System-Level Action Required for Wide-Scale Improvement in Quality of Primary Health Care: Synthesis of Feedback from an Interactive Process to Promote Dissemination and Use of Aggregated Quality of Care Data

Supporting alcohol brief interventions and pharmacotherapy provision in Australian First Nations primary care: exploratory analysis of a cluster randomised trial

INTRODUCTION

Primary care provides an important opportunity to detect unhealthy alcohol use and offer assistance but many barriers to this exist. In an Australian context, Aboriginal Community Controlled Health Services (ACCHS) are community-led and run health services, which provide holistic primary care to Aboriginal and Torres Strait Islander peoples. A recent cluster randomised trial conducted with ACCHS provided a service support model which showed a small but significant difference in provision of 'any treatment' for unhealthy alcohol use. However, it was not clear which treatment modalities were increased.

AIMS

To test the effect of an ACCHS support model for alcohol on: (i) delivery of verbal alcohol intervention (alcohol advice or counselling); (ii) prescription of relapse prevention pharmacotherapies.

METHODS

Intervention: 24-month, multi-faceted service support model.

DESIGN

cluster randomised trial; equal allocation to early-support ('treatment') and waitlist control arms.

PARTICIPANTS

22 ACCHS.

ANALYSIS

Multilevel logistic regression to compare odds of a client receiving treatment in any two-month period as routinely recorded on practice software.

RESULTS

Support was associated with a significant increase in the odds of verbal alcohol intervention being recorded (OR = 7.60, [95% CI = 5.54, 10.42], p < 0.001) from a low baseline. The odds of pharmacotherapies being prescribed (OR = 1.61, [95% CI = 0.92, 2.80], p = 0.1) did not increase significantly. There was high heterogeneity in service outcomes.

CONCLUSIONS

While a statistically significant increase in verbal alcohol intervention rates was achieved, this was not clinically significant because of the low baseline. Our data likely underestimates rates of treatment provision due to barriers documenting verbal interventions in practice software, and because different software may be used by drug and alcohol teams. The support made little impact on pharmacotherapy prescription. Changes at multiple organisational levels, including within clinical guidelines for primary care, may be needed to meaningfully improve provision of alcohol treatment in ACCHS.

TRIAL REGISTRATION

ACTRN12618001892202 (retrospectively registered on 21/11/2018).

A rapid review to inform the policy and practice for the implementation of chronic disease prevention and management programs for Aboriginal and Torres Strait Islander people in primary care

BACKGROUND

More than 35% of Aboriginal and Torres Strait Islander adults live with cardiovascular disease, diabetes, or chronic kidney disease. There is a pressing need for chronic disease prevention and management among Aboriginal and Torres Strait Islander people in Australia. Therefore, this review aimed to synthesise a decade of contemporary evidence to understand the barriers and enablers of chronic disease prevention and management for Aboriginal and Torres Strait Islander People with a view to developing policy and practice recommendations.

METHODS

We systematically searched for peer-reviewed published articles between January 2014 to March 2023 where the search was performed using subject headings and keywords related to "Aboriginal and Torres Strait Islander peoples," "Chronic Disease," and "Primary Health Care". Quality assessment for all included studies was conducted using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. The data were extracted and summarised using a conventional content analysis approach and applying strength-based approaches.

RESULTS

Database searches identified 1653 articles where 26 met inclusion criteria. Studies varied in quality, primarily reporting on 14 criteria of the Aboriginal and Torres Strait Islander Quality Appraisal Tool. We identified six key domains of enablers and barriers of chronic disease prevention and management programs and implied a range of policy and practice options for improvement. These include culturally acceptable and safe services, patient-provider partnerships, chronic disease workforce, primary health care service attributes, clinical care pathways, and accessibility to primary health care services. This review also identified the need to address social and cultural determinants of health, develop the Aboriginal and Torres Strait Islander and non-Indigenous chronic disease workforce, support multidisciplinary teams through strengthening clinical care pathways, and engage Aboriginal and Torres Strait Islander communities in chronic disease prevention and management program design and delivery.

CONCLUSION

Enabling place-based partnerships to develop contextual evidence-guided strategies that align with community priorities and aspirations, with the provision of funding mechanisms and models of care through policy and practice reforms will strengthen the chronic disease prevention and management program for Aboriginal and Torres Strait Islander people.

Producing knowledge together: a participatory approach to synthesising research across a large-scale collaboration in Aboriginal and Torres Strait Islander health

BACKGROUND

Despite that stakeholder participation in evidence synthesis could result in more useful outcomes, there are few examples of processes that actively involve them in synthesis work. Techniques are needed that engage diverse stakeholders as equal partners in knowledge co-production. The aims of this paper are to describe an innovative participatory process of synthesising a large body of academic research products and compare the findings of the participatory process against two traditional approaches to synthesis: a rapid review and a structured review.

METHODS

First, a rapid synthesis of all research outputs (n = 86) was conducted by researchers with in-depth knowledge of the collaboration's research. Second, a team of researchers and service providers conducted a structured synthesis of seventy-eight peer-reviewed articles and reports generated by the collaboration. Fifty-five publications were brought forward for further synthesis in part three, a facilitated participatory synthesis. Finally, we explored the value added by the participatory method by comparing findings generated across the three synthesis approaches.

RESULTS

Twelve researchers and 11 service providers/policy partners-8 self-identified as Aboriginal and/or Torres Strait Islander-participated in two facilitated workshops (totalling 4 h). Workshop activities engaged participants in reviewing publication summaries, identifying key findings, and evoked review, discussion and refinement. The process explicitly linked experiential knowledge to citations of academic research, clearly connecting the two knowledge types. In comparing the findings generated across all three methods we found mostly consistencies; the few discrepancies did not contradict but gave deeper insights into statements created by the other methods. The participatory synthesis generated the most, detailed, and unique findings, and contextual insights about the relevance of the key messages for practice.

CONCLUSION

The participatory synthesis engaged stakeholders with diverse backgrounds and skillsets in synthesising a large body of evidence in a relatively short time. The participatory approach produced findings comparable to traditional synthesis methods while extending knowledge and identifying lessons most relevant for the participants who, ultimately, are the end users of the research. This process will interest other large-scale research collaborations seeking to engage stakeholders in evidence synthesis.

Support for Aboriginal health services in reducing harms from alcohol: 2-year service provision outcomes in a cluster randomized trial

BACKGROUND AND AIMS

There is a higher prevalence of unhealthy alcohol use among Indigenous populations, but there have been few studies of the effectiveness of screening and treatment in primary health care. Over 24 months, we tested whether a model of service-wide support could increase screening and any alcohol treatment.

DESIGN

Cluster-randomized trial with 24-month implementation (12 months active, 12 months maintenance).

SETTING

Australian Aboriginal Community Controlled primary care services.

PARTICIPANTS

Twenty-two services (83 032 clients) that use Communicare practice software and see at least 1000 clients annually, randomized to the treatment arm or control arm.

INTERVENTION AND COMPARATOR

Multi-faceted early support model versus a comparator of waiting-list control (11 services).

MEASUREMENTS

A record (presence = 1, absence = 0) of: (i) Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screening (primary outcome), (ii) any-treatment and (iii) brief intervention. We received routinely collected practice data bimonthly over 3 years (1-year baseline, 1-year implementation, 1-year maintenance). Multi-level logistic modelling was used to compare the odds of each outcome before and after implementation.

FINDINGS

The odds of being screened within any 2-month reference period increased in both arms post-implementation, but the increase was nearly eight times greater in early-support services [odds ratio (OR) = 7.95, 95% confidence interval (CI) = 4.04-15.63, P < 0.001]. The change in odds of any treatment in early support was nearly double that of waiting-list controls (OR = 1.89, 95% CI = 1.19-2.98, P = 0.01) but was largely driven by decrease in controls. There was no clear evidence of difference between groups in the change in the odds of provision of brief intervention (OR = 1.95, 95% CI = 0.53-7.17, P = 0.32).

CONCLUSIONS

An early support model designed to aid routine implementation of alcohol screening and treatment in Aboriginal health services resulted in improvement of Alcohol Use Disorders Identification Test-Consumption screening rates over 24 months of implementation, but the effect on treatment was less clear.

Improving systems of prenatal and postpartum care for hyperglycemia in pregnancy: A process evaluation

OBJECTIVE

To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health outcomes for women with hyperglycemia in pregnancy in regional and remote Australia.

METHODS

A qualitative evaluation, underpinned by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid-intervention. Semi-structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff.

RESULTS

Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor-intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy.

CONCLUSION

The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy.

Respect Is Central: A Critical Review of Implementation Frameworks for Continuous Quality Improvement in Aboriginal and Torres Strait Islander Primary Health Care Services

Background: Primary health care (PHC) services are complex systems, shaped by an interplay of factors at individual, organisational and broader system levels. For Aboriginal and Torres Strait Islander PHC services, closer relationships with the people they serve, local knowledge of community, and cultural awareness are critical. Continuous quality improvement (CQI) has proven to be an effective process for identification of priority issues in health care delivery and for instigating the design, implementation and evaluation of improvement interventions in these settings. However, wide-scale variation in care quality persists partly due to the mismatch between CQI interventions and context. Methods: This critical review of implementation frameworks for CQI in Aboriginal and Torres Strait Islander primary health care was conducted in two phases: (1) a review of primary published implementation frameworks used in PHC contexts, and (2) a comparison of key features of these frameworks with quality concepts identified by high-improving Aboriginal and Torres Strait Islander PHC services in remote Australia. Results: We found nine primary implementation frameworks previously used in PHC contexts guiding interventions within and between macro (broader contextual) level; meso (health service) level; and micro (community and inter-personal) level systems. There was commonality between these frameworks and key quality concepts in Aboriginal and Torres Strait Islander PHC. However, none of the frameworks covered all concepts with rare consideration of communities driving health improvement, two-way learning (integrating cultural knowledge into healthcare provision), and caring staff-engendering trusting relationships with community enacted through respect. Conclusion: Respect, as a secret essence, privileges the importance of culture, and is an essential element of CQI implementation frameworks for positive change in Aboriginal and Torres Strait Islander PHC services. It is essential to work with communities to design workforce models that grow a caring stable workforce to ensure improvements in quality of care that are effective for their context.

A community-based service enhancement model of training and employing Ear Health Facilitators to address the crisis in ear and hearing health of Aboriginal children in the Northern Territory, the Hearing for Learning Initiative (the HfLI): study protocol for a stepped-wedge cluster randomised trial

Background

Almost all Aboriginal children in remote communities have persistent bilateral otitis media affecting hearing and learning throughout early childhood and school years, with consequences for social and educational outcomes, and later employment opportunities. Current primary health care and specialist services do not have the resources to meet the complex needs of these children.

Method/design

This stepped-wedge cluster randomised trial will allocate 18 communities to one of five 6-monthly intervention start dates. Stratification will be by region and population size. The intervention (Hearing for Learning Initiative, HfLI) consists of six 20-h weeks of training (delivered over 3 months) that includes Certificate II in Aboriginal Primary Health Care (3 modules) and competencies in ear and hearing data collection (otoscopy, tympanometry and hearScreen), plus 3 weeks of assisted integration into the health service, then part-time employment as Ear Health Facilitators to the end of the trial. Unblinding will occur 6 months prior to each allocated start date, to allow Community Reference Groups to be involved in co-design of the HfLI implementation in their community. Relevant health service data will be extracted 6-monthly from all 18 communities. The primary outcome is the difference in proportion of children (0 to 16 years of age) who have at least one ear assessment (diagnosis) documented in their medical record within each 6-month period, compared to control periods (no HfLI). Secondary outcomes include data on sustainability, adherence to evidence-based clinical guidelines for otitis media, including follow-up and specialist referrals, and school attendance. Structured interviews with staff working in health and education services, Ear Health Trainees, Ear Health Facilitators and families will assess process outcomes and the HfLI broader impact.

Discussion

The impact of training and employment of Ear Health Facilitators on service enhancement will inform the health, education and employment sectors about effectiveness of skills and job creation that empowers community members to contribute to addressing issues of local importance, in this instance ear and hearing health of children.

Trial registration

ClinicalTrials.gov NCT03916029. Registered on 16 April 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05215-7.

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.

Collaboration and knowledge generation in an 18-year quality improvement research programme in Australian Indigenous primary healthcare: a coauthorship network analysis

OBJECTIVES

Though multidisciplinary research networks support the practice and effectiveness of continuous quality improvement (CQI) programmes, their characteristics and development are poorly understood. In this study, we examine publication outputs from a research network in Australian Indigenous primary healthcare (PHC) to assess to what extent the research network changed over time.

SETTING

Australian CQI research network in Indigenous PHC from 2002 to 2019.

PARTICIPANTS

Authors from peer-reviewed journal articles and books published by the network.

DESIGN

Coauthor networks across four phases of the network (2002-2004; 2005-2009; 2010-2014; 2015-2019) were constructed based on author affiliations and examined using social network analysis methods. Descriptive characteristics included organisation types, Indigenous representation, gender, student authorship and thematic research trends.

RESULTS

We identified 128 publications written by 308 individual authors from 79 different organisations. Publications increased in number and diversity over each funding phase. During the final phase, publication outputs accelerated for organisations, students, project officers, Indigenous and female authors. Over time there was also a shift in research themes to encompass new clinical areas and social, environmental or behavioural determinants of health. Average degree (8.1), clustering (0.81) and diameter (3) indicated a well-connected network, with a core-periphery structure in each phase (p≤0.03) rather than a single central organisation (degree centralisation=0.55-0.65). Academic organisations dominated the core structure in all funding phases.

CONCLUSION

Collaboration in publications increased with network consolidation and expansion. Increased productivity was associated with increased authorship diversity and a decentralised network, suggesting these may be important factors in enhancing research impact and advancing the knowledge and practice of CQI in PHC. Publication diversity and growth occurred mainly in the fourth phase, suggesting long-term relationship building among diverse partners is required to facilitate participatory research in CQI. Despite improvements, further work is needed to address inequities in female authorship and Indigenous authorship.

Evaluation of the B.strong Queensland Indigenous Health Worker Brief Intervention Training Program for Multiple Health Risk Behaviours

Queensland's B.strong brief intervention training program was a complex intervention developed for Aboriginal and Torres Strait Islander health workers to assist clients address multiple health risks of smoking, poor nutrition and physical inactivity. This study evaluates program effectiveness by applying the Kirkpatrick four-level evaluation model: (1) Reaction, participants' satisfaction; (2) Learning, changes in participants' knowledge, confidence, attitudes, skills and usual practice; (3) Behaviour, application of learning to practice; and (4) Results, outcomes resulting from training. A retrospective analysis was conducted on data for respondents completing pre-training, post-workshop and follow-up surveys. Changes in domains such as training participant knowledge, confidence, attitudes, and practices between survey times were assessed using paired-samples t-tests. From 2017-2019, B.strong trained 1150 health professionals, reaching targets for workshop and online training. Findings showed statistically significant improvements from baseline to follow-up in: participants' knowledge, confidence, and some attitudes to conducting brief interventions in each domain of smoking cessation, nutrition and physical activity; and in the frequency of participants providing client brief interventions in each of the three domains. There was a statistically significant improvement in frequency of participants providing brief interventions for multiple health behaviours at the same time from pre-workshop to follow-up. Indigenous Queenslander telephone counselling referrals for smoking cessation increased during the program period. B.strong improved practitioners' capacity to deliver brief interventions addressing multiple health risks with Indigenous clients.

How to implement patient experience surveys and use their findings for service improvement: a qualitative expert consultation study in Australian general practice

Objective

To identify barriers (patient, provider, practice and system levels) to consider when implementing patient experience surveys in Australian general practice and enablers of their systematic use to inform service improvement in clinical practice as well as the broader health system.

Methods and analysis

An expert consultation and qualitative content analysis of cross-sectional, open-text survey data. Data were collected from key international and Australian experts in the areas of measurement and quality improvement in general practice.

Results

Responses from 20 participants from six countries were included in the study. Participants discussed the importance of ensuring value and relevance of surveys to stakeholders. Lack of resources, IT infrastructure, capacity building and sustained funding were identified as barriers to implementing surveys. Participants discussed the importance of clearly defining and communicating the purpose of surveys and agreed on the value of using patient experience to inform reflective, team-based learning at the practice level. Opinions differed on the use of patient experience data at the system level, with some questioning its utility or fairness for external performance reporting. Others recommended the aggregation and reporting of these data under certain conditions, including for the purpose of triangulation with other quality and outcome data. The study identified an evidence gap in the assessment and interpretation of patient experience data at the practice and system levels, including the analysis and contextualisation of survey findings at the system level.

Conclusion

Patient experience surveys have potential for guiding practice level quality improvement, but many barriers to their implementation remain. There is need for greater research and policy efforts to understand how this information can be used at the system level for improving Australian general practice.

A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement

BACKGROUND

Unhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. However, sustained and systematic implementation has proven challenging. The Continuing Quality Improvement (CQI) process is designed to enable services to detect barriers, then devise and implement changes, resulting in service improvements.

METHODS

We conducted a systematic review of literature reporting on strategies to improve implementation of screening and interventions for unhealthy alcohol use in primary care (MEDLINE EMBASE, PsycINFO, CINAHL, the Australian Indigenous Health InfoNet). Additional inclusion criteria were: (1) pragmatic setting; (2) reporting original data; (3) quantitative outcomes related to provision of service or change in practice. We investigate the extent to which the three essential elements of CQI are being used (data-guided activities, considering local conditions; iterative development). We compare characteristics of programs that include these three elements with those that do not. We describe the types, organizational levels (e.g. health service, practice, clinician), duration of strategies, and their outcomes.

RESULTS

Fifty-six papers representing 45 projects were included. Of these, 24 papers were randomized controlled trials, 12 controlled studies and 20 before/after and other designs. Most reported on strategies for improving implementation of screening and brief intervention. Only six addressed relapse prevention pharmacotherapies. Only five reported on patient outcomes and none showed significant improvement. The three essential CQI elements were clearly identifiable in 12 reports. More studies with three essential CQI elements had implementation and follow-up durations above the median; utilised multifaceted designs; targeted both practice and health system levels; improved screening and brief intervention than studies without the CQI elements.

CONCLUSION

Utilizing CQI methods in implementation research would appear to be well-suited to drive improvements in service delivery for unhealthy alcohol use. However, the body of literature describing such studies is still small. More well-designed research, including hybrid studies of both implementation and patient outcomes, will be needed to draw clearer conclusions on the optimal approach for implementing screening and treatment for unhealthy alcohol use. (PROSPERO registration ID: CRD42018110475).

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.

Wide-Scale Continuous Quality Improvement: A Study of Stakeholders' Use of Quality of Care Reports at Various System Levels, and Factors Mediating Use

Introduction: Increasing the use of evidence in healthcare policy and practice requires greater understanding of how stakeholders use evidence to inform policy, refine systems and change practice. Drawing on implementation theory, we have used system-focused participatory research to engage diverse stakeholders in using aggregated continuous quality improvement (CQI) data from Australian Indigenous primary health care settings to identify priority evidence-practice gaps, barriers/enablers and strategies for improvement. This article reports stakeholders' use or intended use of evidence at various levels of the system, and factors mediating use. Material and Methods: Interviews were undertaken with a purposeful sample of 30 healthcare stakeholders in different roles, organization types and settings in one Australian jurisdiction and with national participants, as part of the project's developmental evaluation. Qualitative data were analyzed to identify themes and categories relating to use of evidence. Results: Context-specific aggregated CQI data that were relatable to the diverse professional roles and practices provided an effective starting point for sharing perspectives, generating practice-based evidence and mobilizing evidence-use. Interviewees perceived the co-produced findings as applicable at different levels and useful for planning, policy development, supporting best practice and reflection, capacity strengthening and developing new research. Factors mediating use were commitment to best practice; the credibility of the evidence and its perceived relevance to work roles, contexts and decision needs; report format and language; facilitation and communication; competing work pressures and the organizational environment for change. Conclusions: This study found that primary health care stakeholders used evidence on quality of care for a variety of purposes. This could be linked to the interactive research processes used to engage stakeholders in different roles and settings in interpreting data, sharing and generating knowledge. Findings indicate that system-based participatory research using CQI data and iterative, interactive and systematic CQI-based methods can be applied at scale to support concurrent action for healthcare improvement at different system levels. Factors known to influence implementation should be addressed within the research design to optimize evidence use. Further research is needed to explore the utility of interactive dissemination for engaging healthcare stakeholders in informing policy and system change.

Application of the i-PARIHS framework for enhancing understanding of interactive dissemination to achieve wide-scale improvement in Indigenous primary healthcare

BACKGROUND

Participatory research approaches improve the use of evidence in policy, programmes and practice. Few studies have addressed ways to scale up participatory research for wider system improvement or the intensity of effort required. We used the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to analyse implementation of an interactive dissemination process engaging stakeholders with continuous quality improvement (CQI) data from Australian Indigenous primary healthcare centres. This paper reports lessons learnt about scaling knowledge translation research, facilitating engagement at a system level and applying the i-PARIHS framework to a system-level intervention.

METHODS

Drawing on a developmental evaluation of our dissemination process, we conducted a post-hoc analysis of data from project records and interviews with 30 stakeholders working in Indigenous health in different roles, organisation types and settings in one Australian jurisdiction and with national participants. Content-analysed data were mapped onto the i-PARIHS framework constructs to examine factors contributing to the success (or otherwise) of the process.

RESULTS

The dissemination process achieved wide reach, with stakeholders using aggregated CQI data to identify system-wide priority evidence-practice gaps, barriers and strategies for improvement across the scope of care. Innovation characteristics influencing success were credible data, online dissemination and recruitment through established networks, research goals aligned with stakeholders' interest in knowledge-sharing and motivation to improve care, and iterative phases of reporting and feedback. The policy environment and infrastructure for CQI, as well as manager support, influenced participation. Stakeholders who actively facilitated organisational- and local-level engagement were important for connecting others with the data and with the externally located research team. Developmental evaluation was facilitative in that it supported real-time adaptation and tailoring to stakeholders and context.

CONCLUSIONS

A participatory research process was successfully implemented at scale without intense facilitation efforts. These findings broaden the notion of facilitation and support the utility of the i-PARIHS framework for planning participatory knowledge translation research at a system level. Researchers planning similar interventions should work through established networks and identify organisational- or local-level facilitators within the research design. Further research exploring facilitation in system-level interventions and the use of interactive dissemination processes in other settings is needed.

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.

An "All Teach, All Learn" Approach to Research Capacity Strengthening in Indigenous Primary Health Care Continuous Quality Improvement

In Australia, Indigenous people experience poor access to health care and the highest rates of morbidity and mortality of any population group. Despite modest improvements in recent years, concerns remains that Indigenous people have been over-researched without corresponding health improvements. Embedding Indigenous leadership, participation, and priorities in health research is an essential strategy for meaningful change for Indigenous people. To centralize Indigenous perspectives in research processes, a transformative shift away from traditional approaches that have benefited researchers and non-Indigenous agendas is required. This shift must involve concomitant strengthening of the research capacity of Indigenous and non-Indigenous researchers and research translators-all must teach and all must learn. However, there is limited evidence about how to strengthen systems and stakeholder capacity to participate in and lead continuous quality improvement (CQI) research in Indigenous primary health care, to the benefit of Indigenous people. This paper describes the collaborative development of, and principles underpinning, a research capacity strengthening (RCS) model in a national Indigenous primary health care CQI research network. The development process identified the need to address power imbalances, cultural contexts, relationships, systems requirements and existing knowledge, skills, and experience of all parties. Taking a strengths-based perspective, we harnessed existing knowledge, skills and experiences; hence our emphasis on capacity "strengthening". New insights are provided into the complex processes of RCS within the context of CQI in Indigenous primary health care.

Identifying evidence-practice gaps and strategies for improvement in Aboriginal and Torres Strait Islander maternal health care

INTRODUCTION

Adverse pregnancy outcomes are more common among Aboriginal and Torres Strait Islander populations than non-Indigenous populations in Australia. Later in life, most of the difference in life expectancy between Aboriginal and Torres Strait Islander women and non-Indigenous women is due to non-communicable diseases (NCDs). Most Aboriginal and Torres Strait Islander women attend health services regularly during pregnancy. Providing high-quality care within these appointments has an important role to play in improving the current and future health of women and babies.

AIM

This study engaged stakeholders in a theory-informed process to use aggregated continuous quality improvement (CQI) data to identify 1) priority evidence-practice gaps in Aboriginal and Torres Strait Islander maternal health care, 2) barriers and enablers to high-quality care, and 3) strategies to address identified priorities.

METHODS

Three phases of reporting and feedback were implemented using de-identified CQI data from 91 health services between 2007 and 2014 (4,402 client records). Stakeholders (n = 172) from a range of professions and organisations participated.

RESULTS

Stakeholders identified four priority areas relating to NCDs: smoking, alcohol, psychosocial wellbeing and nutrition. Barriers or enablers to high-quality care included workforce support, professional development, teamwork, woman-centred care, decision support, equipment and community engagement. Strategies to address the priorities included upskilling staff to provide best practice care in priority areas, advocating for availability of healthy food, housing and local referral options, partnering with communities on health promotion projects, systems to facilitate continuity of care and clear referral pathways.

CONCLUSIONS

This novel use of large-scale aggregate CQI data facilitated stakeholder input on priority evidence-practice gaps in maternal health care in Australia. Evidence-practice gaps relating to NCD risk factors and social determinants of health were prioritised, and stakeholders suggested both healthcare-focussed initiatives and approaches involving the community and the wider health sector. The findings can inform health service planning, advocacy, inter-agency strategies, and future research.

A Qualitative Study of Provider Perceptions of Influences on Uptake of Pediatric Hospital Guidelines in Lao PDR

Strategies to improve the quality of hospital care are needed if ongoing gains in child health and survival are to be made. We previously reported on improvements in the quality of case management in hospitals following a guideline-based intervention in Lao PDR, with variation in the degree of change achieved between clinical conditions. This study aims to understand the factors that influenced the uptake of the guideline-based intervention, and its impact on care. This qualitative study was embedded in a mixed-methods evaluation of guideline implementation in nine hospitals in Lao PDR. Focus groups and individual interviews were conducted with 70 health staff from central, provincial, and district hospitals. The interview guide was based on the Theoretical Domains Framework. Inductive content analysis was performed on interview transcripts to identify themes, supported by field notes from the intervention. Findings were triangulated against previously reported quantitative outcomes using driver diagrams. Key influences on guidelines uptake related to the guideline and intervention (filling a void, physical accessibility, comprehensibility, training in guideline use), health staff (behavior regulation, trust in guidelines, and beliefs about consequences), and the environment (social influences particularly consensus and incorporation into clinical norms). The major barrier was family preference for treatments in conflict with guideline recommendations. This study identifies contextual factors that explain, as well as validate previously identified improvements in care following guideline implementation in Lao PDR. It provides novel understanding of why the same intervention may have a differential impact on different clinical conditions.

Improving preventive health care in Aboriginal and Torres Strait Islander primary care settings

BACKGROUND

Like other colonised populations, Indigenous Australians experience poorer health outcomes than non-Indigenous Australians. Preventable chronic disease is the largest contributor to the health differential between Indigenous and non-Indigenous Australians, but recommended best-practice preventive care is not consistently provided to Indigenous Australians. Significant improvement in health care delivery could be achieved through identifying and minimising evidence-practice gaps. Our objective was to use clinical audit data to create a framework of the priority evidence-practice gaps, strategies to address them, and drivers to support these strategies in the delivery of recommended preventive care.

METHODS

De-identified preventive health clinical audit data from 137 primary health care (PHC) centres in five jurisdictions were analysed (n = 17,108 audited records of well adults with no documented major chronic disease; 367 system assessments; 2005-2014), together with stakeholder survey data relating to interpretation of these data, using a mixed-methods approach (n = 152 responses collated in 2015-16). Stakeholders surveyed included clinicians, managers, policy officers, continuous quality improvement (CQI) facilitators and academics. Priority evidence-practice gaps and associated barriers, enablers and strategies to address the gaps were identified and reported back through two-stages of consultation. Further analysis and interpretation of these data were used to develop a framework of strategies and drivers for health service improvement.

RESULTS

Stakeholder identified priorities were: following-up abnormal test results; completing cardiovascular risk assessments; timely recording of results; recording enquiries about living conditions, family relationships and substance use; providing support for clients identified with emotional wellbeing risk; enhancing systems to enable team function and continuity of care. Drivers identified for improving care in these areas included: strong Indigenous participation in the PHC service; appropriate team structure and function to support preventive care; meaningful use of data to support quality of care and CQI; and corporate support functions and structures.

CONCLUSION

The framework should be useful for guiding development and implementation of barrier-driven, tailored interventions for primary health care service delivery and policy contexts, and for guiding further research. While specific strategies to improve the quality of preventive care need to be tailored to local context, these findings reinforce the requirement for multi-level action across the system. The framework and findings may be useful for similar purposes in other parts of the world, with appropriate attention to context in different locations.

A developmental evaluation to enhance stakeholder engagement in a wide-scale interactive project disseminating quality improvement data: study protocol for a mixed-methods study

INTRODUCTION

Bringing together continuous quality improvement (CQI) data from multiple health services offers opportunities to identify common improvement priorities and to develop interventions at various system levels to achieve large-scale improvement in care. An important principle of CQI is practitioner participation in interpreting data and planning evidence-based change. This study will contribute knowledge about engaging diverse stakeholders in collaborative and theoretically informed processes to identify and address priority evidence-practice gaps in care delivery. This paper describes a developmental evaluation to support and refine a novel interactive dissemination project using aggregated CQI data from Aboriginal and Torres Strait Islander primary healthcare centres in Australia. The project aims to effect multilevel system improvement in Aboriginal and Torres Strait Islander primary healthcare.

METHODS AND ANALYSIS

Data will be gathered using document analysis, online surveys, interviews with participants and iterative analytical processes with the research team. These methods will enable real-time feedback to guide refinements to the design, reports, tools and processes as the interactive dissemination project is implemented. Qualitative data from interviews and surveys will be analysed and interpreted to provide in-depth understanding of factors that influence engagement and stakeholder perspectives about use of the aggregated data and generated improvement strategies. Sources of data will be triangulated to build up a comprehensive, contextualised perspective and integrated understanding of the project's development, implementation and findings.

ETHICS AND DISSEMINATION

The Human Research Ethics Committee (HREC) of the Northern Territory Department of Health and Menzies School of Health Research (Project 2015-2329), the Central Australian HREC (Project 15-288) and the Charles Darwin University HREC (Project H15030) approved the study. Dissemination will include articles in peer-reviewed journals, policy and research briefs. Results will be presented at conferences and quality improvement network meetings. Researchers, clinicians, policymakers and managers developing evidence-based system and policy interventions should benefit from this research.