1. Ongoing verification of findings with services
Lessons from the best: scaling up quality improvement through learning from successful Aboriginal and Torres Strait Islander primary health care services
Health service CQI supports
Authors: Sarah Larkins1, Judy Taylor1, Cindy Woods,1Nalita Turner2, Kerry Copley3 Jacinta Elston1, Sandra Thompson4, Veronica Matthews2, Christine Connors5, Roderick Wright6, Karen Carlisle1,Ross Bailie2,7,
College of Medicine and Dentistry, AITHM, ABRCHSS, James Cook University, Townsville, Queensland, Australia
Menzies School of Health Research, Brisbane, Queensland, Australia
Aboriginal Medical Service Alliance Northern Territory, Darwin, Northern Territory, Australia
Western Australian Centre for Rural Health, University of Western Australia, Australia
Northern Territory Department of Health, Darwin, NT, Australia
Queensland Aboriginal and Islander Health Council, Brisbane, Australia
University Centre for Rural Health, Lismore, NSW, Australia
Background
Continuous quality improvement (CQI) processes appear successful in improving quality of care1,2.
Improving the effectiveness of CQI, particularly on a broad scale, is an important factor in supporting Indigenous primary health care (PHC) in rural and remote Australia
Although variability in response has been demonstrated,1 the contextual reasons behind this variability have been inadequately explored
Findings from within case analysis: Case study Health Care Centre C
Health care centre C was selected as one of six Indigenous Primary health care services that were classified as “High-Improving services” based on the improvement in quality of care generated in response to ABCD One21seventy CQI audits
Thematic analysis explored the interaction of various contextual factors in facilitating quality improvement
Continuous quality improvement (CQI) processes appear successful in improving quality of care1,2.
Improving the effectiveness of CQI, particularly on a broad scale, is an important factor in supporting Indigenous primary health care (PHC) in rural and remote Australia.
Although variability in response has been demonstrated,1,2 the contextual reasons behind this variability have been inadequately explored.
Findings from across case analysis
Across case analysis revealed the complex interplay of contextual factors that are individualised; health services operationalised quality improvement quite differently
Themes such as prepared workforce, teamwork, strong partnerships within community and broader networks, and culturally secure and embedded health systems for CQI were common at the macro, meso and micro systems level but not universal
Project aims
OUR CULTURE IS OUR FOUNDATION
I’ve encouraged a lot of the staff to work with and particularly consolidate those links with other external agencies and providers because if there are other organisations that we can work with to capitalise-to make things better for our clients, that’s what we do.
Figure 2: Across case factors affecting continuous quality improvement
Select Indigenous primary health care services able to consistently improve their quality of care performance in more than one audit area in response to CQI initiatives
Explore, qualitatively and quantitatively, the factors within the service and their support network that facilitate this improvement
Linkages/ partnerships
OUR QUALITY FRAMEWORK IS INSTITUTIONALISED
Health service external policies
Health service CQI supports
Methodology
WE ALL KNOW WHY WE’RE HERE
FROM THE FIRST DAY I DIDN’T KNOW HOW EASY IT WAS TO GET THINGS DONE
Stage 1: Identification of high improving Indigenous primary healthcare services
-Analysis of 130 Indigenous primary health care services involved in the (ABCD) National Research Partnership
-A ‘high improving service’ defined as demonstrating consistent improvement over three or more audits in two or more audit tools (six services identified)
-Quantitative analysis of historical audit data and system assessment tools data for high improving services conducted to identify predictors for high improvement3
Stage 2: Cross jurisdictional multiple case study methodology with participatory approach
-Documentary analysis (strategic plans, population profile data, site and service data, staff retention/turnover, staff participation in CQI process)
-Semi structured interviews with service providers, managers and service users at each service (n=134)
-Non participant observation
Analysis and feedback
-Inductive thematic analysis to explore themes at macro, meso and micro system level within and across cases
-Informed by systems theory, reinforcing loops used to explore interactions between themes within and across cases
-Mapping against National CQI Framework2
We go through a report…after the audits are done and… brainstorm as to why it’s not in there. How can we improve it to make it you know, become part of everyone’s routine when they’re screening clients.
Teamwork & collaboration
CAPACITY BUILDING
THEY’RE DOING EVERYTHING ALRIGHT.THEY GET ALONG WITH THE COMMUNITY
Users/ community engaged with the service
Historical/ cultural context
MICRO
STABLE LEADERSHIP TEAM
Prepared workforce
Consumer input into the governance of care…I think that makes a big difference. ...but anything new that comes to us is provided in terms of a cultural and security framework and you know that does help with engagement in care.
MESO
Caring staff
MACRO
COLLABORATIVE APPROACH
Figure 1: Health Care Centre C Continuous Quality Improvement Systems
What are the qualities of high improving services?
CQI is everybody’s business
Involves active, visible, and actionable engagement with the community
Purpose of quality improvement is explicit and shared with a focus on improving client care and health outcomes
NT POLICIES & PROCEDURES
They’re a team that work together well. They have good structures to work within you know. They’re participating in those quality improvement activities that are around checking and reflecting on their practice.
Implications
Understanding variability in response to CQI initiatives is vital to improving Indigenous primary health care (and likely health outcomes) in rural and remote Australia
In this complex environment, lessons can be learnt from "high-improving" services that might be applicable to other services
Participatory development of a customisable set of resources and interventions to assist a wider range of services to achieve their quality goals is in progress.
Ongoing verification of findings with services
…the way care’s provided in terms of a cultural and security framework… is quite strong and you know that does help with engagement in care and participation and some of the self management stuff
I think very much it is just part of our system. It’s part of the way that we operate. It’s probably core to everything we do…
Contact: Professor Sarah Larkins E. Ph
College of Medicine and Dentistry
Australian Institute of Tropical Health & Medicine
Anton Breinl Research Centre for Health Systems Strengthening
James Cook University, Townsville, Qld, Australia
(2016, PHCR/GHSR)
…and these people wanting a wee bit more I think. They want more. They want quality of life…
1.Bailie R, Si D, Connors C, et al. Variation in quality of preventive care for well adults in Indigenous community health centres in Australia. BMC Health Services Research. 2011;11(1):139.
2.The Lowitja Institute. National CQI Framework for Aboriginal and Torres Strait Islander Primary Health Care Draft prepared for the Commonwealth Department of Health
3. Larkins S, Woods CE, Matthews V, Thompson SC, Schierhout G, Mitropoulos M, Patrao T, Panzera A and Bailie RS. Responses of
Aboriginal and Torres Strait Islander Primary Health-Care Services to Continuous Quality Improvement Initiatives. Front. Public Health ; 3:288.
Centre for Research Excellence-Integrated Quality Improvement
We acknowledge funding for this study from the National Health and Medical Research Council Grant ID