Prehospital qualitology – towards a harmonised conceptual framework for prehospital care quality and its evaluation

Ambulance services are increasingly integrated within broader healthcare systems and are adopting the language of ‘quality’, yet prehospital care quality is seldom explicitly defined and conceptualised. This creates risks of misdirected measurement, meaningless assurance and improvement efforts, and unintended consequences. We propose a harmonised conceptual framework to clarify what quality means in contemporary prehospital care and to guide how it can be evaluated in a meaningful and balanced way. The purpose of this paper is to engage with the topic and offer a coherent conceptual foundation that may underpin indicator selection and use, align quality assurance and improvement activities, and stimulate broader discussion about quality in prehospital care. Our framework centres around a multidimensional definition of prehospital care quality, embedding safety as an integral dimension and recognising that the relative priority of quality dimensions varies across interest-holders. It also identifies these interest-holders as practical targets for improvement strategies, from enhancing patient experience and practitioner decision-making to strengthening organisational governance and incentive structures. Technology can shape how quality is viewed and evaluated, and serve as a tool in assuring and improving care. We position Donabedian's structure–process–outcome model as the organising logic for a balanced suite of measures, while cautioning against overreliance on single proxy metrics or distal outcomes that may be influenced by care that occurs after the prehospital phase. By linking our conceptualisation of quality to pragmatic measurement choices and dual aims of assurance and improvement, our framework offers an adaptable basis for more meaningful, context-sensitive prehospital quality programs, a platform for future research, policy, and practice focused on managing prehospital care quality, and a foundation for prehospital qualitology.