Quality management in primary
health care in Latin America: Impact on patients and services
Gestión de calidad en la atención primaria de salud
en América Latina: Impacto en pacientes y servicios
Tania Elizabeth Arguello
Quintana
Bachelor of Science in Nursing. Universidad Estatal de Bolivar,
tania.arguello@ueb.edu.ec
https://orcid.org/0009-0002-5640-4402
Clara Patricia Guerra Naranjo
Bachelor of Science in Nursing, Master in
Public Health. Specialist in health management and strategic planning
Universidad Estatal De Bolivar, cguerra@ueb.edu.ec https://orcid.org/0000-0002-6477-1539
Ninfa Geovanna Yánez
Barragán
Bachelor of Science in Nursing, Universidad
Estatal De Bolivar ninfa.yanezbarragan@ueb.edu.ec , https://orcid.org/0009-0003-5680-8578
Ana Verónica Pazmiño Verdezoto
Bachelor of Science in Nursing, Universidad Estatal
De Bolivar, ana.pazmino@ueb.edu.ec
https://orcid.org/0009-0009-6190-0348
)%20(inglés%20(americano)).fld/image002.png){kind=small}
The aim of this research was to analyze the impact of
quality management in primary health care (PHC) in Latin America, focusing on
the instruments used, as well as the possible relationship between quality and
satisfaction. Aspects related to the organizational improvements implemented
were also studied. The analysis of the documentary review showed that
evaluation instruments are fundamental for quality in PHC, but require
adaptations to reflect the realities. In addition, it is evident that quality management,
when focused on improving empathy, accessibility and continuity of care, is
closely linked to patient satisfaction. Organizational improvements, such as
implementing process management and adopting technologies, have proven to be
effective in optimizing service quality and increasing user satisfaction. It is
concluded that the strengthening of community participation and the development
of health personnel are essential to ensure efficient PHC.
Keywords: Latin America, primary health care, quality
management, organizational improvements, patient satisfaction.
Resumen
Con
el desarrollo de la presente investigación se buscó analizar el impacto de la
gestión de calidad en la atención primaria de salud (APS) en América Latina,
centrándose en conocer los instrumentos utilizados, así como la posible
relación entre calidad y satisfacción. Así mismo, se estudiaron aspectos
relacionados con las mejoras organizativas implementadas. El análisis de la
revisión documental arrojó que los instrumentos de evaluación son fundamentales
para la calidad en la APS, pero requieren adaptaciones para reflejar las
realidades. Además, se evidencia que la gestión de calidad, cuando se centra en
mejorar la empatía, la accesibilidad y la continuidad del cuidado, está
estrechamente vinculada con la satisfacción del paciente. Las mejoras
organizativas, como el implementar la gestión por procesos y la adopción de
tecnologías, han demostrado ser eficaces para la optimización de calidad del
servicio y aumentar la satisfacción del usuario. Se concluye que el
fortalecimiento de la participación comunitaria y el desarrollo del personal de
salud son esenciales para asegurar una APS eficiente.
Palabras clave: América Latina, atención primaria de salud, gestión
de calidad, mejoras organizativas, satisfacción del paciente
Introduction
The quality of care or services provided in
the health area is an essential aspect for the effective functioning of any health
system, since it helps to ensure that the care activities provided are both
effective and respond adequately to the needs and expectations of patients
(Astier-Peña et al., 2021; Medina et al., 2024). Thus, quality management in
primary health care (PHC) is an aspect of growing interest and relevance, with
greater emphasis within the frameworks of public health and nursing practice
(Puertas et al., 2020). PHC is the basic community care, being the link in the
system that interacts to a greater extent and directly with community health,
providing first-hand care, in basic, preventive, diagnostic and treatment
matters (Lino-Villacreses et al., 2023).
However, PHC has been considered as the
central axis of health services, being responsible for the improvement of
community health, with the purpose of reducing inequalities or difficulties of
community members to access health care (Lissette et al., 2024). In recent
years, significant changes have been generated in the system after the use and
application of quality systems in PHC, in order to continuously improve
services, assistance, care and results obtained in patients, families and
communities, and consequently in their satisfaction (Lizana, Flores,
Carhuayo-Luján, et al., 2020). Technologies and the increasing demand over the
years for accessible and high quality health services have motivated the need
to use systematic approaches to evaluate and continuously improve quality in
PHC.
Several researches have delved into the
implementation of quality management systems in PHC, such as one carried out in
Spain, where an evaluation instrument was designed and used internationally,
which has proven to be effective in the evaluation of primary health care
quality with a focus on the user's perspective. This instrument stands out for
its cultural adaptability and its availability in several languages, which
makes it a valuable tool in different contexts (López García & Barber
Pérez, 2024). Along these lines, in Latin America, specifically in Cuba, an
evaluative model was developed that analyzes four dimensions, divided into 14
variables and 54 criteria to measure the quality of the general services
subprocess, which had not been considered before. In the satisfaction surveys
applied to non-Spanish-speaking patients, more than 90% of the criteria
received a satisfactory evaluation, related to language proficiency and waiting
time to receive the room, as the main areas of dissatisfaction, with 70% and
85% satisfaction, respectively. Evidencing that quality implementation is high,
however, there are still opportunities for improvement in areas related to
communication and non-clinical care (Castellanos et al., 2022).
In line with the above, in Ecuador, relevant
aspects have been identified on the importance of the adoption of quality
management in PHC, and how it influences patient satisfaction and the
optimization of operational and organizational processes (Farias et al., 2023).
In line with this, the study conducted in the city of Riobamba, which addressed
quality in health units, identified that one third of those selected for the
study had a quality management plan. They also identified that a quarter of
those responsible for the district units considered that there were no
effective programs for monitoring user satisfaction, while both internal and
external users reported average levels of satisfaction with the organization
and processes of care (Parreño et al., 2021).
The main objective of this systematic
literature review is to evaluate the impact of quality management in primary
health care 2020-2024, analyzing patient satisfaction with assessment
instruments and organizational improvements. Likewise, this research is guided
by a key question What evidence exists on the impact of quality management in
primary health care, specifically on evaluation instruments, patient
satisfaction and organizational improvements during the period 2020-2024 in
Latin America? This question allows for a comprehensive approach that not only
seeks to understand the theory behind quality management, but also its
practical application and adaptability in the context of primary health care.
In the field of quality management in PHC,
several studies related to the topic have significantly contributed to the
understanding of how to implement and evaluate effective quality practices.
Several instruments used in PHC are identified that help to understand quality
from the user's perspective, offering a comprehensive approach that covers
aspects such as: accessibility, continuity of care, coordination and community
orientation (López García & Barber Pérez, 2024). Recent studies have
highlighted the importance of the commitment of health professionals,
particularly nurses, in improving the quality of PHC services. Research in
Spain and other countries has shown that the organizational commitment of
health professionals is directly related to patient satisfaction and treatment
efficacy (Del Estal García & Melián González, 2022).
This research will be based on a systematic
literature review, using a conceptual approach to analyze studies conducted
between 2020 and 2024 on quality management in PHC. It will include scientific
articles, literature reviews and case studies that address issues related to
quality management, patient satisfaction, effectiveness of PHC services and the
role of nursing in these contexts. The review will be conducted by searching
recognized academic databases using keywords such as "quality management",
"primary health care", "patient satisfaction",
"nursing" and "public health". Inclusion and exclusion
criteria will be based on the relevance of the content to the research
objectives, the methodological quality of the studies, and their practical
application in improving primary health care.
The importance of this research lies in its
ability to provide an in-depth understanding of how quality management in PHC
can be a key factor in improving public health and patient satisfaction. Aiming
to evaluate the impact of quality management in primary health care 2020 to
2024 in the Latin American context and analyzing patient satisfaction with
assessment instruments and organizational improvements. This can guide decision
makers in implementing training and continuing professional development programs
that empower nurses to lead quality initiatives in PHC.
Methodology
In the development of the research, a
structured search organized in four main phases was conducted over a period of
three months. These included the exhaustive exploration of various relevant
sources and databases, followed by the establishment of inclusion and exclusion
criteria to select relevant studies. Subsequently, the most relevant references
were identified and refined, ending with a detailed analysis of the tools,
methodologies and approaches used in the selected studies. This systematic
approach ensured a comprehensive and accurate review of the literature . During
this time, specific steps were defined to ensure coverage of a number of
databases that were relevant to the study, sources in different languages were
consulted and a large number of materials dedicated to quality management in
the health area in Latin America were examined.
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Image 1: research phases.
Elaboration: own.
In order to improve the results, multiple
keyword combinations were used including, but not limited to, "Quality
management in health care", "Patient satisfaction",
"Primary care", "Organizational improvements in health",
"Health assessment instruments" and "Latin America". These
keywords were merged using Boolean operators such as AND, OR and NOT to narrow
the results so that the studies shown were more focused on evaluating the
effect of quality management in that area.
Considering the focus on Latin American
issues and the available scientific literature, sources in Spanish, English and
Portuguese were considered. This linguistic selection made it possible to cover
global research, as well as specific empirical studies in that given region. In
addition, some types of sources were analyzed, including scientific articles on
the subject published in indexed journals, master's and doctoral theses
containing unpublished research, specialized books on quality management and
primary care, and reports from international organizations such as the Pan
American Health Organization (PAHO) and the World Health Organization (WHO).
Regarding the specific databases used, the
Western Library of Toronto was used to find studies on public health and
related quality management at the global level, while Scopus and Web of Science
(WoS) proved to be crucial for the retrieval of multidisciplinary peer-reviewed
literature. In addition, SciELO and Redalyc were fundamental for the retrieval
of research in Spanish and Portuguese specifically focused on Latin America.
Apart from that, requests were made to Google Scholar to search for additional
research studies such as dissertations and technical papers that are not easily
retrievable from more specifically designed databases.
In order to carry out this process, inclusion
and exclusion criteria were defined. Articles published between 2010 and 2024
were included; those who located their research in a Latin American country or
conducted a comparative study, as well as documents in the three established
languages. Repeated studies, non-primary care research or research that did not
use quality assessment instruments were excluded.
From the result of the first search, more
than 200 studies were obtained and after the use of inclusion and exclusion of
50 key references was necessary. The orderly and systematic application of
these criteria allowed the search for research that did not determine
situations such as, for example, that which was mapped in the literature and
seven other years.
This study adopts a documentary design with
an analytical-synthetic approach, focused on analyzing the role of health
professionals, the effectiveness of communication practices and strategies, and
the use of technology in the promotion of healthy lifestyles in Latin America.
The research is based on the collection, analysis and synthesis of information
from 19 academic and scientific papers selected from recognized databases such
as PubMed, SciELO and ScienceDirect.
The databases were selected for their
relevance and prestige in the publication of peer-reviewed scientific research.
The search was carried out using Boolean operators (AND, OR) to combine
keywords such as "health promotion," "lifestyle,"
"Latin America," "healthcare professionals," and
"technology in health promotion." These search strategies allowed
optimizing the retrieval of relevant information, ensuring accurate and focused
results in the regional context.
To ensure the quality and relevance of the
documents, inclusion criteria were established, such as relevance of the topic,
focus on Latin America, publication in indexed journals and timeliness of the
studies (2014-2023). Articles that did not specifically address health
promotion, lacked analysis on social determinants or were limited exclusively
to clinical interventions without considering preventive or community
strategies were excluded.
The analysis of the documents was structured
through a matrix designed to record key information, including aspects such as
the location of the study, main findings and authors' recommendations. This
tool facilitated the identification of patterns, comparisons between studies
and the grouping of information into three main categories: the role of health
professionals, the evaluation of the effectiveness of practices, and the use of
communication strategies and technology.
The analysis process was carried out in
several stages. First, an initial review of the documents was carried out to
identify recurrent themes and relevant keywords. Subsequently, the data were
organized into the defined categories, which allowed a critical and structured
synthesis of the information . Finally, the findings were integrated to
highlight best practices, challenges and opportunities in promoting healthy
lifestyles.
This methodological approach ensures that the
results of the study are rigorous, evidence-based and aimed at improving health
promotion strategies in Latin America. The combination of different sources and
the thematic analysis allows a comprehensive view to be obtained, providing a
solid basis for formulating recommendations applicable to health systems in the
region.
Results
Quality assessment in primary health care
(PHC) is a key point to certify that care and assistance services are provided
in a timely, efficient and patient-focused manner. In an environment where health systems face
high demand and pressure, having the support of concrete evaluation tools is
essential to measure the performance of services and, based on this, to
establish actions for continuous improvement. These tools make it easier for
health systems to identify critical areas for improvement, ensure user
satisfaction and improve the quality of the services provided, adapting to the
specificities of each context.
Based on the results identified in the
literature, one of the most outstanding instruments to assess quality in PHC is
the Primary Care Assessment Tool (PCAT), widely recognized for its ability to
measure fundamental aspects of primary care from the user's perspective. This
instrument encompasses several key dimensions such as access to health,
coordination among the team, capacity to offer a continuum of care,
comprehensive and intercultural approach.
This tool also has the capacity to adapt to different economic or
cultural scenarios, an aspect that makes it versatile and can be used in
international evaluations, which facilitates the comparison of results and the
identification of best practices at a global level (López García & Barber
Pérez, 2024).
However, another aspect of this type of
standardized instruments is that they not only allow measuring quality from a
technical approach, but also incorporate the perception of patients, families
or communities, resulting in a crucial aspect to assess whether health services
actually respond to the needs of the population. This multidimensional
approach, which encompasses the organizational structural level, as well as
processes and outcomes, allows for a more complete picture of PHC quality
(Tafur Contreras et al., 2022). However, the correct implementation of PCAT
requires an adjustment to the specific characteristics of each circumstance,
since sociocultural and economic conditions change considerably between
countries, regions and even at the community level.
In this order of ideas, another instrument,
the SERVQUAL, which is a tool that helps in the measurement of service quality
by means of 5 dimensions: tangibility, reliability, responsiveness, empathy and
safety of the services provided, was recognized among the contributions. In
contrast to PCAT, which focuses on PHC, SERVQUAL is used in the evaluation of
quality in different sectors, including hospital care, emergency and other
health services. One of the most outstanding attributes of this tool is that it
allows effective measurement of the gap between patients' expectations and the
perceived quality of services received (Guaita Pintado et al., 2023). This
aspect is of importance in PHC, since it allows the identification of specific
areas where patients' expectations and requirements are not being met, offering
a more precise vision of where improvements should be made.
Another of the strengths highlighted is the
adoption of a mixed approach (quantitative and qualitative) in the data
collection process through surveys and interviews aimed at evaluating the
quality of certain aspects of the service. These allow us to objectively obtain
the user's voice on aspects where they perceive deficiencies in the care
provided, in order to better understand their interaction with the health
system. This qualitative information complements the quantitative results
obtained through instruments such as the PCAT and the SERVQUAL and is
especially useful for problematizing the issue of quality from the point of
view of patient users (Pazmiño et al., 2020).
Likewise, quality assessment in PHC is not
limited to standardized instruments; some authors have used qualitative
analysis methods that gather patients' experiences and perceptions. These
methodologies are useful for the identification of problems that are sometimes
not evidenced by structured spaces, such as those related to accessibility and
trust in health professionals, as well as the vision of comprehensive care.
Qualitative methods also allow patients to provide care they believe they have
not received and any other concerns they may have. Therefore, this can be very
useful when designing interventions.
Finally, when choosing assessment
instruments, the particular context and objectives of the assessment should be
taken into account, as, for example, in certain quality assessments in PHC,
care has been directed towards the assessment of coordination and continuity of
care; in others, accessibility or cultural agency have been more emphasized. In
fact, recent research emphasizes that health systems should follow an
integrated evaluation approach that combines different tools and techniques to
understand quality from many angles.
The development and implementation of
instruments such as the PCAT have made it possible to determine and identify
specific shortcomings in various contexts, such as the deficit of
community-centered care or barriers in access to primary care (Lizana, Flores,
& Carhuayo-Luján, 2020). This has led those responsible for health
management to design improvement plans that are adapted to the characteristics
of each region, altering resources and procedures to raise the quality of
service. In many cases, these instruments have been used together with other
qualitative and quantitative techniques, making it possible to provide reports
that are more elaborate and contextualized, and, therefore, a more
comprehensive and nuanced evaluation (Parreño Urquizo et al., 2021).
In line with this, the validation of the
instruments used is considered important for the evaluation of PHC quality.
Measuring instruments must have validity and reliability, since they are
essential for the approval that the measures taken accurately delineate the
realities of the services provided. In this sense, the use of Aiken's V
Coefficient as an indicator of content validation and Cronbach's Alpha
Coefficient to validate internal consistency are methodologies that are
commonly used in the validation of instruments (Tafur Contreras et al, 2022).
These methods ensure that the tools used are appropriate for the scenario in
which they are applied, in addition to providing measures that enable
decision-making aimed at improving services.
With the increasing complexity of health
systems, the importance of measuring quality in an efficient manner is becoming
more critical. In this sense, evaluation tools should not only be created for
the purpose of assessing the current strengths and weaknesses of services, but
also to provide relevant information to assist in the strategic planning of PHC
service delivery. This means that the instruments should not only assess what
has been achieved in the past, but also facilitate the identification of future
demands and the development of strategies to meet those demands, as well as to
improve quality.
In this sense, the literature also mentions
the need for assessment instruments to be localized. Although the use of
instruments such as the PCAT or SERVQUAL in measuring international evaluations
is practically being used, these tools need to be contextualized in the
culture, economy and organization of many areas of application. This requires a
more continuous validation process and requires an adaptation of the items used
in the different instruments to suit local conditions. Under these conditions, the
results obtained may not be valid and therefore all interventions based on
these results may not be effective.
In this context, it is important that health
systems adopt a scalable and multidimensional approach in the evaluation of the
quality of social services. This means that quality assessment in PHC should go
beyond the use of a single tool or approach, but should involve different
methodologies or instruments that can help to objectively understand the
different dimensions of quality. In this way, complete and detailed
measurements are obtained, which collaterally makes the subsequent intervention
more effective and user-centered.
In addition to conventional evaluation
instruments, there is an approach that consists of implementing process
management models, which allows the restructuring of care activities in a more
integrated vision. These models seek to facilitate the chain of care and reduce
variability, while promoting the improvement of service quality (Rodriguez,
2021). Another important aspect that has been analyzed in the literature is the
application of quality standards, such as ISO 9001 and EFQM in hospital management
(Sánchez Suárez et al., 2022). Thanks to these methods, the performance of
clinical processes is facilitated in a chain of continuous improvement,
allowing procedures to be performed uniformly and efficiently.
The work of quality assessment in the PHC
scheme in the Latin American region faces different challenges that may be
associated to the social, economic and cultural particularities of this region.
Although instruments such as PCAT and SERVQUAL have shown their effectiveness
in the region, it is necessary to implement a series of modifications that help
to adequately reflect the reality of health services. Health systems in the
area of interest tend to be under-capitalized and are recipients of excessive
demands for services, which makes it difficult to maintain their uniform
application. Although they make it possible to identify areas for improvement
and measure the level of patient satisfaction, their effectiveness is subject
to the need for constant adjustment to specific conditions, including cultural
and structural ones. In addition, the combination of qualitative and
quantitative approaches is essential for a deeper understanding of quality, at
particularly in prescribing or for the protection of marginalized or
inaccessible communities. However, the lack of availability of funds and the
continuous need for these tools to be validated restrict their effectiveness,
calling for a more pragmatic approach that assesses the technical quality of
service delivery and the experience of service users in order to improve the
quality of PHC.
Process management also emphasizes the
importance of patient satisfaction as one of the most important objectives to
be achieved to improve quality. Reorganizing clinical tasks with a focus on
patient needs can be used to reduce waiting times and improve efficiency
(Huilcavil & Riveros, 2023; Medina et al., 2024). This is crucial as it is
directly related to the quality assessment performed by users, given that
patient satisfaction is highly dependent on the individual's commitment to the
healthcare system.
Thus, within this line of literature, it is
emphasized that users' opinions are particularly important in the measurement
of quality in PHC. Qualitative studies in which patient narratives are
collected allow the elucidation of latent motives that would remain invisible
in other more formalized approaches. Qualitative and quantitative methodologies
appear to be crucial to carry out an effective and consistent evaluation of the
quality of services (Gómez Mendoza et al., 2022; Nahuelquin et al., 2022).
Relationship between quality management and
patient satisfaction
Coordination between quality activities and
patient satisfaction is an important issue for the continuous improvement of
health services, especially in primary health care (PHC). At the international
level, a change has occurred where user satisfaction has become an important
indicator of the quality of care, since it reflects the user's perspective on
effectiveness, warmth of treatment and the level of response provided. Guaita
Pintado et al. (2023) explain that, despite the efforts made within the health system
in Ecuador, there is considerable dissatisfaction among users, especially for
the attributes of empathy, reliability and responsiveness. This reinforces the
importance of evaluating and modifying existing quality management systems.
Their improvement is necessary so that patients' requirements and demands are
better met, which is essential to foster patient satisfaction.
Adverse events or complications that are a
common result of the provision of existing health services do not seem to be a
satisfactory quality for patients. In this sense, Lages and Martinez (2021)
propose that the correct structuring and implementation of systematic processes
such as process management or benchmarking can result in improvements in the
delivery of health services. Optimization tools make it possible to identify
areas of dissatisfaction and influence them with, for example, business process
redesign, continuous improvement of staff qualifications, and patient-centered
care culture. As the efficiency of the healthcare system increases, so do the
user's feelings and experience, and thus satisfaction.
One of the important elements in the
interrelation between quality and satisfaction is the attitude and commitment
of the health personnel, in this case the nursing staff. According to the
literature, quality assessment by the patient is determined by the
responsibility and responsiveness of health professionals. On the other hand,
Pazmiño et al. (2020), emphasize that quality must have a resource that ensures
the implementation of the necessary steps for the education and training of
professionals in human-oriented care and the effectiveness of the message. By
strengthening these elements, PHC not only improves patient satisfaction, but
also helps in the loyalty of users and improves the overall image of the health
services provided.
Regarding PHC attributes, Lizana, Flores and
Carhuayo-Luján (2020) explain that patient satisfaction is closely linked to
first contact, continuity and coordination. The results of their studies reveal
that there is a varied perception of quality among the different health centers
that have been evaluated, where the fact of treating the family and orienting
care towards the community are critical aspects that must be solved in order to
increase user satisfaction. Thus, quality management should focus on relativizing
these attributes in order to guarantee a successful and pleasant experience for
the patient.
The validity and reliability of the
instruments used in the evaluation of PHC functions are also a relevant factor.
According to Tafur Contreras et al. (2022), patient satisfaction depends mainly
on whether health institutions live up to users' needs and expectations. The
adoption of such evaluation tools helps to point out certain aspects of the
quality of something that needs to be improved - in this case the quality of
service, which optimizes patient satisfaction. It is a fact that in quality
management the direct relationship with user satisfaction is used, which in
this methodology requires applying very specific and localized measures and
evaluations.
Parreño Urquizo et al.'s (2021) analysis of
quality management in the health care setting of the specific city also pointed
out that there is a scarce presence of quality plans and programs for
monitoring user satisfaction. Only one in three health centers, represented as
33.33%, had a quality management plan, while three out of four authorities
reported a lack of follow-up programs for user satisfaction. These results
reflect very strongly that there is a relationship between quality plans and
user satisfaction with respect to that service, and therefore make it more
urgent to establish much more effective management mechanisms.
According to Rodriguez (2021), the process
management approach is an effective strategy to improve patient satisfaction.
If care processes become more patient-centered with the involvement of
healthcare professionals and appropriate clinical practices, a considerable
improvement in patient experience is likely to be achieved. To meet the
objectives, all involved must release a number of processes that do not provide
added value so that patients can enjoy a more pleasant journey through the
healthcare system. All of this leads to a more favorable patient impression and
increased satisfaction indicators in the end.
Sanchez Suarez et al (2022) also attempt to
establish a correlation between patient satisfaction and efficient resource
utilization. Lean manufacturing and operations planning are verified as direct
influences on the quality and efficiency of care processes, which in turn has a
positive effect on patient experience and thus patient satisfaction. Such
improvement in operational practices has a very high potential to improve
users' perception of quality and is an integral part of quality management
programs in primary care.
The role of health staff commitment is also
essential, as it has direct effects on patient satisfaction (Del Estal García
and Melián González, 2022). Motivated and committed staff are likely to provide
quality care, resulting in high levels of customer satisfaction. This
highlights the critical need for quality management that fosters the commitment
and well-being of healthcare workers, as the care of healthcare professionals
is key to patients' perceptions of quality.
Finally, the quality of interconsultations,
which is another important dimension of PHC relationships, also has a
differential effect on patient satisfaction. According to Ibáñez et al. (2024),
the efficiency and effectiveness of interconsultation are very essential to
improve the user experience in PHC. There is an improvement in communication
between health professionals and coordination of care, which are also important
aspects of total quality management that significantly improve patient
satisfaction.
Taking into consideration all the reviewed
studies, it is considered important to carry out quality management that
implies organizational actions focused on users and staff commitment, in order
to achieve a better quality of PHC services and, therefore, increase the
instrumentalized satisfaction of users. The adoption of systematic processes
and adequate tools for evaluation makes it possible to identify dark areas in
the system, leading to a better health system and better experiences for
patients.
Organizational improvements implemented in
the primary health care system
The use of organizational improvements in PHC
is crucial in optimizing the quality of services and improving patient
satisfaction. Organizational improvements can encompass a variety of approaches
including process management, ICT integration, and patient-centered program
development, each with the goal of streamlining workflow and quality of care.
These strategies help to optimize services while strengthening the
organizational structure of PHC, thus achieving a more efficient and
patient-friendly care environment.
However, according to the authors consulted,
management by process focuses on optimizing results throughout the flow of care
activities provided in health services. Lages Ruíz and Martínez Trujillo (2021)
highlight that process management, combined with tools such as benchmarking or
the reference of other competitors, helps to redesign activities in PHC
services, increasing efficiency and effectiveness. Process management involves
the analysis of each step of the service, starting from patient reception to post-treatment
follow-up, discarding redundancies and ensuring greater effectiveness in care.
In turn, the use of benchmarking facilitates the comparison of an institution's
processes with those of other leaders in the sector, identifying areas where
improvements can be implemented based on the best practices observed.
On the other hand, Guaita Pintado et al.
(2023) highlight important aspects of the implementation of improvements at the
organizational level, explaining that they should be centered on quality
management program guidelines. The use of indicators or KPIs that facilitate
the continuous measurement of user satisfaction should be integrated. In
addition, it should be accompanied by training programs for staff and internal
guidelines that promote user-centered care. This very approach by systems helps
to ensure that PHC services reach quality standards, resulting in greater trust
and satisfaction among patients accessing health services. The integration of
quality programs in turn allows health services to recognize failures and
correct deficiencies in services on an ongoing basis, thus improving the
patient's experience.
Lizana et al. (2020), on the other hand,
state the importance of recognizing and analyzing the key points of PHC in
order to improve them in a timely manner, such as the family approach and
community orientation. In their analysis of PHC developed in Ayacucho, Peru,
they provide that shortcomings at the organizational level may be overcome or
improved by implementing coordination between care systems and the
implementation of strategies with an integrative approach that responds to the
needs of patients and the community. Organizational improvements should focus
not only on adjusting the structure of PHC services, but also on promoting more
equitable and accessible care.
In this regard, Parreño Urquizo et al. (2021)
also stress the importance of implementing quality management programs in
health units. These programs should focus on identifying and correcting factors
that affect user satisfaction. The authors recommend designing quality plans
and establishing continuous monitoring programs to ensure that PHC services are
constantly improving. Monitoring patient satisfaction and continuous evaluation
of services allows health managers to make informed decisions about areas that
require greater attention and resources.
Regarding specific methodologies for
organizational improvement in PHC services, Rodriguez (2021) and Sanchez Suarez
et al. (2022) propose the adoption of tools such as process management based on
ISO standards and excellence models such as EFQM. These approaches stress the
importance of standardizing care activities and reorganizing workflows to
achieve more efficient and safer care. In addition, Rodriguez stresses that the
implementation of process management reduces variability in healthcare services,
which contributes to greater patient satisfaction. Along the same lines,
Sánchez Suárez et al. point out that the integration of methodologies such as
Lean Manufacturing in hospitals can optimize the quality of care, improving the
planning and control of operational processes.
Likewise, the adoption of a strategic
approach to quality management is crucial for organizational improvement in
PHC. Guilabert et al. (2024) emphasize the importance of implementing efficient
management systems that include the continuous evaluation of processes, the use
of quality indicators and staff training. These elements are essential to
guarantee the quality of PHC services and user satisfaction. Training of health
personnel not only improves their technical skills, but also strengthens their
ability to provide patient-centered care, which contributes to a more positive
user experience.
It is also pointed out that another relevant
aspect for organizational improvements in PHC is the incorporation of
technologies such as virtual interconsultations, a space that has been
developing in recent years. According to Ibáñez et al. (2024), these virtual
interconsultations may contribute to the improvement of the quality of PHC
services in the sense of favoring continuity of care and intercommunication
among health professionals. Consequently, organizational improvements make
faster and more effective care possible. Waiting times are reduced and this
translates into better patient care. The development of such protocols allows,
as well as the use of technological tools, greater integration of PHC
professionals in care, thus increasing patient satisfaction.
Motivation and commitment of health personnel
also play a very important role in improving organizational quality. Del Estal
García and Melián González (2022) suggest that organizational improvements
should focus on establishing a culture of continuous training and leadership
within healthcare teams. The motivation of staff is crucial to ensure that the
professionals involved are committed to quality care and, most importantly, to
patient satisfaction. A well-trained and motivated healthcare team can deliver
more cost-effective care, which in turn improves patients' evaluation of the
services provided.
The same model proposed by Solis (2023) puts
forward the proposal to manage nursing care at the primary health care levels,
in terms of severity and risk. This is a model that allows preventing problems
and applying a more efficient management of services. The use of these
organizational models optimizes care processes, promoting health and providing
more comprehensive care to patients. These models are key to ensure that PHC
services respond to the changing expectations of the population and guarantee that
resources are used appropriately.
On the other hand, as highlighted by
Rivera-Pico et al. (2022), there are other aspects that are key to PHC
management, such as resources, both human and economic. What is advocated in
view of these structural shortcomings is the active participation of nurses in
the management and coordination of the service. These are the people who, in
the care of patients, are in the first place. If the employees of the
organization, its structure and its management activities are involved in
structural decision making, then not only the management of the services
becomes efficient, but also the patient care is personalized and tailored to
the needs.
In this line, Huilcavil and Riveros (2023),
in their work on care management in Chile, argue that there should be a
reinforcement of PHC by management structures that focus on prevention and
community organization. In this sense, the introduction of organizational
changes facilitates the preparation of health services to anticipate and
address emerging phenomena such as those that occurred during the COVID-19 era.
The lesson of the pandemic is that organizational improvements should enable
appropriate ADRs to be implemented to meet community health needs and desired
changes.
Finally, studies such as Mora Medina et al.
(2024) and Puertas et al. (2020) point out the problem of formulating planning
measures that affect not only organizational structure, but also space and
skilled labor. These studies advocate strategic leadership as a critical factor
for successful organizational improvement in PHC. Strong and dedicated
leadership means that health institutions carry out the organizational change
necessary to improve service accessibility and quality care for every segment
of the population.
PA in healthcare can be influenced by a
number of challenges as areas with a residential focus are generally more
complex than those with a population focus. Therefore, the complexity of the
organizational scope model has to run in tandem with the implementation of a
normative, standardized and broadly based, cross-functional model. This allows
for organizational improvements including facilitating additional tools for
changes in the way healthcare professionals work, which are more focused on the
patient and the health outcomes to be achieved, in addition to changes in the
quality of service.
Primary health care (PHC) in Latin America is
in a delicate situation due to socioeconomic problems, inequality in the
distribution of health services, as well as an evident need to improve the
quality of care. Over the years, countries in the region have implemented
various reforms and organizational strategies in an attempt to improve the
quality of PHC service and patient complaints. The analysis of three key
categories - quality assessment instruments, the relationship between quality
management and patient satisfaction, and organizational improvements - reveals
essential aspects for the transformation of health systems in Latin America.
A major concern in the region is the effort
to adapt international quality assessment tools for primary health care to
local circumstances. In Latin America , the Primary Care Assessment Tool (PCAT)
has been mentioned, which has received validation in several countries in the
region to measure accessibility, coordination, continuity and community
orientation, among other issues. However, the use of these tools has
highlighted the need for some cultural and structural modification to reflect
the realities on the ground (Lizana et al., 2020).
In the case of the Latin American region, the
disparity in the quality of PHC services is a common occurrence. Guaita Pintado
et al. (2023) state that assessment tools such as the PCAT are placed in cases
where there are great disparities between urban and rural areas. Services, when
available, in these rural areas where access to services is scarce, the results
of quality assessments indicate significant deficits in availability and
accessibility to policies. In such circumstances, it can be observed that the
assessment of PHC quality does not rely solely on the tools used, but on the
capacity of health systems to conform to local requirements.
Another important instrument in the Americas
region is SERVQUAL, which focuses on the service quality of health services
based on patients' expectations and experiences. In studies in Ecuador, it has
been found that patients' expectations most of the time exceed what the actual
experiences were and this indicates a significant quality gap (Guaita Pintado
et al., 2023). These types of evaluations allow health managers to see areas
that require urgent attention, especially with regard to empathy, responsiveness
and reliability of actions taken.
At the regional level, the lack of
standardization of evaluation instruments has been a challenge. However,
countries such as Brazil, Colombia and Mexico have taken steps towards the
implementation of assessment tools corresponding to their realities, but there
are major challenges at the level of financing, infrastructure and training of
health personnel. In this regard, Ponzo et al. (2018) have included the
harmonization of assessment tools in their recommendations as crucial to
improve the comparability of results between countries in the region.
Now, in relation to the link between quality
management and patient satisfaction, quality management in PHC systems in the
Latin American region has also had some development during the last ten years,
largely due to the emerging emphasis on patient satisfaction. But there are
important challenges in the implementation of quality management in the region
in relation to institutional capacity and resources.
One of the important points that emerges from
the studies is that patient satisfaction in Latin America is generally related
to PHC services, which often turn out to be quite low in the case of users. In
the case of countries such as Peru and Bolivia, studies show that patients feel
dissatisfied in the dimensions of availability of care and continuity of care
process (Lizana et al., 2020). These results emphasize the need to improve the
structural conditions of health centers and also to formulate public policies
that promote greater access to services.
The literature also emphasizes the need for
adequate care by health personnel. Thus, Pazmiño et al. (2020) indicate that
the quality of care is conditioned by some elements such as dedication and type
of care, especially on the part of the nurse. In many rural areas of Latin
America, these deficiencies can be found because the number of people attending
patients is scarce and the amount of work that these professionals must perform
is far beyond their capacity, which affects the quality of care received by patients.
In this sense, the quality of production must consider the implementation not
only of structural and technological improvements, but also of measures aimed
at strengthening the welfare and training of personnel.
The COVID-19 pandemic exposed weaknesses in
quality management systems in some countries of the region. Lack of
preparedness to respond to public health crises and weaknesses in the
integration of PHC services were critical issues that impacted patient satisfaction.
However, opportunities for effective communication and continuity of care were
also found to be critical in quality management. According to Ibánez et al.
(2024), the introduction of some technologies, such as teleconsultations, has
been considered a significant organizational improvement in several countries,
allowing for better coordination and increased patient satisfaction.
Another relevant aspect addressed was that
organizational improvements in PHC are necessary to address the structural
challenges of health systems in Latin America. Process management has been a
widely adopted strategy in the region with the objective of addressing
efficiency and quality of services. According to Rodriguez (2021), the
institution of process management, founded on ISO standards and quality
management models such as EFQM, can help optimize care activities and
streamline work progress, which, in turn, is directly related to patient
satisfaction with the service provided to them.
The intersectoral coordination of
organizations is also essential for the successful implementation of
organizational changes in PHC. Countries such as Chile and Argentina have
recognized the need to integrate PHC services with other levels of care, which
facilitates more comprehensive care and prevents duplication of services.
Sánchez Suárez et al (2022) favor the use of Lean Manufacturing principles in
the analysis and improvement of operational processes and the planning of
demand for PHC services. Not only do these improvements increase efficiency,
but they also help in the long-term sustainable development of health systems.
The inclusion of communities has been a
determining factor in the progress of PHC in some countries, such as Brazil.
The model supported by the neighborhood in the Family Health strategy in Brazil
has been mentioned as a successful model for the region. This leads to greater
involvement of the community in the planning and governance of health services
and this has been shown to have a benefit in the HUP-CC Electra USA, equity in
access to services and patient satisfaction (Rivera-Pico et al., 2022).
In addition, the limitations of health
workers in PHC process management vary according to capable residents and it is
necessary to emphasize them as non-student subjects, main actors in the
implementation of changes and leadership of impacts. Del Estal García &
Melián González (2022) extend that changes in health are necessary and there
are factors that frame: motivation and willingness of health personnel for the
adoption of changes. Such factors can be person-centered; hence, building
skills and increasing leadership capabilities are ways to circumvent most such
improvements at the organizational level.
Conclusions
Numerous studies have addressed
organizational difficulties in PHC and, as demonstrated by the development of
the present research, an important change in the understanding of the elements
that determine the quality of care and patient satisfaction can be appreciated.
The literature review of the scientific production shows that one of the most
important contributions in the field is the lack of understanding of the need
to modify evaluation instruments to local contexts. This adaptation is not only
explained by the cultural and economic variables between nations, but also by
the structural specificities of the region's health systems. In this sense, the
harmonization of tools such as the PCAT has been shown to be an indispensable
element in the progress of the quality level of PHC, allowing for a more
uniform evaluation among the different Latin American contexts. In this way, it
facilitates the development of public policies that are more informed and in
accordance with the situation of the population.
An additional contribution that should be
taken into account refers to the relationship between quality management and
patient satisfaction. In a scenario where infrastructure and resources are
scarce, research shows that the adoption of technologies and process management
are key strategies for improving the efficiency and effectiveness of services.
These organizational innovations not only elevate the technical quality of care
services, but also extend and alter their direct effect on the user experience.
This finding highlights the need to implement technologies such as virtual
consultations and to employ methodologies such as Lean Manufacturing within the
PHC domain. In addition, the research complements the scientific domain by
showing the relevance of health care workers, where continuous education and
motivation emerge as fundamental in the construction of more humane and
supportive care environments. Thus, the improvement in the management of human
resources not only brings more effective medical care, but also more
satisfactory care for patients, demonstrating the importance of policies that
promote the professional advancement of health workers.
Finally, the review provides a more
comprehensive perspective on intersectoral coordination as a fundamental pillar
that is crucial to guarantee the quality of primary health care. In several
Latin American countries, it can be noted that the integration of PHC with
other levels of care and the active participation of communities in the
planning and management of service delivery are vital strategies aimed at
improving equity in access to health. These approaches not only improve the
sustainability of health systems, but also represent a breakthrough in how the
PHC concept is perceived in highly vulnerable contexts. In this sense, the
reviewed studies not only emphasize the essence of access and organizational
improvement in PHC, but also extend further efforts that seek to explore
patterns of community participation and the construction of health systems that
are more resilient to the present and future needs of the population.
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