primary care services can prevent the need for hospitalisation.54 55 Overuse of healthcare has also been measured in terms of the frequency of hospitalisation and emergency department attendance for patients with multiple morbidities.56 These measures are not disease-specific, so they could be used to assess overall quality of care for patients with multiple health problems. One of the main challenges, which takes a different form in each context, is to develop appropriate incentives that promote and encourage a collective commitment to this alternative paradigm of continuous performance improvement.57 The organisational leadership should maintain the organisation’s focus on the use of information for improvement rather than sanction or punishment. This involves being able to establish a trusting and working relationship with the potential users, and to move away from a controlling or paternalistic approach.

Client satisfaction

An important consequence of how care of patients with chronic disease is managed relates to perceived quality or satisfaction, which itself is associated with the health of the population as a whole.32 Patient satisfaction is associated with clinical outcomes, patient retention and medical malpractice claims, so it is a proxy, but nonetheless is a very effective indicator of the success of a primary care system. Different tools have been developed to assess perceived health quality for chronic diseases. A recent European project58 focused on perceptions of quality in primary healthcare in seven countries, highlighting the natural impact of waiting time on patient satisfaction, and the more complex association between equity and access to primary healthcare services. There is strong evidence that one of the most important determinants affecting satisfaction with health services is the patient-practitioner relationship, including the information the former receives from the latter.59 This is a crucial issue in the long-term management of chronic conditions. Different conceptual frameworks have been created to understand patient satisfaction, which is recognised as a critical issue to developing service improvement strategies. For example, Dagger et al 32 have proposed service quality as a multidimensional, higher order construct, with four overarching dimensions (interpersonal quality, technical quality, environment quality and administrative quality) and nine subdimensions. They suggest that consumers assess service quality at a global level, a dimensional level and at a subdimensional level, with each level influencing perceptions at the level above.

Patient activation and self-management

The evidence linking patient activation, including person’s beliefs, motivation and actions for self-care, with health outcomes, the patient experience and cost has grown substantially over the past decade.60 Higher activation levels in chronically ill patients are associated with higher levels of adherence to treatments, self-monitoring of conditions and regular chronic care. Patient activation to enhance patients' skills, knowledge and confidence in their ability to take healthy action and manage their disease should therefore be one of the main goals of a primary care health system. Patient activation can increase the motivation for self-management for chronic diseases, such as creating durable healthy lifestyle changes and improving adherence to treatment recommendations. In this respect, self-management reaches beyond traditional disease management by incorporating the wider concept of prevention, emphasising the notion that people who are chronically ill still need preventive services to promote their wellness and mitigate any further deterioration of their health. Self-management is consequently an excellent way to address chronic conditions as a major public health issue.61 Researchers have also placed a strong emphasis on the crucial role of family in patient self-management, recognising that enhancing families’ self-management generates better health outcomes.62 Despite its important beneficial effects, many factors threaten effective empowerment, including individual patient characteristics, poor technological or IT infrastructure, poor educational or communications strategies and communication and language barriers between healthcare providers and patients.

Performance monitoring

Where performance monitoring systems are adopted as a management approach, performance tends to be better than when such systems are not in place. Reverse causality could be argued, higher quality primary care organisations may be more likely to implement performance evaluation. Healthcare professionals are generally keen to measure, know and demonstrate that they are making an important difference for their patients. Although there is little evidence of its effect on health outcomes or overall value for money,63 64 the emphasis on performance management in primary care is growing. A recent report highlighted how performance management is influenced by its own understanding, the systems used and the evaluator-evaluated relationship.48 Performance management needs an appropriate set of valid of indicators relevant to primary care practice that recognise the complexities of different clinical pathways, multimorbidity, educational and counselling activities, goals and other activities typical in primary care.65

An example of such indicators was identified by the Australian Institute of Primary Care,66 which classified them as discipline-specific, disease-specific or systemic; these indicators could effectively inform primary care governance. Where instances of poor quality were not assessed, the management was to be ineffective, staff concerns about standards of care were marginalised or worse, adequate improvement systems were not in place and the service was not seen through the patients’ eyes. Clinical pathways are quite popular as a format for translating guidelines into practice and facilitating an integrated approach to care that is supported by scientific evidence, but is also respectful of organisational issues. These pathways design an optimal pathway (or series of pathways) for managing clinical problems within a healthcare organisation. Their development engages all of the professionals responsible for managing the disease or problem, and provides an opportunity to establish clinical and organisational indicators, and to define information flows. Certainly, the management of multiple conditions using clinical pathways requires a comprehensive approach that should consider many aspects, such as establishing the patient’s priorities, evaluating the disease and treatment burdens and having a discussion of the benefits and risks of specific interventions. As part of the patient-health professional relationship, the individualised management plan constitutes the foundation of a shared explicit decision-making process. It is a written agreement that includes all relevant decisions, such as starting or stopping a treatment, anticipating the possible disease evolution and future healthcare appointments. It should assign responsibility for processes and interventions to specific health professionals, to ensure appropriate communication with the patient and caregivers, and with other providers.67 68

Clinical risk management

In 2012, WHO prioritised clinical risk management in primary care, forming its Safer Primary Care Expert Working Group that recently produced a technical series.69 70 International data suggest that safety incidents in primary care are mainly diagnostic and prescribing errors, with a rate estimated between <1 and up to 24 safety incidents per 100 consultations reviewed.71 Key elements influencing patient safety are related to structural and technological prerequisites (eg, electronic health records, decision support systems), including organisational structure (eg, leadership, governance structure, organisation of work shifts, workload); human factors (eg, individual perception, diligence, decision-making ability, professionalism, interpersonal and group dynamics) and community characteristics (eg, epidemiological profile, resilience), and external influences (eg, media and public opinion). At the international level, the commitment to improving safety in primary care has focused mainly on building and implementing incident-reporting systems, and on proactive or reactive risk analysis systems (eg, analysis of critical incidents and adverse events, root cause analysis, failure mode effect analysis). Several interventions in primary care at the local level have been suggested by national agencies, including improving incident and adverse event reporting, integrating comprehensive risk management systems and continuous learning environments. Specifically, pharmacist-led medication review, computerised physician order entry, computerised decision support systems, error alert systems and education of professionals have all been shown to be effective interventions that could potentially prevent up to half of all errors.71

Education and learning

A continuous, proactive learning environment in primary care enables health professionals to deepen their knowledge and expand their skills, which even at the end of formal postgraduate professional medical are insufficient to ensure competence and performance over a life-long career. In addition, continuing professional development systems whose relevance has been widely recognised,72. Ways to keep clinicians updated with practice relevant information have evolved since the late 1990s, in the form of useful criteria to identify patient-oriented, evidence-based information. One example is the Information Mastery framework, which emphasises Patient-Oriented Evidence that Matters (POEMs) of Slawson et al.46 POEMs are studies that are relevant to primary care decision-making, have been assessed for validity and have the potential to change practice. Each year, only about 200–250 studies from the top 100 clinical journals meet these criteria. An evolution of this concept has been translated into an online resource, Essential Evidence Plus, which is unique in comparison to other point-of-care tools in that it provides daily emailed POEMs to subscribers.73

Regarding the telephone and email consultation skills of clinicians, which are important for effective remote consulting, we do not yet have strong evidence regarding how health professionals should be trained to make the best use of this communication challenge.52 Educational gaming is potentially a way to improve health professionals’ knowledge and skills, in particular for its motivating competitive nature. However, evidence of its effectiveness is limited, with only two studies identified and no difference seen between the intervention and control groups.74

Interprofessional education is increasingly recommended as an approach that has the potential to improve communication between different types of healthcare providers, as well as an improved understanding of the skills and capabilities of different team members, and better team functioning. However, the evidence regarding its effectiveness is limited. In one study, improvements in diabetic health outcomes, greater attainment of healthcare quality goals and improved patient satisfaction and team behaviour have been reported and sustained over time.75

This framework however has a number of limitations. First of all, the umbrella review considered only EPOC Group and Cochrane Library database, other systematic review or meta-analysis not included in this paper could be examined to support and develop evidence-based healthcare management. Another limitation is the difficult to derive evidence easily transferable by researches in healthcare services. In fact, the generalisability or transferability of healthcare services research findings from one setting to another could be also often problematic. Furthermore, the importance of local organisational context and culture, and the structural differences in health organisations and health systems make challenging the exportation of organisational models. However, the a culture that supports and encourages innovation in organisational models should stimulate managers in routinely reviewing the findings of relevant research studies and research syntheses before making important decisions.76


The number of patients with chronic diseases will continue to increase with the ageing of the population, and the ongoing existence of risk factors for chronic diseases. We offer this framework with the aim of shedding light on how to reorganise primary care health systems, identifying and implementing an organic approach to optimising care for patients with chronic disease. Implementing such a framework will be a responsibility shared by the public and private health sectors, as well as by the communities where patients live and the primary health system operates. Strengthening partnerships with and between these sectors will be crucial to achieving the vision of a quality of care for multiple chronic conditions.


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  • Contributors AB, RT and VB: conceptualisation, design of the methodologies, wrote and approved the final manuscript as submitted. MC: review analysis, wrote and revised the manuscript, approved the final manuscript as submitted. GD: conceptualisation, supervision of the study, approved the final manuscript as submitted. MHE and WR: supervision, critically reviewed the manuscript, approved the final manuscript as submitted.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data available.