‘At the grass roots level it’s about sitting down and talking’: exploring quality improvement through case studies with high-improving Aboriginal and Torres Strait Islander primary healthcare services

Abstract

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.

Let’s CHAT (community health approaches to) dementia in Aboriginal and Torres Strait Islander communities: protocol for a stepped wedge cluster randomised controlled trial

“…Previous research has demonstrated the efficacy of participatory research design frameworks in Aboriginal and Torres Strait Islander health contexts. Such research projects have proven successful because they embrace two-way learning and are adapted to the cultural and historical community setting, increasing chances of uptake [28]. This project will involve the ACCHS research partners and their staff in decision-making processes pertaining to the design and implementation of the study, as well as appointing a project Aboriginal and Torres Strait Islander Reference Group whose members will be Aboriginal and Torres Strait Islander researchers, professionals in the health sector and community members with a background/interest in advocating for Elders, ageing well and cognitive health issues.…”

“…In the context of Indigenous research, a community participatory approach is essential to ensure the community, service providers and stakeholders are involved at all stages enabling successful translation into sustainable outcomes [28]. The CQI "plan, study, do, act" cycle will be utilised in combination with the i-PARIHS framework with the purpose of being a practical and familiar way to engage staff in practice change [29,30].…”

Using developmental evaluation to support knowledge translation: reflections from a large-scale quality improvement project in Indigenous primary healthcare

“…Stakeholders reported learning new skills in data analysis and being stimulated by the improvement ideas of others [55, 63]. CQI research in Indigenous PHC indicates that support for pooled knowledge assists engagement in improvement initiatives [21, 64, 65]. It is also recognised that co-production can have subtle impact on research capacity-building and knowledge sharing, as well as demonstrable benefits such as policy and practice [66].…”

What was the impact of a participatory research project in Australian Indigenous primary healthcare services? Applying a comprehensive framework for assessing translational health research to Lessons for the Best

“…The team also used a participatory method of research that involved researchers working with health centre staff and the Indigenous community to co-create new knowledge on a range of factors that appeared to be associated with CQI success. 13 LFTB aimed to use these learnings to empower Indigenous communities and striving PHC centres to improve their systems and service delivery performance and share those lessons widely, including with policy makers.…”