System-level action required for wide-scale improvement in quality of primary health care Jodie Bailie1, Alison Laycock2, Veronica Matthews1, Ross Bailie1 1University centre for rural health, university of Sydney, Australia 2Menzies School of Health Research, Charles Darwin university, Australia I would like to acknowledge the traditional owners of the land, I extend my respect to the Aboriginal or Torres Strait Islander people who are present. I would also like to acknowledge my co-authors. PHCRIS Conference Brisbane, August, 2017

interventions designed to address known barriers and based on evidence produce change in clinical care context - major disparities in health outcomes between Indigenous and non-Indigenous Australians We know from the literature that interventions designed to address known barriers to care and based on evidence are more likely to produce the desired change in clinical care. Despite this knowledge, few interventions implemented are based on theory or a systematic assessment of barriers. In the context of major disparities in health outcomes between Indigenous and non-Indigenous Australians – the importance of developing tailored interventions is even greater. Baker et al, 2010, Cochrane Database Syst Rev; French et al, 2012, Implement Sci; Huijg et al, 2014, Implement Sci

continuous quality improvement (CQI) data collected, 2005-2014: - 175 Indigenous PHC centres - 56,000 patient records - 492 system assessments We drew on quality improvement data collected from over 175 Indigenous PHC centres who were participating in a research based CQI initiative – the ABCD National Research Partnership. 56,000 patient records ; 492 systems assessments were available for analysis The CQI data from the Partnership provide the most comprehensive picture of the quality of primary health care that Indigenous people receive around Australia. So we have a large data set and we wanted to engage stakeholders in the dissemination and interpretation of this data. data on chronic illness, child, maternal, preventive and mental health care Bailie R et al, 2010, BMC Health Services Research

Engaging Stakeholders in identifying Priority evidence-practice gaps and strategies for improvement (ESP Project) areas of care: chronic illness child health preventive mental health maternal health We designed the ESP Project as an interactive dissemination strategy, engaging a diverse range of stakeholders in using and interpreting the CQI data collected – using an iterative approach with online reports and surveys In phase 1 we presented CQI data that I was referring to in a previous slide in an aggregated form and asked stakeholders to identify priority evidence- practice gaps In phase 2 , we reported the agreed priority evidence-practice gaps and asked stakeholders to identify the barriers and enablers to addressing these identified gaps [CLICK] We repeated this process for a number of different areas of care. Laycock et al, 2016, Frontiers in Public Health; Bailie J et al, 2016, Frontiers in Public Health

aim describe stakeholders perceptions of: - priority evidence-practice gaps - barriers to addressing identified gaps So specifically in this presentation we aim to describe the common priority evidence- practice gaps and barriers to addressing these identified gaps.

number of stakeholders providing feedback to the ESP Process, either as an individual or part of a group, by different areas of care and by phase Phase 1 Phase 2 Child health Chronic Illness Preventive care Maternal health Mental health This figure represents the number of people providing feedback as part of a group or as an individual. Indigenous people were well represented in group feedback across most ESP cycles.

recruitment and responses roles - nurse, CQI facilitator, policy staff, Aboriginal and Torres Strait Islander health practitioner, academic, doctor, manager, other jurisdictions - NSW, SA, QLD, WA, NT, Victoria organisations - community-controlled health centre, peak body; government health centre, department; primary health care network; academic institution Stakeholders were from a diverse range of organisations and roles, across multiple jurisdictions.

common priority evidence-practice gaps follow-up of abnormal clinical findings and laboratory results recording of risk factors and brief interventions emotional wellbeing assessment and support systems to strengthen links between communities and health services Across all of these areas of care we identified that there were many aspects of care that are being delivered relatively well and aspects where there are consistent evidence-practice gaps across the system. The consistent gaps in order of perceived priority were: [CLICK] where aspects of care are not being done well across a range of PHC centres, this is likely due to inadequacies in the broader system

goal barriers workforce recruitment and retention systems to support recruitment and retention of Indigenous staff, in particular Indigenous health workers systems to ensure support from more experienced staff improve delivery of care to address identified evidence –practice gaps use of clinical information systems ongoing staff training in availability and use of clinical information systems approach to quality improvement management support and training in quality improvement effective use of data to inform decision making systems to support patient-centred care systems in place to train & support staff to deliver appropriate, respectful & responsive care taking into account individual patient preferences, needs and values training and development of health staff systems to support inter and intra-organisational learning In our analysis , we identified six barriers to addressing the gaps in care shown on the previous slide – the barriers are listed here in the coloured boxes. [CLICK] Workforce issues were frequently identified as impacting on the effectiveness of delivery of care, including high staff turn over and skill mix. Development of regional support systems for recruiting and retaining staff, especially Indigenous staff was identified. Recruiting Indigenous staff (particularly local staff) and ensuring effective support, was seen as critical to ensuring community connections and provision of a culturally appropriate service. Secondly, clinical information systems were viewed as being in place and having the required functionalities to support high quality care, [CLICK] though the need for ongoing staff training in the use of these systems was identified Quality improvement tools were viewed as being available to support and improve delivery of best practice care, [CLICK] however managers need to be trained to support effective use of tools. Training is needed more broadly for staff in use of data to support decision making and planning Patient – centred care – [click] Inadequate systems are in place to train & support staff to deliver appropriate, respectful & responsive care that takes into account individual patient preferences, needs and values A number of areas were identified for further staff training such as effective use of clinical information systems, quality improvement and patient-centred care. [CLICK] In addition it was noted that systems are needed to support inter and intra organisational learning. Finally, certainly not least, [CLICK] there was an identified need to strengthen links between the local health services and communities and to establish systems to strengthen community health leadership links between community and health service systems to strengthen community health leadership strength of links between local health service and community

use of a comprehensive and large-scale data set strengths use of a comprehensive and large-scale data set reflects knowledge held by a range of stakeholders limitations not possible to accurately measure reach or response rates audit data based on recorded delivery of services Strengths Use of a comprehensive and large scale data set Findings represent the feedback from a diverse range of stakeholders Limitations The ESP project has relied, in part, on stakeholders sending reports to others. Thus, a limitation of the study is that it has not been possible to accurately measure the reach of report dissemination and survey response rates. Audit data are based on recorded delivery of services, which generally underestimate actual service delivery.

conclusion findings identify areas of focus for development of barrier-driven, tailored interventions to improve health outcomes findings reinforce the importance of multi-level action across the system to improve health centre performance Conclusion: Findings identify areas of focus for development of barrier-driven, tailored interventions to improve health outcomes. They reinforce the importance of system-level action to improve health centre performance and health outcomes These findings can assist policy-makers and regional health service providers to develop and test barrier-driven interventions at multiple levels of the health system and to guide further research.

Jodie Bailie, Research Fellow (Evaluation) jodie.bailie@sydney.edu.au The Centre for Research Excellence in Integrated Quality Improvement is a collaboration between research organisations, universities, service and policy organisations, managers and service providers Where to? The ESP Project is a Flagship project of the Centre for Research Excellence in Integrated Quality Improvement We will continue to disseminate the findings of the ESP project through the development of plain language briefs, presentations and journal articles