Development and pilot study of the Primary Care Practice Improvement Tool (PC-PIT): an innovative approach

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.

The Primary Care Practice Improvement Tool (PC-PIT) process for organisational improvement in primary care: application by Australian Primary Health Networks

The Primary Care Practice Improvement Tool (PC-PIT) is an organisational performance improvement tool recently implemented by two Primary Health Networks (PHNs). This study explored barriers and facilitators to implementing the PC-PIT process at scale, from the initial introduction of the tool to completion of Plan-Do-Study-Act cycles with general practices. Using a qualitative design, in-depth, semi-structured interviews were conducted with 10 PHN staff to seek feedback on the delivery of the PC-PIT to general practices. Interview results were analysed using a grounded theory approach. The identification of barriers such as difficulty engaging practices and lack of report sharing with the PHNs will help streamline future implementation. The PC-PIT was highly compatible with existing quality improvement programs and offers enhanced opportunity to support capacity building and implementation of the Health Care Home model.

Creating and facilitating change for Person-Centred Coordinated Care (P3C): The development of the Organisational Change Tool (P3C-OCT)

BACKGROUND

Person Centred Coordinated Care (P3C) is a UK priority for patients, carers, professionals, commissioners and policy makers. Services are developing a range of approaches to deliver this care with a lack of tools to guide implementation.

METHODOLOGY

A scoping review and critical examination of current policy, key literature and NHS guidelines, together with stakeholder involvement led to the identification of domains, subdomains and component activities (processes and behaviours) required to deliver P3C. These were validated through codesign with stakeholders via a series of workshops and cognitive interviews.

RESULTS

Six core domains of P3C were identified as follows: (i) my goals, (ii) care planning, (iii) transitions, (iv) decision making (v), information and communication and (vi) organizational support activities. These were populated by 29 core subdomains (question items). A number of response codes (components) to each question provide examples of the processes and activities that can be actioned to achieve each core subdomain of P3C.

CONCLUSION

The P3C-OCT provides a coherent approach to monitoring progress and supporting practice development towards P3C. It can be used to generate a shared understanding of the core domains of P3C at a service delivery level, and support reorganization of care for those with complex needs. The tool can reliably detect change over time, as demonstrated in a sample of 40 UK general practices. It is currently being used in four UK evaluations of new models of care and being further developed as a training tool for the delivery of P3C.

Achieving Research Impact Through Co-creation in Community-Based Health Services: Literature Review and Case Study

Policy Points:

Co‐creation—collaborative knowledge generation by academics working alongside other stakeholders—is an increasingly popular approach to aligning research and service development.

It has potential for “moving beyond the ivory towers” to deliver significant societal impact via dynamic, locally adaptive community‐academic partnerships.

Principles of successful co‐creation include a systems perspective, a creative approach to research focused on improving human experience, and careful attention to governance and process.

If these principles are not followed, co‐creation efforts may fail.

Context

Co‐creation—collaborative knowledge generation by academics working alongside other stakeholders—reflects a “Mode 2” relationship (knowledge production rather than knowledge translation) between universities and society. Co‐creation is widely believed to increase research impact.

Methods

We undertook a narrative review of different models of co‐creation relevant to community‐based health services. We contrasted their diverse disciplinary roots and highlighted their common philosophical assumptions, principles of success, and explanations for failures. We applied these to an empirical case study of a community‐based research‐service partnership led by the Centre of Research Excellence in Quality and Safety in Integrated Primary‐Secondary Care at the University of Queensland, Australia.

Findings

Co‐creation emerged independently in several fields, including business studies (“value co‐creation”), design science (“experience‐based co‐design”), computer science (“technology co‐design”), and community development (“participatory research”). These diverse models share some common features, which were also evident in the case study. Key success principles included (1) a systems perspective (assuming emergence, local adaptation, and nonlinearity); (2) the framing of research as a creative enterprise with human experience at its core; and (3) an emphasis on process (the framing of the program, the nature of relationships, and governance and facilitation arrangements, especially the style of leadership and how conflict is managed). In both the literature review and the case study, co‐creation “failures” could often be tracked back to abandoning (or never adopting) these principles. All co‐creation models made strong claims for significant and sustainable societal impacts as a result of the adaptive and developmental research process; these were illustrated in the case study.

Conclusions

Co‐creation models have high potential for societal impact but depend critically on key success principles. To capture the nonlinear chains of causation in the co‐creation pathway, impact metrics must reflect the dynamic nature and complex interdependencies of health research systems and address processes as well as outcomes.

Trial of the Primary Care Practice Improvement Tool: building organisational performance in Australian general practice and primary health care

OBJECTIVE

To nationally trial the Primary Care Practice Improvement Tool (PC-PIT), an organisational performance improvement tool previously co-created with Australian primary care practices to increase their focus on relevant quality improvement (QI) activities.

DESIGN

The study was conducted from March to December 2015 with volunteer general practices from a range of Australian primary care settings. We used a mixed-methods approach in two parts. Part 1 involved staff in Australian primary care practices assessing how they perceived their practice met (or did not meet) each of the 13 PC-PIT elements of high-performing practices, using a 1-5 Likert scale. In Part 2, two external raters conducted an independent practice visit to independently and objectively assess the subjective practice assessment from Part 1 against objective indicators for the 13 elements, using the same 1-5 Likert scale. Concordance between the raters was determined by comparing their ratings. In-depth interviews conducted during the independent practice visits explored practice managers' experiences and perceived support and resource needs to undertake organisational improvement in practice.

RESULTS

Data were available for 34 general practices participating in Part 1. For Part 2, independent practice visits and the inter-rater comparison were conducted for a purposeful sample of 19 of the 34 practices. Overall concordance between the two raters for each of the assessed elements was excellent. Three practice types across a continuum of higher- to lower-scoring practices were identified, with each using the PC-PIT in a unique way. During the in-depth interviews, practice managers identified benefits of having additional QI tools that relate to the PC-PIT elements.

CONCLUSIONS

The PC-PIT is an organisational performance tool that is acceptable, valid and relevant to our range of partners and the end users (general practices). Work is continuing with our partners and end users to embed the PC-PIT in existing organisational improvement programs.

Quality tools and resources to support organisational improvement integral to high-quality primary care: a systematic review of published and grey literature

OBJECTIVE

To conduct a systematic review of the literature to identify existing online primary care quality improvement tools and resources to support organisational improvement related to the seven elements in the Primary Care Practice Improvement Tool (PC-PIT), with the identified tools and resources to progress to a Delphi study for further assessment of relevance and utility.

STUDY DESIGN

Systematic review of the international published and grey literature.

DATA SOURCES

CINAHL, Embase and PubMed databases were searched in March 2014 for articles published between January 2004 and December 2013. GreyNet International and other relevant websites and repositories were also searched in March-April 2014 for documents dated between 1992 and 2012.

STUDY SELECTION

All citations were imported into a bibliographic database. Published and unpublished tools and resources were included in the review if they were in English, related to primary care quality improvement and addressed any of the seven PC-PIT elements of a high-performing practice. Tools and resources that met the eligibility criteria were then evaluated for their accessibility, relevance, utility and comprehensiveness using a four-criteria appraisal framework.

DATA EXTRACTION AND SYNTHESIS

We used a data extraction template to systematically extract information from eligible tools and resources. A content analysis approach was used to explore the tools and resources and collate relevant information: name of the tool or resource, year and country of development, author, name of the organisation that provided access and its URL, accessibility information or problems, overview of each tool or resource and the quality improvement element(s) it addresses. If available, a copy of the tool or resource was downloaded into the bibliographic database, along with supporting evidence (published or unpublished) on its use in primary care.

CONCLUSIONS

This systematic review identified 53 tools and resources that can potentially be provided as part of a suite of tools and resources to support primary care practices in improving the quality of their practice, to achieve improved health outcomes.

Clinical service integration: a stocktake of the Australian experience

Australia, in common with most developed countries, needs to reorientate its health system to meet the needs of the future. There is general acceptance that the current approach geared towards acute episodic care is no longer fit for purpose. This article explores the concept of integration in healthcare in Australia and specifically describes the role of clinicians over the last five years in brokering and supporting change in the way services are delivered.