Understanding uptake of continuous quality improvement in Indigenous primary health care: lessons from a multi-site case study of the Audit and Best Practice for Chronic Disease project

Barriers and Challenges to Implementing a Quality Improvement Program: Political and Administrative Challenges

Quality improvement (QI) programs have rapidly grown in health care over recent years. Despite increasing evidence of successful QI initiatives resulting in improved outcomes, the adoption and implementation of QI programs remain a challenge worldwide. This paper briefly describes political and administrative barriers that impede the implementation of QI programs, including political and ideological factors, socioeconomic and educational barriers, and barriers related to data collection, privacy, and security. Key political and administrative barriers identified include resource limitations due to inadequate public funding, stringent laws, and change resistance. Potential solutions include support and commitment from regional and national authorities, consultation of all involved parties during QI program development, and financial incentives. The barrier of limited resources is starker among low- and middle-income countries (LMICs) compared with high-income countries (HICs) due to the absence of adequate infrastructure, personnel equipped with QI-oriented skills, and analytical technology. Solutions that have facilitated QI programs in some LMICs include outreach and collaboration with other health centers and established QI programs in HICs. The lack of QI-specific training and education in medical curricula challenges QI implementation but can be mitigated through the provision of QI promotion webinars, QI-specific project opportunities, and formalized QI training modules. Finally, barriers related to data collection, privacy, and security include laws hindering the availability of quality data, inefficient data collection and processes, and outdated clinical information systems. Access to high-quality data, organized record-keeping, and alignment of data collection processes will help alleviate these barriers to QI program implementation. The multidimensional nature of these barriers means that proposed solutions will require coordination from multiple stakeholders, government support, and leaders across multiple fields.

Collaborative implementation of an evidence-based package of integrated primary mental healthcare using quality improvement within a learning health systems approach: Lessons from the Mental health INTegration programme in South Africa

Introduction

The treatment gap for mental health disorders persists in low- and middle-income countries despite overwhelming evidence of the efficacy of task-sharing mental health interventions. Key barriers in the uptake of these innovations include the absence of policy to support implementation and diverting of staff from usual routines in health systems that are already overstretched. South Africa enjoys a conducive policy environment; however, strategies for operationalizing the policy ideals are lacking. This paper describes the Mental health INTegration Programme (MhINT), which adopted a health system strengthening approach to embed an evidence-based task-sharing care package for depression to integrate mental health care into chronic care at primary health care (PHC).

Methods

The MhINT care package consisting of psycho-education talks, nurse-led mental health assessment, and a structured psychosocial counselling intervention provided by lay counsellors was implemented in Amajuba district in KwaZulu-Natal over a 2-year period. A learning health systems approach was adopted, using continuous quality improvement (CQI) strategies to facilitate embedding of the intervention.MhINT was implemented along five phases: the project phase wherein teams to drive implementation were formed; the diagnostic phase where routinely collected data were used to identify system barriers to integrated mental health care; the intervention phase consisting of capacity building and using Plan-Do-Study-Act cycles to address implementation barriers and the impact and sustaining improvement phases entailed assessing the impact of the program and initiation of system-level interventions to sustain and institutionalize successful change ideas.

Results

Integrated planning and monitoring were enabled by including key mental health service indicators in weekly meetings designed to track the performance of noncommunicable diseases and human immunovirus clinical programmes. Lack of standardization in mental health screening prompted the validation of a mental health screening tool and testing feasibility of its use in centralized screening stations. A culture of collaborative problem-solving was promoted through CQI data-driven learning sessions. The province-level screening rate increased by 10%, whilst the district screening rate increased by 7% and new patients initiated to mental health treatment increased by 16%.

Conclusions

The CQI approach holds promise in facilitating the attainment of integrated mental health care in resource-scarce contexts. A collaborative relationship between researchers and health system stakeholders is an important strategy for facilitating the uptake of evidence-based innovations. However, the lack of interventions to address healthcare workers' own mental health poses a threat to integrated mental health care at PHC.

A realist synthesis of multicentre comparative audit implementation: exploring what works and in which healthcare contexts

BACKGROUND

Multicentre comparative clinical audits have the potential to improve patient care, allow benchmarking and inform resource allocation. However, implementing effective and sustainable large-scale audit can be difficult within busy and resource-constrained contemporary healthcare settings. There are little data on what facilitates the successful implementation of multicentre audits. As healthcare environments are complex sociocultural organisational environments, implementing multicentre audits within them is likely to be highly context dependent.

OBJECTIVE

We aimed to examine factors that were influential in the implementation process of multicentre comparative audits within healthcare contexts-what worked, why, how and for whom?

METHODS

A realist review was conducted in accordance with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards reporting standards. A preliminary programme theory informed two systematic literature searches of peer-reviewed and grey literature. The main context-mechanism-outcome (CMO) configurations underlying the implementation processes of multicentre audits were identified and formed a final programme theory.

RESULTS

69 original articles were included in the realist synthesis. Four discrete CMO configurations were deduced from this synthesis, which together made up the final programme theory. These were: (1) generating trustworthy data; (2) encouraging audit participation; (3) ensuring audit sustainability; and (4) facilitating audit cycle completion.

CONCLUSIONS

This study elucidated contexts, mechanisms and outcomes influential to the implementation processes of multicentre or national comparative audits in healthcare. The relevance of these contextual factors and generative mechanisms were supported by established theories of behaviour and findings from previous empirical research. These findings highlight the importance of balancing reliability with pragmatism within complex adaptive systems, generating and protecting human capital, ensuring fair and credible leadership and prioritising change facilitation.

Decision-maker roles in healthcare quality improvement projects: a scoping review

OBJECTIVES

Evidence suggests that healthcare quality improvement (QI) projects are more successful when decision-makers are involved in the process. However, guidance regarding the engagement of decision-makers in QI projects is lacking. We conducted a scoping review to identify QI projects involving decision-makers published in the literature and to describe the roles decision-makers played.

METHODS

Following the Joanna Briggs Institute framework for scoping reviews, we systematically searched for all types of studies in English or French between 2002 and 2023 in: EMBASE, MEDLINE via PubMed, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature. Criteria for inclusion consisted of literature describing health sector QI projects that involved local, regional or system-level decision-makers. Descriptive analysis was performed. Drawing on QI and participatory research literature, the research team developed an inductive data extraction grid to provide a portrait of QI project characteristics, decision-makers' contributions, and advantages and challenges associated with their involvement.

RESULTS

After screening and review, we retained 29 references. 18 references described multi-site projects and 11 were conducted in single sites. Local decision-makers' contributions were documented in 27 of the 29 references and regional decision-makers' contributions were documented in 12. Local decision-makers were more often active participants in QI processes, contributing toward planning, implementation, change management and capacity building. Regional decision-makers more often served as initiators and supporters of QI projects, contributing toward strategic planning, recruitment, delegation, coordination of local teams, as well as assessment and capacity building. Advantages of decision-maker involvement described in the retained references include mutual learning, frontline staff buy-in, accountability, resource allocation, effective leadership and improved implementation feasibility. Considerations regarding their involvement included time constraints, variable supervisory expertise, issues concerning centralised leadership, relationship strengthening among stakeholders, and strategic alignment of frontline staff and managerial priorities CONCLUSIONS: This scoping review provides important insights into the various roles played by decision-makers, the benefits and challenges associated with their involvement, and identifies opportunities for strengthening their engagement. The results of this review highlight the need for practical collaboration and communication strategies that foster partnership between frontline staff and decision-makers at all levels.

Exploring quality improvement for diabetes care in First Nations communities in Canada: a multiple case study

BACKGROUND

Indigenous peoples in Canada experience higher rates of diabetes and worse outcomes than non-Indigenous populations in Canada. Strategies are needed to address underlying health inequities and improve access to quality diabetes care. As part of the national FORGE AHEAD Research Program, this study explores two primary healthcare teams' quality improvement (QI) process of developing and implementing strategies to improve the quality of diabetes care in First Nations communities in Canada.

METHODS

This study utilized a community-based participatory and qualitative case study methodology. Multiple qualitative data sources were analyzed to understand: (1) how knowledge and information was used to inform the teams' QI process; (2) how the process was influenced by the context of primary care services within communities; and (3) the factors that supported or hindered their QI process.

RESULTS

The findings of this study demonstrate how teams drew upon multiple sources of knowledge and information to inform their QI work, the importance of strengthening relationships and building relationships with the community, the influence of organizational support and capacity, and the key factors that facilitated QI efforts.

CONCLUSIONS

This study contributes to the ongoing calls for research in understanding the process and factors affecting the implementation of QI strategies, particularly within Indigenous communities. The knowledge generated may help inform community action and the future development, implementation and scale-up of QI programs in Indigenous communities in Canada and globally.

Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study

OBJECTIVE

We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework.

DESIGN AND METHODS

This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies.

RESULTS

The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters.

CONCLUSIONS

The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.

What can healthcare systems learn from looking at tensions in innovation processes? A systematic literature review

Background

Until now, scholarship on innovation processes in healthcare systems lack an in-depth appreciation of tensions. Tensions often revolve around barriers and result from individual assessments and prioritizations that guide actions to eventually overcome these barriers. In order to develop a more differentiated understanding of tensions’ role in healthcare innovation processes, this paper aims to shed light on the multifaceted ways in which tensions emerge, are being dealt with, and how they hinder or, at times, facilitate innovation processes.

Methods

A systematic review of published and grey literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. The review involved searching three databases for original research articles and manually searching citations. Twenty-nine original full texts were identified, evaluated, and coded. These include papers on innovation in healthcare systems that investigated innovation-related organizational tensions. The findings were synthesized into different types of tensions in healthcare system innovation and the descriptions of the conflicting elements. We also analyzed the investigated innovations by type, process stages, and across different countries and healthcare systems.

Results

A total of forty-two tensions were identified and grouped into nine categories. Organizing tensions were predominant, followed by learning/belonging, performing, and performing/organizing tensions. Tensions most frequently occurred in the implementation phase and in the form of a dilemma. Included studies were conducted mainly in government-funded healthcare systems.

Conclusion

Our data suggest that innovation processes in healthcare systems are impaired by conflicts between contradictory elements, working cultures, and convictions and the organizational and regulatory context. Since the majority of the tensions we collected in our study can be addressed, future policy-making and research should take advantage of this fact and develop strategies that significantly influence the successful management of tensions and thus improve the implementation of innovations.

Building readiness for inclusive practice in mainstream health services: A pre-inclusion framework to deconstruct exclusion

Across the globe, people are not equitably included or respected by health services. This results in some people being 'hardly reached' and having less access to safe and appropriate care. While some health services have adopted specific agendas to increase inclusion, these services can struggle to implement such strategies because the underlying reasons for exclusion have not been addressed. This calls for preparation prior to implementation of inclusion approaches that deconstructs discourses and practices of exclusion. This paper presents a pre-inclusion framework that seeks to deconstruct exclusion in health services. Authors developed this framework from action research in four 'mainstream' regional health services in southeast Australia over five years. Research identified dominant discourses of exclusion among staff in these services. The study also identified common experiences of residents hardly reached by these services. Following, a range of change activities were undertaken within these services to deconstruct exclusion. Researchers also kept journals, reflected on their impact, and identified lessons learned from trying to deconstruct exclusion. Triangulating these analyses, researchers developed an interdisciplinary framework that weaves together Foucauldian theory on power/discourse with continuous quality improvement processes to embed cultural humility and voices of the hardly reached in health care. The framework outlines five foundational concepts (power as productive, deconstruction, use of continuous quality improvement processes, cultural humility and voices of service users), followed by six principles (a journey, expect resistance, whole of service approach, make visible the reasons for change, we are all cultural beings and people centred care) and six actions undertaken within health services (commitment, assessment of exclusion, action plans, structural change, reflective discussions and engagement). Until such approaches to deconstruct exclusion are implemented, inclusive agendas are likely to be ineffective.

Quality management systems in Aboriginal Community Controlled Health Services: a review of the literature

BACKGROUND

A national accreditation policy for the Australian primary healthcare (PHC) system was initiated in 2008. While certification standards are mandatory, little is known about their effects on the efficiency and sustainability of organisations, particularly in the Aboriginal Community Controlled Health Service (ACCHS) sector.

AIM

The literature review aims to answer the following: to what extent does the implementation of the International Organisation for Standardization 9001:2008 quality management system (QMS) facilitate efficiency and sustainability in the ACCHS sector?

METHODS

Thematic analysis of peer-reviewed and grey literature was undertaken from Australia and New Zealand PHC sector with a focus on First Nations people. The databases searched included Medline, Scopus and three Informit sites (AHB-ATSIS, AEI-ATSIS and AGIS-ATSIS). The initial search strategy included quality improvement, continuous quality improvement, efficiency and sustainability.

RESULTS

Sixteen included studies were assessed for quality using the McMaster criteria. The studies were ranked against the criteria of credibility, transferability, dependability and confirmability. Three central themes emerged: accreditation (n=4), quality improvement (n=9) and systems strengthening (n=3). The accreditation theme included effects on health service expenditure and clinical outcomes, consistency and validity of accreditation standards and linkages to clinical governance frameworks. The quality improvement theme included audit effectiveness and value for specific population health. The theme of systems strengthening included prerequisite systems and embedded clinical governance measures for innovative models of care.

CONCLUSION

The ACCHS sector warrants reliable evidence to understand the value of QMSs and enhancement tools, particularly given ACCHS (client-centric) services and their specialist status. Limited evidence exists for the value of standards on health system sustainability and efficiency in Australia. Despite a mandatory second certification standard, no studies reported on sustainability and efficiency of a QMS in PHC.

Strengthening approaches to respond to the social and emotional well-being needs of Aboriginal and Torres Strait Islander people: the Cultural Pathways Program

Aboriginal and Torres Strait Islander holistic health represents the interconnection of social, emotional, spiritual and cultural factors on health and well-being. Social factors (education, employment, housing, transport, food and financial security) are internationally described and recognised as the social determinants of health. The social determinants of health are estimated to contribute to 34% of the overall burden of disease experienced by Aboriginal and Torres Strait Islander people. Primary health care services currently 'do what it takes' to address social and emotional well-being needs, including the social determinants of health, and require culturally relevant tools and processes for implementing coordinated and holistic responses. Drawing upon a research-setting pilot program, this manuscript outlines key elements encapsulating a strengths-based approach aimed at addressing Aboriginal and Torres Strait Islander holistic social and emotional well-being.The Cultural Pathways Program is a response to community identified needs, designed and led by Aboriginal and Torres Strait Islander people and informed by holistic views of health. The program aims to identify holistic needs of Aboriginal and Torres Strait Islander people as the starting point to act on the social determinants of health. Facilitators implement strengths-based practice to identify social and cultural needs (e.g. cultural and community connection, food and financial security, housing, mental health, transport), engage in a goal setting process and broker connections with social and health services. An integrated culturally appropriate clinical supervision model enhances delivery of the program through reflective practice and shared decision making. These embedded approaches enable continuous review and improvement from a program and participant perspective. A developmental evaluation underpins program implementation and the proposed culturally relevant elements could be further tailored for delivery within primary health care services as part of routine care to strengthen systematic identification and response to social and emotional well-being needs.

Conceptualising interventions to enhance spread in complex systems: a multisite comprehensive medication review case study

Background

Advancing the description and conceptualisation of interventions in complex systems is necessary to support spread, evaluation, attribution and reproducibility. Improvement teams can provide unique insight into how interventions are operationalised in practice. Capturing this ‘insider knowledge’ has the potential to enhance intervention descriptions.

Objectives

This exploratory study investigated the spread of a comprehensive medication review (CMR) intervention to (1) describe the work required from the improvement team perspective, (2) identify what stays the same and what changes between the different sites and why, and (3) critically appraise the ‘hard core’ and ‘soft periphery’ (HC/SP) construct as a way of conceptualising interventions.

Design

A prospective case study of a CMR initiative across five sites. Data collection included: observations, document analysis and semistructured interviews. A facilitated workshop triangulated findings and measured perceived effort invested in activities. A qualitative database was developed to conduct thematic analysis.

Results

Sites identified 16 intervention components. All were considered essential due to their interdependency. The function of components remained the same, but adaptations were made between and within sites. Components were categorised under four ‘spheres of operation’: Accessibility of evidence base; Process of enactment; Dependent processes and Dependent sociocultural issues. Participants reported most effort was invested on ‘dependent sociocultural issues’. None of the existing HC/SP definitions fit well with the empirical data, with inconsistent classifications of components as HC or SP.

Conclusions

This study advances the conceptualisation of interventions by explicitly considering how evidence-based practices are operationalised in complex systems. We propose a new conceptualisation of ‘interventions-in-systems’ which describes intervention components in relation to their: proximity to the evidence base; component interdependence; component function; component adaptation and effort.

A qualitative exploration of priorities for quality improvement amongst Aboriginal and Torres Strait Islander primary health care services

Background

Achieving quality improvement in primary care is a challenge worldwide, with substantial gaps between best practice and actual practice. Within the context of Australia, Aboriginal and Torres Strait Primary Health Care (PHC) services have great variation across settings, structures and context. Research has highlighted how these contextual differences can critically influence the success of Quality Improvement (QI) interventions and outcomes. Less understood is the interaction between local context and other factors, which may impact the implementation of QI interventions. This paper aims to explore the strengths and challenges in QI for Aboriginal and Torres Strait Islander PHC services and their priorities for improvement.

Methods

A multiple case study design was adopted, working with eight Aboriginal and Torres Strait Islander PHC services in Northern Territory, Queensland and Western Australia. Data were collected via a health service survey, semi-structured interviews with health service staff and service users and researcher observations, to explore QI and perceptions of care quality at the service level. Data reported here were analysed using an iterative thematic technique, within-case and across-case.

Results

A total of 135 interviews were conducted with health service staff, service users and community members. Participants emphasised the centrality of resilient community, committed workforce and valued Aboriginal and Torres Strait Islander team members in delivering care. A shared purpose around improving the health of community was a significant driver. Key challenges included staff turnover and shortages, a complex and overwhelming acute and chronic care workload, building relationships and trust between health services and the community. Service-suggested priority areas for improvement were categorised into five themes: i) cultural safety (community driving health and planning for culturally safe services); ii) community engagement (through clinical activities in the community); iii) shared ownership and a team approach around QI; iv) strengthening systems and consistent ways of doing things in the health service; and v) strengthening local workforce (and resources for a culturally safe workforce).

Conclusions

These findings advance understandings of relational, community and cultural factors which are identified priorities for the delivery of quality care in Aboriginal and Torres Strait Islander PHC services across varied contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06383-7.

Scaling Beyond Early Adopters: a Content Analysis of Literature and Key Informant Perspectives

BACKGROUND

Innovations and improvements in care delivery are often not spread across all settings that would benefit from their uptake. Scale-up and spread efforts are deliberate efforts to increase the impact of innovations successfully tested in pilot projects so as to benefit more people. The final stages of scale-up and spread initiatives must contend with reaching hard-to-engage sites.

OBJECTIVE

To describe the process of scale-up and spread initiatives, with a focus on hard-to-engage sites and strategies to approach them.

DESIGN

Qualitative content analysis of systematically identified literature and key informant interviews.

PARTICIPANTS

Leads from large magnitude scale-up and spread projects.

APPROACH

We conducted a systematic literature search on large magnitude scale-up and spread and interviews with eight project leads, who shared their perspectives on strategies to scale-up and spread clinical and administrative practices across healthcare systems, focusing on hard-to-engage sites. We synthesized these data using content analysis.

KEY RESULTS

Searches identified 1919 titles, of which 52 articles were included. Thirty-four discussed general scale-up and spread strategies, 11 described hard-to-engage sites, and 7 discussed strategies for hard-to-engage sites. These included publications were combined with interview findings to describe a fourth phase of the national scale-up and spread process, common challenges for spreading to hard-to-engage sites, and potential benefits of working with hard-to-engage sites, as well as useful strategies for working with hard-to-engage sites.

CONCLUSIONS

We identified scant published evidence that describes strategies for reaching hard-to-engage sites. The sparse data we identified aligned with key informant accounts. Future work could focus on better documentation of the later stages of spread efforts, including specific tailoring of approaches and strategies used with hard-to-engage sites. Spread efforts should include a "flexible, tailored approach" for this highly variable group, especially as implementation science is looking to expand its impact in routine care settings.

Let's CHAT (community health approaches to) dementia in Aboriginal and Torres Strait Islander communities: protocol for a stepped wedge cluster randomised controlled trial

BACKGROUND

Documented rates of dementia and cognitive impairment not dementia (CIND) in older Aboriginal and Torres Strait Islander Peoples is 3-5 times higher than the rest of the population, and current evidence suggests this condition is under-diagnosed and under-managed in a clinical primary care setting. This study aims to implement and evaluate a culturally responsive best practice model of care to optimise the detection and management of people with cognitive impairment and/or dementia, and to improve the quality of life of carers and older Aboriginal and Torres Islander Peoples with cognitive impairment.

METHODS/DESIGN

The prospective study will use a stepped-wedge cluster randomised controlled trial design working with 12 Aboriginal Community Controlled Health Services (ACCHSs) across four states of Australia. Utilising a co-design approach, health system adaptations will be implemented including (i) development of a best practice guide for cognitive impairment and dementia in Aboriginal and Torres Strait Islander communities (ii) education programs for health professionals supported by local champions and (iii) development of decision support systems for local medical software. In addition, the study will utilise a knowledge translation framework, the Integrated Promoting Action on Research Implementation in Health Services (iPARIHS) Framework, to promote long-term sustainable practice change. Process evaluation will also be undertaken to measure the quality, fidelity and contextual influences on the outcomes of the implementation. The primary outcome measures will be rates of documentation of dementia and CIND, and evidence of improved management of dementia and CIND among older Indigenous peoples attending Aboriginal and Torres Strait Islander primary care services through health system changes. The secondary outcomes will be improvements to the quality of life of older Indigenous peoples with dementia and CIND, as well as that of their carers and families.

DISCUSSION

The Let's CHAT Dementia project will co-design, implement and evaluate a culturally responsive best practice model of care embedded within current Indigenous primary health care. The best practice model of care has the potential to optimise the timely detection (especially in the early stages) and improve the ongoing management of people with dementia or cognitive impairment.

TRIAL REGISTRATION

ACTRN12618001485224. Date of registration: 04 of September 2019.

Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study

OBJECTIVES

Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, we evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.

DESIGN

We conducted a cross-sectional observational study using a web survey (contextual factors) and a national hospital database (hospital characteristics).

SETTING

Hospitals participating in the second Multi-Centre Medication Reconciliation Quality Improvement Study (MARQUIS2).

PARTICIPANTS

Implementation team members of 18 participating MARQUIS2 hospitals.

OUTCOMES

Primary outcome: contextual factor ratings (ie, organisational capacity, leadership support, goal alignment, staff involvement, patient safety climate and team cohesion). Secondary outcome: differences in contextual factors by hospital characteristics.

RESULTS

Fifty-five team members from the 18 participating hospitals completed the survey. Ratings of contextual factors differed significantly by domain (p<0.001), with organisational capacity scoring the lowest (mean=4.0 out of 7.0) and perceived team cohesion and goal alignment scoring the highest (mean~6.0 out of 7.0). No statistically significant differences were observed in contextual factors by hospital characteristics (p>0.05). Respondents in the pharmacy profession gave lower ratings of leadership support than did those in the nursing or other professions group (p=0.01).

CONCLUSIONS

Hospital size, type and location did not drive differences in contextual factors, suggesting that tailoring MedRec QI implementation to hospital characteristics may not be necessary. Strong team cohesion suggests the use of interdisciplinary teams does not detract from cohesion when conducting mentored QI projects. Organisational leaders should particularly focus on supporting pharmacy services and addressing their concerns during MedRec QI initiatives. Future research should correlate contextual factors with implementation success to inform how best to prepare sites to implement complex QI interventions such as MedRec.

Conceptualizing the Association Between Community Participation and CQI in Aboriginal and Torres Strait Islander PHC Services

Drawing from Australian Aboriginal and Torres Strait Islander perspectives, we conceptualize the association between community participation and continuous quality improvement (CQI) processes in Indigenous primary health care (PHC) services. Indigenous experiences of community participation were drawn from our study identifying contextual factors affecting CQI processes in high-improving PHC services. Using case study design, we collected quantitative and qualitative data at the micro-, meso-, and macro-health system level in 2014 and 2015 in six services in northern Australia. Analyzing qualitative data, we found community participation was an important contextual factor in five of the six services. Embedded in cultural foundations, cultural rules, and expectations, community participation involved interacting elements of trusting relationships in metaphorically safe spaces, and reciprocated learning about each other's perspectives. Foregrounding Indigenous perspectives on community participation might assist more effective participatory processes in Indigenous PHC including in CQI processes.

Using developmental evaluation to support knowledge translation: reflections from a large-scale quality improvement project in Indigenous primary healthcare

BACKGROUND

Developmental evaluation is a growing area of evaluation practice, advocated for informing the adaptive development of change initiatives in complex social environments. The utilisation focus, complexity perspective and systems thinking of developmental evaluation suggest suitability for evaluating knowledge translation initiatives in primary healthcare. However, there are few examples in the literature to guide its use in these contexts and in Indigenous settings. In this paper, we reflect on our experience of using developmental evaluation to implement a large-scale knowledge translation research project in Australian Aboriginal and Torres Strait Islander primary healthcare. Drawing on principles of knowledge translation and key features of developmental evaluation, we debate the key benefits and challenges of applying this approach to engage diverse stakeholders in using aggregated quality improvement data to identify and address persistent gaps in care delivery.

DISCUSSION

The developmental evaluation enabled the team to respond to stakeholder feedback and apply learning in real-time to successfully refine theory-informed research and engagement processes, tailor the presentation of findings to stakeholders and context, and support the project's dissemination and knowledge co-production aim. It thereby contributed to the production of robust, useable research findings for informing policy and system change. The use of developmental evaluation appeared to positively influence stakeholders' use of the project reports and their responses to the findings. Challenges included managing a high volume of evaluation data and multiple evaluation purposes, balancing facilitative sense-making processes and change with task-focused project management, and lack of experience in using this evaluation approach. Use of an embedded evaluator with facilitation skills and background knowledge of the project helped to overcome these challenges, as did similarities observed between features of developmental evaluation and continuous quality improvement.

CONCLUSION

Our experience of developmental evaluation confirmed our expectations of the potential value of this approach for strengthening improvement interventions and implementation research, and particularly for adapting healthcare innovations in Indigenous settings. In our project, developmental evaluation successfully encompassed evaluation, project adaptation, capacity development and knowledge translation. Further work is warranted to apply this approach more widely to improve primary healthcare initiatives and outcomes, and to evaluate implementation research.

Qualitative perspectives on the sustainability of sexual health continuous quality improvement in clinics serving remote Aboriginal communities in Australia

OBJECTIVES

To examine barriers and facilitators to sustaining a sexual health continuous quality improvement (CQI) programme in clinics serving remote Aboriginal communities in Australia.

DESIGN

Qualitative study.

SETTING

Primary health care services serving remote Aboriginal communities in the Northern Territory, Australia.

PARTICIPANTS

Seven of the 11 regional sexual health coordinators responsible for supporting the Northern Territory Government Remote Sexual Health Program.

METHODS

Semi-structured in-depth interviews conducted in person or by telephone; data were analysed using an inductive and deductive thematic approach.

RESULTS

Despite uniform availability of CQI tools and activities, sexual health CQI implementation varied across the Northern Territory. Participant narratives identified five factors enhancing the uptake and sustainability of sexual health CQI. At clinic level, these included adaptation of existing CQI tools for use in specific clinic contexts and risk environments (eg, a syphilis outbreak), local ownership of CQI processes and management support for CQI. At a regional level, factors included the positive framing of CQI as a tool to identify and act on areas for improvement, and regional facilitation of clinic level CQI activities. Three barriers were identified, including the significant workload associated with acute and chronic care in Aboriginal primary care services, high staff turnover and lack of Aboriginal staff. Considerations affecting the future sustainability of sexual health CQI included the need to reduce the burden on clinics from multiple CQI programmes, the contribution of regional sexual health coordinators and support structures, and access to and use of high-quality information systems.

CONCLUSIONS

This study contributes to the growing evidence on how CQI approaches may improve sexual health in remote Australian Aboriginal communities. Enhancing sustainability of sexual health CQI in this context will require ongoing regional facilitation, efforts to build local ownership of CQI processes and management of competing demands on health service staff.

Defining and Developing a Generic Framework for Monitoring Data Quality in Clinical Research

Evidence for the need for high data quality in clinical research is well established. The rigor of clinical research conclusions rely heavily on good quality data, which relies on good documentation practices. Little attention has been given to clear guidelines and definitions to monitor data quality. To address this, a "fit-for-use" data quality monitoring framework (DQMF) for clinical research was developed based on a holistic design-oriented approach. An integrated literature review and feasibility study underpinned the framework development. Ontology of key terms, concepts, methods, and standards were recorded using a consensus approach and mind mapping technique. The DQMF is presented as a nested concentric network illustrating concept relationships and hierarchy. Face validation was conducted, and common terminology and definitions are listed. The consolidated DQMF can be adapted according to study context and data availability aiding in the development of a long-term strategy with increased efficacy for clinical data quality monitoring.

Implementation of continuous quality improvement in Aboriginal and Torres Strait Islander primary health care in Australia: a scoping systematic review

BACKGROUND

Continuous Quality Improvement (CQI) programs have been taken up widely by Indigenous primary health care (PHC) services in Australia and there has been national policy commitment to support this. However, international evidence shows that implementing CQI is challenging, impacts are variable and little is known about the factors that impede or enhance effectiveness. A scoping review was undertaken to explore uptake and implementation in Indigenous PHC, including barriers and enablers to embedding CQI in routine practice. We provide guidance on how research and evaluation might be intensified to support implementation.

METHODS

Searches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews. Key websites and publications were handsearched. Studies conducted in Indigenous PHC which demonstrated some combination of CQI characteristics and assessed some aspect of implementation were included. A two stage analysis was undertaken. Stage 1 identified the breadth and focus of literature. Stage 2 investigated barriers and enablers. The Framework for Performance Assessment in PHC (2008) was used to frame the analysis. Data were extracted on the study type, approach, timeframes, CQI strategies, barriers and enablers.

RESULTS

Sixty articles were included in Stage 1 and 21 in Stage 2. Barriers to implementing CQI processes relate primarily to professional and organisational processes and operate at multiple levels (individual, team, service, health system) whereas barriers to improved care relate more directly to knowledge of best practice and team processes that facilitate appropriate care. Few studies described implementation timeframes, number of CQI cycles or improvement strategies implemented and only two applied a change theory.

CONCLUSION

Investigating barriers and enablers that modify implementation and impacts of CQI poses conceptual and methodological challenges. More complete description of CQI processes, implementation strategies, and barriers and enablers could enhance capacity for comparisons across settings and contribute to better understanding of key success factors.

Impacts of continuous quality improvement in Aboriginal and Torres Strait islander primary health care in Australia

Purpose Continuous quality improvement (CQI) programmes have been taken up widely by indigenous primary health care services in Australia, but as yet there has not been a systematic assessment of their focus and achievements. A scoping review of the literature from studies of CQI in indigenous primary health care services was undertaken to explore impacts on service systems, care and client outcomes with the aim of providing guidance on future evaluation efforts. The paper aims to discuss these issues, Design/methodology/approach Searches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews to December 2016 and handsearching of key websites and publications. Studies of CQI programs or activities in Indigenous primary health care services which demonstrated some combination of CQI characteristics, as described by Rubenstein (2013) were included. A two-stage approach to analysis was undertaken. Stage 1 identified the range and scope of literature, and Stage 2 investigated impacts to service systems, care and client outcomes. The Framework for Performance Assessment in Primary Health Care was used to frame the Stage 2 analysis. Findings The majority of Aboriginal community controlled health services have been involved in CQI but there are gaps in knowledge about uptake in general practice and government clinics. There are as many baseline studies as studies on impacts over time. Of the 14 studies included for further analysis, 6 reported on impacts on service systems; all 14 reported on impacts on care and 6 on client outcomes. Changes to services systems are variable and studies of impacts on care and client outcomes show promising though uneven improvements. There are no economic studies or studies addressing community engagement in CQI activities. Research limitations/implications To supplement existing limited knowledge about which service system change strategies are effective and sustainable for which problems in which settings, there needs to be investment in research and development. Research needs to be grounded in the realities of service delivery and contribute to the development of CQI capacity at the service level. Knowledge translation needs to be built into implementation to ensure maximum benefit to those endeavouring on a daily basis to constantly reflect on and improve the quality of the care they deliver to clients, and to the stewardship structures supporting services at regional, state/territory and national levels. Practical implications Improved approaches, methods, data capture and reporting arrangements are needed to enhance existing activity and to ensure maximum benefit to services endeavouring to reflect on and improve quality of care and to the stewardship structure supporting services at regional, state/territory and national levels. Originality/value Although there is a growing body of research evidence about CQI both nationally and internationally, and considerable investment by the federal government in Australia to support CQI as part of routine practice, there has not been a systematic assessment of the achievements of CQI in Indigenous primary health care services. Many unanswered questions remain about the extent of uptake, implementation and impacts. This is a barrier to future investment and regional and local programme design, monitoring and evaluation. The authors conducted a scoping review to address these questions. From this, the authors draw conclusions about the state of knowledge in Australia with a view to informing how future CQI research and evaluation might be intensified.

Assessing data quality and the variability of source data verification auditing methods in clinical research settings

INTRODUCTION

Data audits within clinical settings are extensively used as a major strategy to identify errors, monitor study operations and ensure high-quality data. However, clinical trial guidelines are non-specific in regards to recommended frequency, timing and nature of data audits. The absence of a well-defined data quality definition and method to measure error undermines the reliability of data quality assessment. This review aimed to assess the variability of source data verification (SDV) auditing methods to monitor data quality in a clinical research setting.

MATERIAL AND METHODS

The scientific databases MEDLINE, Scopus and Science Direct were searched for English language publications, with no date limits applied. Studies were considered if they included data from a clinical trial or clinical research setting and measured and/or reported data quality using a SDV auditing method.

RESULTS

In total 15 publications were included. The nature and extent of SDV audit methods in the articles varied widely, depending upon the complexity of the source document, type of study, variables measured (primary or secondary), data audit proportion (3-100%) and collection frequency (6-24 months). Methods for coding, classifying and calculating error were also inconsistent. Transcription errors and inexperienced personnel were the main source of reported error. Repeated SDV audits using the same dataset demonstrated ∼ 40% improvement in data accuracy and completeness over time. No description was given in regards to what determines poor data quality in clinical trials.

CONCLUSIONS

A wide range of SDV auditing methods are reported in the published literature though no uniform SDV auditing method could be determined for "best practice" in clinical trials. Published audit methodology articles are warranted for the development of a standardised SDV auditing method to monitor data quality in clinical research settings.

Experiences of General Practitioners and Practice Support Staff Using a Health and Lifestyle Screening App in Primary Health Care: Implementation Case Study

Background

Technology-based screening of young people for mental health disorders and health compromising behaviors in general practice increases the disclosure of sensitive health issues and improves patient-centered care. However, few studies investigate how general practitioners (GPs) and practice support staff (receptionists and practice managers) integrate screening technology into their routine work, including the problems that arise and how the staff surmount them.

Objective

The aim of this study was to investigate the implementation of a health and lifestyle screening app, Check Up GP, for young people aged 14 to 25 years attending an Australian general practice.

Methods

We conducted an in-depth implementation case study of Check Up GP in one general practice clinic, with methodology informed by action research. Semistructured interviews and focus groups were conducted with GPs and support staff at the end of the implementation period. Data were thematically analyzed and mapped to normalization process theory constructs. We also analyzed the number of times we supported staff, the location where young people completed Check Up GP, and whether they felt they had sufficient privacy and received a text messaging (short message service, SMS) link at the time of taking their appointment.

Results

A total of 4 GPs and 10 support staff at the clinic participated in the study, with all except 3 receptionists participating in the final interviews and focus groups. During the 2-month implementation period, the technology and administration of Check Up GP was iterated through 4 major quality improvement cycles in response to the needs of the staff. This resulted in a reduction in the average time taken to complete Check Up GP from 14 min to 10 min, improved SMS text messaging for young people, and a more consistent description of the app by receptionists to young people. In the first weeks of implementation, researchers needed to regularly support staff with the app’s administration; however, this support decreased over time, even as usage rose slightly. The majority of young people (73/87, 84%) completed Check Up GP in the waiting room, with less than half (35/80, 44%) having received an SMS from the clinic with a link to the tool. Participating staff valued Check Up GP, particularly its facilitation of youth-friendly practice. However, there was at first a lack of organizational systems and capacity to implement the app and also initially a reliance on researchers to facilitate the process.

Conclusions

The implementation of a screening app in the dynamic and time-restricted general practice setting presents a range of technical and administrative challenges. Successful implementation of a screening app is possible but requires adequate time and intensive facilitation. More resources, external to staff, are needed to drive and support sustainable technology innovation and implementation in general practice settings.

What can we learn from interventions that aim to increase policy-makers' capacity to use research? A realist scoping review

Background

Health policy-making can benefit from more effective use of research. In many policy settings there is scope to increase capacity for using research individually and organisationally, but little is known about what strategies work best in which circumstances. This review addresses the question: What causal mechanisms can best explain the observed outcomes of interventions that aim to increase policy-makers’ capacity to use research in their work?

Methods

Articles were identified from three available reviews and two databases (PAIS and WoS; 1999–2016). Using a realist approach, articles were reviewed for information about contexts, outcomes (including process effects) and possible causal mechanisms. Strategy + Context + Mechanism = Outcomes (SCMO) configurations were developed, drawing on theory and findings from other studies to develop tentative hypotheses that might be applicable across a range of intervention sites.

Results

We found 22 studies that spanned 18 countries. There were two dominant design strategies (needs-based tailoring and multi-component design) and 18 intervention strategies targeting four domains of capacity, namely access to research, skills improvement, systems improvement and interaction. Many potential mechanisms were identified as well as some enduring contextual characteristics that all interventions should consider. The evidence was variable, but the SCMO analysis suggested that tailored interactive workshops supported by goal-focused mentoring, and genuine collaboration, seem particularly promising. Systems supports and platforms for cross-sector collaboration are likely to play crucial roles. Gaps in the literature are discussed.

Conclusion

This exploratory review tentatively posits causal mechanisms that might explain how intervention strategies work in different contexts to build capacity for using research in policy-making.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0277-1) contains supplementary material, which is available to authorized users.

Perspectives of primary health care staff on the implementation of a sexual health quality improvement program: a qualitative study in remote aboriginal communities in Australia

BACKGROUND

Young people living in remote Australian Aboriginal communities experience high rates of sexually transmissible infections (STIs). STRIVE (STIs in Remote communities, ImproVed and Enhanced primary care) was a cluster randomised control trial of a sexual health continuous quality improvement (CQI) program. As part of the trial, qualitative research was conducted to explore staff perceptions of the CQI components, their normalisation and integration into routine practice, and the factors which influenced these processes.

METHODS

In-depth semi-structured interviews were conducted with 41 clinical staff at 22 remote community clinics during 2011-2013. Normalisation process theory was used to frame the analysis of interview data and to provide insights into enablers and barriers to the integration and normalisation of the CQI program and its six specific components.

RESULTS

Of the CQI components, participants reported that the clinical data reports had the highest degree of integration and normalisation. Action plan setting, the Systems Assessment Tool, and the STRIVE coordinator role, were perceived as adding value to the program, but were less readily integrated or normalised. The remaining two components (dedicated funding for health promotion and service incentive payments) were seen as least relevant. Our analysis also highlighted factors which enabled greater integration of the CQI components. These included familiarity with CQI tools, increased accountability of health centre staff and the translation of the CQI program into guideline-driven care. The analysis also identified barriers, including high staff turnover, limited time involved in the program and competing clinical demands and programs.

CONCLUSIONS

Across all of the CQI components, the clinical data reports had the highest degree of integration and normalisation. The action plans, systems assessment tool and the STRIVE coordinator role all complemented the data reports and allowed these components to be translated directly into clinical activity. To ensure their uptake, CQI programs must acknowledge local clinical guidelines, be compatible with translation into clinical activity and have managerial support. Sexual health CQI needs to align with other CQI activities, engage staff and promote accountability through the provision of clinic specific data and regular face-to-face meetings.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12610000358044 . Registered 6/05/2010. Prospectively Registered.

Quality of social and emotional wellbeing services for families of young Indigenous children attending primary care centers; a cross sectional analysis

BACKGROUND

The quality of social and emotional wellbeing services for Indigenous families of young children is not known, in many settings especially services provided by primary care centers.

METHODS

Our primary objective was to assess delivery of social and emotional wellbeing services to the families of young (3-11 months) and older (12-59 months) Indigenous children attending primary care centers. Our secondary objective was to assess if delivery differed by geographic location. Two thousand four hundred sixty-six client files from 109 primary care centers across Australia from 2012 to 2014 were analysed using logistic regression and generalised estimating equations.

RESULTS

The proportion of families receiving social and emotional wellbeing services ranged from 10.6% (102) (food security) to 74.7% (1216) (assessment of parent child interaction). Seventy one percent (71%, 126) of families received follow up care. Families of children aged 3-11 months (39.5%, 225) were more likely to receive social and emotional wellbeing services (advice about domestic environment, social support, housing condition, child stimulation) than families of children aged 12-59 months (30.0%, 487) (adjusted odds ratio [aOR] 1.68 95% CI 1.33 to 2.13). Remote area families (32.6%, 622) received similar services to rural (29.4%, 68) and urban families (44.0%, 22) (aOR 0.64 95% CI 0.29, 1.44).

CONCLUSIONS

The families of young Indigenous children appear to receive priority for social and emotional wellbeing care in Australian primary care centers, however many Indigenous families are not receiving services. Improvement in resourcing and support of social and emotional wellbeing services in primary care centers is needed.

Sustained participation in annual continuous quality improvement activities improves quality of care for Aboriginal and Torres Strait Islander children

AIM

To determine whether participation in the continuous quality improvement (CQI) Audit and Best Practice for Chronic Disease programme improved care and outcomes for Indigenous children.

METHODS

Data were collected from 59 Australian primary health-care centres providing services to Indigenous people and participating in the programme (February 2008 and December 2013). Indigenous children aged less than 2 years and centres that completed three or more consecutive annual audits within the 6-year study period were included. Crude and adjusted logistic generalised estimating equation models were used to examine the effect of year of audit on the delivery of care. Odds ratio (OR) and 95% confidence interval (CI) were calculated. Outcomes were related to age-relevant health issues, including prevention and early intervention. These included administrative, health check, anticipatory guidance and specific health issues.

RESULTS

During the audit period, there were 2360 files from 59 centres. Those that had a recall recorded, improved from 84 to 95% (OR 2.44, 95% CI 1.44-4.11). Hearing assessments improved from 52 to 89% (OR 1.37, 95% CI 1.22-1.54). Improvement in anticipatory guidance, treatment and follow-up of medical conditions was almost universal.

CONCLUSION

We documented significant improvements in quality of care of Indigenous children. Outcomes and their corresponding treatment and follow-ups improved over time. This appears to be related to services participating in annual CQI activities. However, these services may be more committed to CQI than others and therefore possibly better performing.

Characteristics of Indigenous primary health care service delivery models: a systematic scoping review

Background

Indigenous populations have poorer health outcomes compared to their non-Indigenous counterparts. The evolution of Indigenous primary health care services arose from mainstream health services being unable to adequately meet the needs of Indigenous communities and Indigenous peoples often being excluded and marginalised from mainstream health services. Part of the solution has been to establish Indigenous specific primary health care services, for and managed by Indigenous peoples. There are a number of reasons why Indigenous primary health care services are more likely than mainstream services to improve the health of Indigenous communities. Their success is partly due to the fact that they often provide comprehensive programs that incorporate treatment and management, prevention and health promotion, as well as addressing the social determinants of health. However, there are gaps in the evidence base including the characteristics that contribute to the success of Indigenous primary health care services in providing comprehensive primary health care. This systematic scoping review aims to identify the characteristics of Indigenous primary health care service delivery models.

Method

This systematic scoping review was led by an Aboriginal researcher, using the Joanna Briggs Institute Scoping Review Methodology. All published peer-reviewed and grey literature indexed in PubMed, EBSCO CINAHL, Embase, Informit, Mednar, and Trove databases from September 1978 to May 2015 were reviewed for inclusion. Studies were included if they describe the characteristics of service delivery models implemented within an Indigenous primary health care service. Sixty-two studies met the inclusion criteria. Data were extracted and then thematically analysed to identify the characteristics of Indigenous PHC service delivery models.

Results

Culture was the most prominent characteristic underpinning all of the other seven characteristics which were identified – accessible health services, community participation, continuous quality improvement, culturally appropriate and skilled workforce, flexible approach to care, holistic health care, and self-determination and empowerment.

Conclusion

While the eight characteristics were clearly distinguishable within the review, the interdependence between each characteristic was also evident. These findings were used to develop a new Indigenous PHC Service Delivery Model, which clearly demonstrates some of the unique characteristics of Indigenous specific models.

Electronic supplementary material

The online version of this article (10.1186/s12992-018-0332-2) contains supplementary material, which is available to authorized users.

Impact of policy support on uptake of evidence-based continuous quality improvement activities and the quality of care for Indigenous Australians: a comparative case study

OBJECTIVES

To examine the impact of state/territory policy support on (1) uptake of evidence-based continuous quality improvement (CQI) activities and (2) quality of care for Indigenous Australians.

DESIGN

Mixed-method comparative case study methodology, drawing on quality-of-care audit data, documentary evidence of policies and strategies and the experience and insights of stakeholders involved in relevant CQI programmes. We use multilevel linear regression to analyse jurisdictional differences in quality of care.

SETTING

Indigenous primary healthcare services across five states/territories of Australia.

PARTICIPANTS

175 Indigenous primary healthcare services.

INTERVENTIONS

A range of national and state/territory policy and infrastructure initiatives to support CQI, including support for applied research. PRIMARY AND SECONDARY OUTCOME MEASURES: (i) Trends in the consistent uptake of evidence-based CQI tools available through a research-based CQI initiative (the Audit and Best Practice in Chronic Disease programme) and (ii) quality of care (as reflected in adherence to best practice guidelines).

RESULTS

Progressive uptake of evidence-based CQI activities and steady improvements or maintenance of high-quality care occurred where there was long-term policy and infrastructure support for CQI. Where support was provided but not sustained there was a rapid rise and subsequent fall in relevant CQI activities.

CONCLUSIONS

Health authorities should ensure consistent and sustained policy and infrastructure support for CQI to enable wide-scale and ongoing improvement in quality of care and, subsequently, health outcomes. It is not sufficient for improvement initiatives to rely on local service managers and clinicians, as their efforts are strongly mediated by higher system-level influences.

Health service changes to address diabetes in pregnancy in a complex setting: perspectives of health professionals

Background

Australian Aboriginal and Torres Strait Islander women have high rates of gestational and pre-existing type 2 diabetes in pregnancy. The Northern Territory (NT) Diabetes in Pregnancy Partnership was established to enhance systems and services to improve health outcomes. It has three arms: a clinical register, developing models of care and a longitudinal birth cohort. This study used a process evaluation to report on health professional’s perceptions of models of care and related quality improvement activities since the implementation of the Partnership.

Methods

Changes to models of care were documented according to goals and aims of the Partnership and reviewed annually by the Partnership Steering group. A ‘systems assessment tool’ was used to guide six focus groups (49 healthcare professionals). Transcripts were coded and analysed according to pre-identified themes of orientation and guidelines, education, communication, logistics and access, and information technology.

Results

Key improvements since implementation of the Partnership include: health professional relationships, communication and education; and integration of quality improvement activities. Focus groups with 49 health professionals provided in depth information about how these activities have impacted their practice and models of care for diabetes in pregnancy. Co-ordination of care was reported to have improved, however it was also identified as an opportunity for further development. Recommendations included a central care coordinator, better integration of information technology systems and ongoing comprehensive quality improvement processes.

Conclusions

The Partnership has facilitated quality improvement through supporting the development of improved systems that enhance models of care. Persisting challenges exist for delivering care to a high risk population however improvements in formal processes and structures, as demonstrated in this work thus far, play an important role in work towards improving health outcomes.

'There's only one enabler; come up, help us': staff perspectives of barriers and enablers to continuous quality improvement in Aboriginal primary health-care settings in South Australia

This paper presents the findings from a qualitative study, which sought to investigate the barriers and enablers to implementation of a continuous quality improvement (CQI) program by health-care professionals in Aboriginal primary health-care services in South Australia. Eighteen semi-structured interviews across 11 participating services were conducted alongside CQI implementation activities. Multiple barriers exist, from staff perspectives, which can be categorised according to different levels of the primary health-care system. At the macro level, barriers related to resource constraints (workforce issues) and access to project support (CQI coordinator). At the meso level, barriers related to senior level management and leadership for quality improvement and the level of organisational readiness. At the micro level, knowledge and attitudes of staff (such as resistance to change; lack of awareness of CQI) and lack of team tenure were cited as the main barriers to implementation. Staff identified that successful and sustained implementation of CQI requires both organisational systems and individual behaviour change. Improvements through continuing regional level collaborations and using a systems approach to develop an integrated regional level CQI framework, which includes building organisational and clinic team CQI capacity at the health centre level, are recommended. Ideally, this should be supported at the broader national level with dedicated funding.

Cardiovascular disease risk in young Indigenous Australians: a snapshot of current preventive health care

OBJECTIVE

To examine preventive health attendance and recording of type 2 diabetes and cardiovascular disease risk factors and their management in young Aboriginal peoples and Torres Strait Islanders (Indigenous Australians) at primary health care centres (PHCs).

METHODS

This descriptive cross-sectional study audited medical records of 1,986 Indigenous people aged 15-34 years attending 93 Australian PHCs. Measurements included blood pressure (BP), blood glucose level (BGL), smoking status, body mass index (BMI) and lipid profile.

RESULTS

Last attendance was most commonly for acute care (46%); 12% attended for preventive assessment. BP was recorded in 85% (1,686/1,986), BGL 63% (1,244/1,986), smoking status 52% (1,033/1,986), BMI 37% (743/1,986) and lipids 31% (625/1,986). Of those with a recorded assessment, elevated BGL (39%, 479/1,244), smoking (63%, 649/1,033), overweight/obesity (51%, 381/743) and dyslipidaemia (73%, 458/625) were common. Follow-up of abnormal results was documented for elevated BP 28% (34/120), elevated BGL 17% (79/479), smoking 65% (421/649), overweight/obesity 11% (40/381) and abnormal lipids 16% (75/458).

CONCLUSIONS

These findings highlight the importance of raising awareness and assessment of chronic disease risk factors in young Indigenous people and implementing preventive health care strategies.

IMPLICATIONS

Strengthening the capacity of PHCs to provide preventive health care may contribute to reducing the chronic disease burden experienced by young Indigenous people.

Increasing Pap smear rates at an urban Aboriginal Community Controlled Health Service through translational research and continuous quality improvement

This article describes translational research (TR) and continuous quality improvement (CQI) processes used to identify and address barriers and facilitators to Pap smear screening within an urban Aboriginal Community Controlled Health Service (ACCHS). Rapid Plan-Do-Study-Act (PDSA) cycles were conducted, informed by client surveys, a data collection tool, focus groups and internal research. There was a statistically significant increase in Pap smear numbers during PDSA cycles, continuing at 10 months follow up. The use of TR with CQI appears to be an effective and acceptable way to affect Pap smear screening. Community and service collaboration should be at the core of research in Aboriginal and Torres Strait Islander health settings. This model is transferrable to other settings and other health issues.

Building better research partnerships by understanding how Aboriginal health communities perceive and use data: a semistructured interview study

OBJECTIVE

To describe the attitudes and beliefs of health professionals working in Aboriginal Community Controlled Health Services (ACCHS) towards the access, usage and potential value of routinely obtained clinical and research data.

DESIGN, SETTING AND PARTICIPANTS

Face-to-face, semistructured interviews were conducted with 35 health professionals from 2 urban and 1 regional ACCHS in New South Wales. The interviews were transcribed and themes were identified using an adapted grounded theory approach.

RESULTS

Six major themes were identified: occupational engagement (day-to-day relevance, contingent on professional capacity, emphasising clinical relevance), trust and assurance (protecting ownership, confidence in narratives, valuing local sources), motivation and empowerment (engaging the community, influencing morale, reassuring and encouraging clients), building research capacity (using cultural knowledge, promoting research aptitude, prioritising specific data), optimising service provision (necessity for sustainable services, guiding and improving services, supporting best practice), and enhancing usability (ensuring ease of comprehension, improving efficiency of data management, valuing accuracy and accessibility).

CONCLUSIONS

Participants were willing to learn data handling procedures that could further enhance health service delivery and enable more ACCHS-led research, but busy workloads restrict these opportunities. Staff held concerns regarding the translation of research data into beneficial services, and believed that the outcome and purpose of data collection could be communicated more clearly. Promoting research partnerships, ensuring greater awareness of positive health data and the purposes of data collection, and communicating data in a user-friendly format are likely to encourage greater data use, build research capacity and improve health services within the Aboriginal community.

Improving Health Promotion Using Quality Improvement Techniques in Australian Indigenous Primary Health Care

Although some areas of clinical health care are becoming adept at implementing continuous quality improvement (CQI) projects, there has been limited experimentation of CQI in health promotion. In this study, we examined the impact of a CQI intervention on health promotion in four Australian Indigenous primary health care centers. Our study objectives were to (a) describe the scope and quality of health promotion activities, (b) describe the status of health center system support for health promotion activities, and (c) introduce a CQI intervention and examine the impact on health promotion activities and health centers systems over 2 years. Baseline assessments showed suboptimal health center systems support for health promotion and significant evidence-practice gaps. After two annual CQI cycles, there were improvements in staff understanding of health promotion and systems for planning and documenting health promotion activities had been introduced. Actions to improve best practice health promotion, such as community engagement and intersectoral partnerships, were inhibited by the way health center systems were organized, predominately to support clinical and curative services. These findings suggest that CQI can improve the delivery of evidence-based health promotion by engaging front line health practitioners in decision-making processes about the design/redesign of health center systems to support the delivery of best practice health promotion. However, further and sustained improvements in health promotion will require broader engagement of management, senior staff, and members of the local community to address organizational and policy level barriers.

The effectiveness of implementation in Indigenous Australian healthcare: an overview of literature reviews

BACKGROUND

Effective implementation can maximise the beneficial impacts of health services. It is therefore important to review implementation in the context of Indigenous populations, who suffer some of the greatest disadvantage within developed countries. This paper analyses Aboriginal and Torres Strait Islander (hereafter Indigenous) Australian health implementation reviews to examine the research question: What is the effectiveness of implementation, as reported in the Indigenous Australian health implementation literature?

METHODS

Eight databases were systematically searched to find reviews of Indigenous Australian health services and/or programs where implementation was the focus. Search terms included Aborigin* OR Indigen* OR Torres AND health AND service OR program* OR intervention AND implementation (or like terms) AND Australia AND review. Review findings were analysed through the lens of the PARiHS framework which theorises that successful implementation occurs through the interplay of evidence, context and facilitation. The review followed Cochrane methods but was not registered.

RESULTS

Six reviews were found; these encompassed 107 studies that considered health service/program implementation. Included studies described many health services implemented across Australia as not underpinned by rigorous impact evaluation; nevertheless implementers tended to prefer evidence-based interventions. Effective implementation was supported by clearly defined management systems, employment of Indigenous health workers as leaders, community control, partnerships, tailoring for diverse places and settings; and active facilitation methods. Short-term funding meant most studies focused on implementation in one site through pilot initiatives. Only two mentioned cost effectiveness. Indigenous Australian studies incorporated two elements not included in the PARiHS reference guide: the value of community control and equity of service provision across sites.

CONCLUSIONS

Comparison of the Indigenous Australian review findings against the PARiHS reference guide elements suggested a fledgling but growing state of Indigenous implementation research, and considerable scope to improve the effectiveness of implementation. Further research is required to explore Indigenous people's understandings of what is important in healthcare implementation; particularly in relation to the value of community control and equity issues.

Determinants and Gaps in Preventive Care Delivery for Indigenous Australians: A Cross-sectional Analysis

Background

Potentially preventable chronic diseases are the greatest contributor to the health gap between Aboriginal and Torres Strait Islander peoples and non-­Indigenous Australians. Preventive care is important for earlier detection and control of chronic disease, and a number of recent policy initiatives have aimed to enhance delivery of preventive care. We examined documented delivery of recommended preventive services for Indigenous peoples across Australia and investigated the influence of health center and client level factors on adherence to best practice guidelines.

Methods

Clinical audit data from 2012 to 2014 for 3,623 well adult clients (aged 15–54) of 101 health centers from four Australian states and territories were analyzed to determine adherence to delivery of 26 recommended preventive services classified into five different modes of care on the basis of the way in which they are delivered (e.g., basic measurement; laboratory tests and imaging; assessment and brief interventions, eye, ear, and oral checks; follow-up of abnormal findings). Summary statistics were used to describe the delivery of each service item across jurisdictions. Multilevel regression models were used to quantify the variation in service delivery attributable to health center and client level factors and to identify factors associated with higher quality care.

Results

Delivery of recommended preventive care varied widely between service items, with good delivery of most basic measurements but poor follow-up of abnormal findings. Health center characteristics were associated with most variation. Higher quality care was associated with Northern Territory location, urban services, and smaller service population size. Client factors associated with higher quality care included age between 25 and 34 years, female sex, and more regular attendance.

Conclusion

Wide variation in documented preventive care delivery, poor follow-up of abnormal findings, and system factors that influence quality of care should be addressed through continuous quality improvement approaches that engage stakeholders at multiple levels (including, for example, access to care in the community, appropriate decision support for practitioners, and financial incentives and context appropriate guidelines).

Responses of Aboriginal and Torres Strait Islander Primary Health-Care Services to Continuous Quality Improvement Initiatives

Background

Indigenous primary health-care (PHC) services participating in continuous quality improvement (CQI) cycles show varying patterns of performance over time. Understanding this variation is essential to scaling up and sustaining quality improvement initiatives. The aim of this study is to examine trends in quality of care for services participating in the ABCD National Research Partnership and describe patterns of change over time and examine health service characteristics associated with positive and negative trends in quality of care.

Setting and participants

PHC services providing care for Indigenous people in urban, rural, and remote northern Australia that had completed at least three annual audits of service delivery for at least one aspect of care (n = 73).

Methods/design

Longitudinal clinical audit data from use of four clinical audit tools (maternal health, child health, preventive health, Type 2 diabetes) between 2005 and 2013 were analyzed. Health center performance was classified into six patterns of change over time: consistent high improvement (positive), sustained high performance (positive), decline (negative), marked variability (negative), consistent low performance (negative), and no specific increase or decrease (neutral). Backwards stepwise multiple logistic regression analyses were used to examine the associations between health service characteristics and positive or negative trends in quality of care.

Results

Trends in quality of care varied widely between health services across the four audit tools. Regression analyses of health service characteristics revealed no consistent statistically significant associations of population size, remoteness, governance model, or accreditation status with positive or negative trends in quality of care.

Conclusion

The variable trends in quality of care as reflected by CQI audit tools do not appear to be related to easily measurable health service characteristics. This points to the need for a deeper or more nuanced understanding of factors that moderate the effect of CQI on health service performance for the purpose of strengthening enablers and overcoming barriers to improvement.

Improving physiotherapy services to Indigenous children with physical disability: Are client perspectives missed in the continuous quality improvement approach?

OBJECTIVE

To compare the outcomes of two cycles of continuous quality improvement (CQI) at a paediatric physiotherapy service with findings from interviews with clients and their carers using the service.

DESIGN

Case study based at one paediatric physiotherapy service

SETTING

Community-based paediatric allied health service in Northern Australia.

PARTICIPANTS

Forty-nine clinical records and four staff at physiotherapy service, five Indigenous children with physical disability aged 8-21 years, and nine carers of Indigenous children aged 0-21 years (current or previous clients).

INTERVENTIONS

The CQI process based on the Audit and Best Practice for Chronic Disease involved a clinical audit; a workshop where clinicians assessed their health care systems, identified weaknesses and strengths, and developed goals and strategies for improvement; and reassessment through a second audit and workshop. Twelve open-ended, in-depth interviews were conducted with previous or current clients selected through purposive and theoretical sampling. CQI and interview results were then compared.

MAIN OUTCOME MEASURE

Comparison of findings from the two studies

RESULTS

Both CQI and interview results highlighted service delivery flexibility and therapists' knowledge, support and advocacy as service strengths, and lack of resources and a child-friendly office environment as weaknesses. However, the CQI results reported better communication and client input into the service than the interview results.

CONCLUSION

The CQI process, while demonstrating improvements in clinical and organisational aspects of the service, did not always reflect or address the primary concerns of Indigenous clients and underlined the importance of including clients in the CQI process.

Community health workers as chronic care coordinators: evaluation of an Australian Indigenous primary health care program

OBJECTIVES

To explore how a client-centred Chronic Care model was implemented by Indigenous Health Workers (IHWs) at participating sites in a trial of IHW-led case management. To understand the experiences of engaging with the model from the perspective of the IHWs, health team members and clients.

METHODS

The review was conducted within a cluster randomised trial of the model in six remote Indigenous communities in north Queensland over 18 months. Content analysis was undertaken on 377 project records of health worker activity. Descriptive coding was used to classify issues that were grouped under key themes. Open-ended interviews were conducted with 21 stakeholders and analysed using the key themes.

RESULTS

Implementation of all elements of the intervention was not achieved. Key themes identified that describe the issues affecting the IHWs' capacity to implement the model were: service management, training, client engagement, clarification of IHW role and infrastructure.

CONCLUSIONS

Placing skilled and dedicated IHWs to improve care coordination is insufficient to improve chronic disease outcomes. A supportive and systematic service delivery system is also required.

IMPLICATIONS

The PHC model in remote Indigenous communities needs to be re-oriented to actively support the unique contributions of IHWs to chronic care coordination.

Strengthening primary health care: achieving health gains in a remote region of Australia

OBJECTIVE

To evaluate the impact of a comprehensive primary health care service model on key health performance indicators in a remote region of Australia.

DESIGN AND SETTING

A cross-sectional 6-year retrospective evaluation of the results of a health service partnership between an Aboriginal community controlled health service, a hospital and a community health service in north-west Western Australia.

INTERVENTION

Integration of health promotion, health assessments and chronic disease management with an acute primary health care service as a result of the formal partnership.

MAIN OUTCOME MEASURES

Cross-sectional data on use and outcomes of health care from 1 July 2006 to 30 June 2012 are reported in accordance with national key performance indicators.

RESULTS

There were increases in occasions of service (from 21 218 to 33 753), most notably in primary health care services provided to very remote outlying communities (from 863 to 11 338). Health assessment uptake increased from 13% of the eligible population to 61%, leading to 73% of those identified with diabetes being placed on a care plan. Quality-of-care indicators (glycated haemoglobin checks and proportion of people with diabetics receiving antihypertensives) showed improvements over the 6-year study period, and there was also a downward trend in mortality.

CONCLUSIONS

This study demonstrates that strengthening primary health care services by addressing key enablers and sustainability requirements can translate into population health gains consistent with the goals underpinning the National Health Care Reform and Closing the Gap policies, and may potentially reduce health inequity for remote-living Aboriginal Australians.

Enablers and barriers to the implementation of primary health care interventions for Indigenous people with chronic diseases: a systematic review

BACKGROUND

Access to appropriate, affordable, acceptable and comprehensive primary health care (PHC) is critical for improving the health of Indigenous populations. Whilst appropriate infrastructure, sufficient funding and knowledgeable health care professionals are crucial, these elements alone will not lead to the provision of appropriate care for all Indigenous people. This systematic literature review synthesised international evidence on the factors that enable or inhibit the implementation of interventions aimed at improving chronic disease care for Indigenous people.

METHODS

A systematic review using Medical Literature Analysis and Retrieval System Online (MEDLINE) (PubMed platform), Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Excerpta Medica Database (EMBASE), ATSIHealth, Australian Indigenous HealthInfoNet via Informit Online and Primary Health Care Research and Information Service (PHCRIS) databases was undertaken. Studies were included if they described an intervention for one or more of six chronic conditions that was delivered in a primary health care setting in Australia, New Zealand, Canada or the United States. Attitudes, beliefs, expectations, understandings and knowledge of patients, their families, Indigenous communities, providers and policy makers were of interest. Published and unpublished qualitative and quantitative studies from 1998 to 2013 were considered. Qualitative findings were pooled using a meta-aggregative approach, and quantitative data were presented as a narrative summary.

RESULTS

Twenty three studies were included. Meta-aggregation of qualitative data revealed five synthesised findings, related to issues within the design and planning phase of interventions, the chronic disease workforce, partnerships between service providers and patients, clinical care pathways and patient access to services. The available quantitative data supported the qualitative findings. Three key features of enablers and barriers emerged from the findings: (1) they are not fixed concepts but can be positively or negatively influenced, (2) the degree to which the work of an intervention can influence an enabler or barrier varies depending on their source and (3) they are inter-related whereby a change in one may effect a change in another.

CONCLUSIONS

Future interventions should consider the findings of this review as it provides an evidence-base that contributes to the successful design, implementation and sustainability of chronic disease interventions in primary health care settings intended for Indigenous people.

Duration of participation in continuous quality improvement: a key factor explaining improved delivery of Type 2 diabetes services

Background

It is generally recognised that continuous quality improvement (CQI) programs support development of high quality primary health care systems. However, there is limited evidence demonstrating their system-wide effectiveness. We examined variation in quality of Type 2 diabetes service delivery in over 100 Aboriginal and Torres Strait Islander primary health care centres participating in a wide-scale CQI project over the past decade, and determined the influence of health centre and patient level factors on quality of care, with specific attention to health centre duration of participation in a CQI program.

Methods

We analysed over 10,000 clinical audit records to assess quality of Type 2 diabetes care of patients in 132 Aboriginal and Torres Strait Islander community health centres in five states/territories participating in the ABCD project for varying periods between 2005 and 2012. Process indicators of quality of care for each patient were calculated by determining the proportion of recommended guideline scheduled services that were documented as delivered. Multilevel regression models were used to quantify the amount of variation in Type 2 diabetes service delivery attributable to health centre or patient level factors and to identify those factors associated with greater adherence to best practice guidelines.

Results

Health centre factors that were independently associated with adherence to best practice guidelines included longer participation in the CQI program, remoteness of health centres, and regularity of client attendance. Significantly associated patient level variables included greater age, and number of co-morbidities and disease complications. Health centre factors explained 37% of the differences in level of service delivery between jurisdictions with patient factors explaining only a further 1%.

Conclusions

At the health centre level, Type 2 diabetes service delivery could be improved through long term commitment to CQI, encouraging regular attendance (for example, through patient reminder systems) and improved recording and coordination of patient care in the complex service provider environments that are characteristic of non-remote areas.

Characteristics of a self-management support programme applicable in primary health care: a qualitative study of users' and health professionals' perceptions

Background

Development of more self-management support programmes in primary health care has been one option used to enhance positive outcomes in chronic disease management. At present, research results provide no consensus on what would be the best way to develop support programmes into new settings. The aim of the present study was therefore to explore users’ and health professionals’ perceptions of what would be the vital elements in a self - management support programme applicable in primary health care, how to account for them, and why.

Methods

Four qualitative, semi-structured focus group interviews were conducted in Central Norway. The informants possessed experience in development, provision, or participation in a self-management support programme. Data was analysed by the Systematic Text Condensation method.

Results

The results showed an overall positive expectation to the potential benefits of development of a self-management support programme in primary health care. Despite somewhat different arguments and perspectives, the users and the health professionals had a joint agreement on core characteristics; a self-management support programme in primary health care should therefore be generic, not disease specific, and delivered in a group- based format. A special focus should be on the everyday- life of the participants. The most challenging aspect was a present lack of competence and experience among health professionals to moderate self-management support programmes.

Conclusions

The development and design of a relevant and applicable self-management support programme in primary health care should balance the interests of the users with the possibilities and constraints within each municipality. It would be vital to benefit from the closeness of the patients’ every-day life situations. The user informants’ perception of a self-management support programme as a supplement to regular medical treatment represented an expanded understanding of the self-management support concept. An exploring approach should be applied in the development of the health professionals’ competence in practice. The effect of a self-management support programme based on the core characteristics found in this study needs to be evaluated.

Quality improvement in practice: improving diabetes care and patient outcomes in Aboriginal Community Controlled Health Services

Background

Management of chronic disease, including diabetes, is a central focus of most Aboriginal Community Controlled Health Services (ACCHSs) in Australia. We have previously demonstrated that diabetes monitoring and outcomes can be improved and maintained over a 10-year period at Derby Aboriginal Health Service (DAHS). While continuous quality improvement (CQI) has been shown to improve service delivery rates and clinical outcome measures, the process of interpreting audit results and developing strategies for improvement is less well described. This paper describes the evaluation of care of patients with type 2 diabetes mellitus (T2DM) and features of effective CQI in ACCHSs in the remote Kimberley region of north Western Australia.

Methods

Retrospective audit of records for Aboriginal and Torres Strait Islander primary care patients aged ≥15 years with a confirmed diagnosis of T2DM at four Kimberley ACCHSs from 1 July 2011 to 30 June 2012. Interviews with health service staff and focus group discussions with patients post audit. Main outcome measures: diabetes care related activities, clinical outcome measures and factors influencing good diabetes related care and effective CQI.

Results

A total of 348 patients from the four ACCHSs were included in the study. Clinical care activities were generally high across three of the four health services (at least 71% of patients had cholesterol recorded, 89% blood pressure, 84% HbA_1c). Patients from DAHS had lower median cholesterol levels (4.4 mmol/L) and the highest proportion of patients meeting clinical targets for HbA_1c (31% v 16% ACCHS-3; P = 0.02). Features that facilitated good care included clearly defined staff roles for diabetes management, support and involvement of Aboriginal Health Workers, efficient recall systems, and well-coordinated allied health services. Effective CQI features included seamless and timely data collection, local ownership of the process, openness to admitting deficiencies and willingness to embrace change.

Conclusions

Well-designed health care delivery and CQI systems, with a strong sense of ownership over diabetes management led to increased service delivery rates and improved clinical outcome measures in ACCHSs. Locally run CQI processes may be more responsive to individual health services and more sustainable than externally driven systems.

How public hospitals respond to and use a national serious and sentinel events report: A qualitative study in New Zealand

How and if public hospital leaders in a national health system use an annual Serious and Sentinel Events (SSE) report, an aim of which is to stimulate improvements in health care quality and patient safety, is an important question that is under-researched. This exploratory qualitative study in New Zealand using semi-structured interviews was undertaken in response. Interviewees included 29 representatives in patient safety leadership roles from 20 hospital districts, each of whom were recommended by their Chief Executives. Four themes describing factors contributing to the use of the SSE report were identified: response to the report itself; perceived use of and value of the report as a quality improvement tool; collaboration amongst hospitals around the findings; and, the priority given to improving quality within respondents' healthcare organisations. This article provides examples of these themes and how they relate to the use of the SSE report as a quality improvement tool. The article concludes that an annual SSE report has the potential to be a very useful tool for health care leaders in addressing SSEs. However, it also suggests that the report is underutilised and consequently some of this potential is lost. This may be explained by hospital capacity to absorb information from, and respond to, the SSE report.

Improvement in rheumatic fever and rheumatic heart disease management and prevention using a health centre-based continuous quality improvement approach

BACKGROUND

Rheumatic heart disease (RHD) remains a major health concern for Aboriginal Australians. A key component of RHD control is prevention of recurrent acute rheumatic fever (ARF) using long-term secondary prophylaxis with intramuscular benzathine penicillin (BPG). This is the most important and cost-effective step in RHD control. However, there are significant challenges to effective implementation of secondary prophylaxis programs. This project aimed to increase understanding and improve quality of RHD care through development and implementation of a continuous quality improvement (CQI) strategy.

METHODS

We used a CQI strategy to promote implementation of national best-practice ARF/RHD management guidelines at primary health care level in Indigenous communities of the Northern Territory (NT), Australia, 2008-2010. Participatory action research methods were employed to identify system barriers to delivery of high quality care. This entailed facilitated discussion with primary care staff aided by a system assessment tool (SAT). Participants were encouraged to develop and implement strategies to overcome identified barriers, including better record-keeping, triage systems and strategies for patient follow-up. To assess performance, clinical records were audited at baseline, then annually for two years. Key performance indicators included proportion of people receiving adequate secondary prophylaxis (≥80% of scheduled 4-weekly penicillin injections) and quality of documentation.

RESULTS

Six health centres participated, servicing approximately 154 people with ARF/RHD. Improvements occurred in indicators of service delivery including proportion of people receiving ≥40% of their scheduled BPG (increasing from 81/116 [70%] at baseline to 84/103 [82%] in year three, p = 0.04), proportion of people reviewed by a doctor within the past two years (112/154 [73%] and 134/156 [86%], p = 0.003), and proportion of people who received influenza vaccination (57/154 [37%] to 86/156 [55%], p = 0.001). However, the proportion receiving ≥80% of scheduled BPG did not change. Documentation in medical files improved: ARF episode documentation increased from 31/55 (56%) to 50/62 (81%) (p = 0.004), and RHD risk category documentation from 87/154 (56%) to 103/145 (76%) (p < 0.001). Large differences in performance were noted between health centres, reflected to some extent in SAT scores.

CONCLUSIONS

A CQI process using a systems approach and participatory action research methodology can significantly improve delivery of ARF/RHD care.

A systems-based partnership learning model for strengthening primary healthcare

Background

Strengthening primary healthcare systems is vital to improving health outcomes and reducing inequity. However, there are few tools and models available in published literature showing how primary care system strengthening can be achieved on a large scale. Challenges to strengthening primary healthcare (PHC) systems include the dispersion, diversity and relative independence of primary care providers; the scope and complexity of PHC; limited infrastructure available to support population health approaches; and the generally poor and fragmented state of PHC information systems.

Drawing on concepts of comprehensive PHC, integrated quality improvement (IQI) methods, system-based research networks, and system-based participatory action research, we describe a learning model for strengthening PHC that addresses these challenges. We describe the evolution of this model within the Australian Aboriginal and Torres Strait Islander primary healthcare context, successes and challenges in its application, and key issues for further research.

Discussion

IQI approaches combined with system-based participatory action research and system-based research networks offer potential to support program implementation and ongoing learning across a wide scope of primary healthcare practice and on a large scale. The Partnership Learning Model (PLM) can be seen as an integrated model for large-scale knowledge translation across the scope of priority aspects of PHC. With appropriate engagement of relevant stakeholders, the model may be applicable to a wide range of settings. In IQI, and in the PLM specifically, there is a clear role for research in contributing to refining and evaluating existing tools and processes, and in developing and trialling innovations. Achieving an appropriate balance between funding IQI activity as part of routine service delivery and funding IQI related research will be vital to developing and sustaining this type of PLM.

Summary

This paper draws together several different previously described concepts and extends the understanding of how PHC systems can be strengthened through systematic and partnership-based approaches. We describe a model developed from these concepts and its application in the Australian Indigenous primary healthcare context, and raise questions about sustainability and wider relevance of the model.