Unveiling the process behind quality indicator selection in Portuguese primary healthcare - a qualitative study

Background: Since 2008, Portugal’s primary healthcare (PHC) units have been evaluated and partially funded based on an extensive set of quality indicators. This study aimed to explore the process of quality indicator selection, and the criteria used to choose among indicators. Methods: We conducted a qualitative study from 2022 to 2023, combining documentary analysis of 38 meeting minutes and 19 appendices from the National Technical Committee (NTC) with semi-structured interviews of 10 NTC members responsible for selecting these indicators. Data were analysed using computer-assisted thematic analysis with an interpretive approach in MAXQDA, and findings were triangulated across sources. The study followed the Standards for Reporting Qualitative Research (SRQR) guideline. Results: Key findings highlighted the importance of indicator validity, emphasizing the need for indicators to accurately reflect clinical performance unaffected by available resources or patients’ characteristics. Relevance was also viewed as a major attribute, requiring alignment with National Health Service goals, the potential to reduce performance gaps, and scientific robustness. Feasibility (e.g. availability of data) and usability (capacity to enhance quality in practice) were also frequently mentioned. Participants raised concerns about their roles within the Committee, noting ambiguity between providing technical input and acting as political representatives, compounded by professional tensions. Many also reported a lack of clarity regarding how indicators were developed, prioritised, and supported by evidence, with limited transparency and communication throughout the process. This contrasts with best practices identified in the literature, which emphasize transparency, pilot testing, and clearly defined roles to ensure effective stakeholder engagement. Conclusions: Our findings contribute to the understanding of quality indicator selection in primary healthcare, highlighting the need for clear stakeholder roles, greater transparency, structured consensus-building, and inclusion of patient and public perspectives. Future research should be embedded within the indicator development process to support continuous learning and improvement.