Keywords: Quality improvement, Simulation-Based Education, Primary Care Teams

Setting:

Simulation-based education (SBE) is increasingly recognized not only for developing clinical competence but also for strengthening emotional resilience, preventing burnout, and fostering psychological safety. In North Macedonia, primary care faces an additional structural challenge: the absence of formal quality departments or organized quality governance at the primary care level.

Target group:

This study aimed to explore whether SBE can initiate quality improvement capability, psychological safety, and team engagement in primary care lacking formal quality infrastructure.

Description of the innovative practice or project:

Multidisciplinary primary care teams (physicians and nurses) participated in simulation-based education (SBE) using realistic primary care scenarios. Simulations addressed clinical and non-clinical quality and safety challenges, including communication, role clarity, workload, and system constraints. Structured debriefings focused on teamwork, human factors, system processes, and quality improvement (QI). Evaluation included post-simulation questionnaires and facilitated reflections examining confidence in QI engagement, team role clarity, and awareness of system-level influences on care.
Focus groups with SBE instructors also explored learning needs and priority QI areas in primary care.

Evaluation:

SBE created a psychologically safe and reflective learning environment in which participants openly discussed challenges, errors, and system limitations. Participants reported increased confidence in participating in QI activities, improved understanding of interprofessional roles, and heightened awareness of organizational and process-related contributors to quality and safety. The debriefing process enabled teams to collaboratively identify concrete QI needs relevant to their daily practice.

Next Steps:

In the absence of a formal primary care quality department, SBE acted as a system-level catalyst for quality improvement, enhancing psychological safety and team resilience. SBE offers a feasible and scalable approach to building QI capability and promoting a culture of continuous improvement in primary care.

Lessons learned:

The establishment of a local QI team within our Center represents an initial step toward sustainable quality governance and provides transferable insights for similar health systems.