ObjectivesImproving the quality of primary care is an important strategy to improve health outcomes. However, responses to continuous quality improvement (CQI) initiatives are variable, likely due in part to a mismatch between interventions and context. This project aimed to understand the successful implementation of CQI initiatives in Aboriginal and Torres Strait Islander health services in Australia through exploring the strategies used by ‘high-improving’ Indigenous primary healthcare (PHC) services.Design, settings and participantsThis strengths-based participatory observational study used a multiple case study method with six Indigenous PHC services in northern Australia that had improved their performance in CQI audits. Interviews with healthcare providers, service users and managers (n=134), documentary review and non-participant observation were used to explore implementation of CQI and the enablers of quality improvement in these contexts.ResultsServices approached the implementation of CQI differently according to their contexts. Common themes previously reported included CQI systems, teamwork, collaboration, a stable workforce and community engagement. Novel themes included embeddedness in the local historical and cultural contexts, two-way learning about CQI and the community ‘driving’ health improvement. These novel themes were implicit in the descriptions of stakeholders about why the services were improving. Embeddedness in the local historical and cultural context resulted in ‘two-way’ learning between communities and health system personnel.ConclusionsPractical interventions to strengthen responses to CQI in Indigenous PHC services require recruitment and support of an appropriate and well prepared workforce, training in leadership and joint decision-making, regional CQI collaboratives and workable mechanisms for genuine community engagement. A ‘toolkit’ of strategies for service support might address each of these components, although strategies need to be implemented through a two-way learning process and adapted to the historical and cultural community context. Such approaches have the potential to assist health service personnel strengthen the PHC provided to Indigenous communities.
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.
IntroductionCommunity-based Participatory Women’s Groups (PWGs) have proven to be an effective intervention to improve maternal and child health (MCH) outcomes in low/middle-income countries (LMICs). Less is known about how PWGs exert their effects in LMICs and virtually nothing is known about the contextual issues, processes and power relationships that affect PWG outcomes in high resource settings. The aim of this systematic review is to synthesise and critically analyse the current evidence on how and why PWGs improve the quality of MCH care. We aim to demonstrate how PWGs function and why PWG interventions contribute to social and health outcomes.Methods and analysisThe protocol will follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. The databases Medline (Ovid): Cumulative Index to Nursing and Allied Health Literature (Ebsco); Informit health suite Scopus, Australian HealthInfoNet, the Cochrane Library and other sources will be searched under broad categories: intervention, context and outcomes to 30 June 2019.Ethics and disseminationAs only secondary data will be analysed; ethical approval is not required. The review will be disseminated to relevant organisations and presented in peer-reviewed papers and at conferences. This will be the first attempt to summarise the current available evidence on the characteristics, contextual influences and mechanisms that are associated with the outcomes and effectiveness of PWGs.PROSPERO registration numberCRD42019126533.
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.
ObjectivesTo (1) apply the Framework to Assess the Impact from Translational health research (FAIT) to Lessons from the Best to Better the Rest (LFTB), (2) report on impacts from LFTB and (3) assess the feasibility and outcomes from a retrospective application of FAIT.SettingThree Indigenous primary healthcare (PHC) centres in the Northern Territory, Australia; project coordinating centre distributed between Townsville, Darwin and Cairns and the broader LFTB learning community across Australia.ParticipantsLFTB research team and one representative from each PHC centre.Primary and secondary outcome measuresImpact reported as (1) quantitative metrics within domains of benefit using a modified Payback Framework, (2) a cost-consequence analysis given a return on investment was not appropriate and (3) a narrative incorporating qualitative evidence of impact. Data were gathered through in-depth stakeholder interviews and a review of project documentation, outputs and relevant websites.ResultsLFTB contributed to knowledge advancement in Indigenous PHC service delivery; enhanced existing capacity of health centre staff, researchers and health service users; enhanced supportive networks for quality improvement; and used a strengths-based approach highly valued by health centres. LFTB also leveraged between $A1.4 and $A1.6 million for the subsequent Leveraging Effective Ambulatory Practice (LEAP) Project to apply LFTB learnings to resource development and creation of a learning community to empower striving PHC centres.ConclusionRetrospective application of FAIT to LFTB, although not ideal, was feasible. Prospective application would have allowed Indigenous community perspectives to be included. Greater appreciation of the full benefit of LFTB including a measure of return on investment will be possible when LEAP is complete. Future assessments of impact need to account for the limitations of fully capturing impact when intermediate/final impacts have not yet been realised and captured.
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