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Structure characteristics, such as available time and staff with quality improvement competence, seem to be strongly related to other aspects of quality systems.
In consequence of Laboratory Analysis management and staff requests for being evaluated, not only for financial outcomes, but also for relationships with community, internal procedures improvement, competence and knowledge, a first application of BSC was carried out with satisfactory results [ 10] in the past.
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Along with cognitive improvement, social competence increase was more durable with combined treatment during 12 months followup [ 75].
Studies have shown that the format of CPD is strongly linked to improvement of competence, with educational techniques that are centered on interaction and active participation (e.g., case discussion, role-play, hands-on practice sessions) being more effective than practice guidelines and formal instruction (e.g., didactic lectures, seminars) [ 19, 20].
It is unknown if the improvements in competence demonstrated in our study translate to in-practice performance, or indeed to improvements in patient outcomes, and these will be important research questions for future studies.
The present paper provides a more comprehensive evaluation concept that contributes to sustainable improvement of competence-based teaching in higher education institutions.
Further research is required to assess how these improvements in competence translate into performance in practice and clinical outcomes for patients.
The minor reduction in record-keeping performance observed in two districts may correspond to the difficulty in obtaining improvements when competence is already high.
In addition, other studies confirmed the "Life-skills" approach [ 35] which focuses on the improvement of competences in stress- and conflict management as well as strengthening self-esteem and empathy.
We consider that this was really a continuous professional development experience [ 10, 11] since we used a competence improvement approach throughout the course, stressing the competencies required to enable the learners to adapt themselves and their context to the changes from a traditional PHC to the renewed model.
An improvement of cytoplasmic competence is proposed as an explanation.
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