Throughout this book we have advocated the use of systems thinking in CQI: analysing how parts of a healthcare system work together to support PHC, and how parts of a system can be changed to produce better outcomes.1 Systems thinking helps in understanding how care systems interact to influence quality of care for clients. Systems thinking also encourages teams to consider the wider contexts in which PHC services operate: the resources available and the historical, social, economic and environmental circumstances that influence people’s health and wellbeing across the life course.2 Examples are the positive health effects of a secure food supply and employment opportunities, or the negative effects of discrimination on health and wellbeing. While these types of determinants of health may not be within the sphere of control of a PHC service or practice, they will be of concern, and the intersectoral action required to improve outcomes can be influenced and facilitated by PHC services.3 

Healthcare equity has been advanced when system-strengthening efforts take account of various determinants of health (for example, social, economic, cultural, structural, political, environmental), and when these efforts are applied on a wide scale and at different levels of the system. In systems thinking, everyone’s actions count, and – while it requires societal and political commitment and collective effort to create change – the quality improvement efforts of PHC professionals and communities make important contributions. These contributions are strengthened when CQI efforts are sustained through policy and funding commitment at a higher system level. This chapter uses real-world examples to illustrate how multi-level and intersectoral systems approaches to CQI can be used to improve the quality of comprehensive PHC, as part of a broader systems approach to improving health and wellbeing.

A systems framework for CQI in PHC services

In Chapter 3, we introduced a systems framework that illustrates the potential for PHC services to support and extend CQI efforts in two dimensions: vertically across the health system and horizontally across sectors (Figure 3.1). The framework demonstrates these features:

• vertical integration, referring to the use of CQI across all levels of health systems from community engagement and client care (base of diagram) to jurisdiction/provincial and national levels (top of diagram)
• horizontal integration, referring to the incorporation of CQI into evidence-based clinical care (left of diagram) and linkages and advocacy for influencing the social and cultural determinants of health (right of diagram)
• within PHC services, the conditions that support an integrated systems approach to improvement are trained and supported staff, engaged and active service users, strong management systems and a culture of CQI, resourcing and cost-effectiveness.4

While the contexts in which PHC operates vary widely, the health of populations is always influenced by a range of determinants, which are in turn influenced by many factors including collective action. And while quality improvement strategies and tools differ, CQI is inherently participatory and requires partnering with other agencies and groups (or teams) to monitor and mobilise action on social, cultural, economic, political and environmental determinants.

The framework in action

In the following examples, people working in different sectors or at different levels of the health system came together in a systems approach to quality improvement. The supportive conditions identified in the framework can be identified to varying degrees within these examples.

The CQI tools described in Box 20.1 were developed to support a systems approach to improving social and environmental determinants of health in rural and remote Australian communities. They were created and piloted through multi-phase and iterative processes that involved a series of consultations with community members and relevant stakeholders. The tools can be used in conjunction with clinical audit tools to promote a holistic, systems-thinking approach to CQI.

A similar approach was used to develop the Good Food Systems Tool described in Chapter 5, which supports community-driven decision-making to tackle inequities in food supply and food access for remote Indigenous communities.10

A multi-level, system-wide approach to improvement

CQI is particularly effective in improving the standard of care when applied system-wide.14 When Ferlie and Shortell examined quality strategies in the United States and the United Kingdom more than two decades ago, they found that efforts relying on narrow, single-level program changes were largely unsuccessful. The health systems researchers argued that system changes are needed concurrently at four levels to achieve and sustain quality improvement:

• individual level (for example, education, leadership development at all levels, guideline use)
• group or team level (for example, clinical audits, team development, guideline use)
• organisation level (for example, CQI, organisational learning, organisational culture)
• larger system or policy environment in which an organisation operates (for example, national improvement policies, accrediting agencies, legal systems, funding policies).15

It is now widely accepted that “for CQI to add value, have impact and realise its potential, it [needs] to be managed at multiple levels”.16 In Australia, for example, efforts to tackle entrenched health inequality for Aboriginal and Torres Strait Islander peoples have featured multi-level investment in CQI. While there are different CQI program approaches across jurisdictions, and different levels of maturity in the use of CQI across services, national level policy and funding agreements require that PHC services use CQI processes to monitor improvement efforts and enhance the quality of service delivery.17 This high-level policy and funding approach helps to sustain CQI processes at the PHC service and practice level. A comparative case study published in 2017 found that consistent and sustained policy and multi-level infrastructure support for CQI in the Northern Territory (as outlined in the following example) enabled wide-scale and ongoing improvement in quality of care, compared with jurisdictions where CQI efforts were generally smaller in scale and more fragmented.18 The authors concluded that it was not sufficient for improvement initiatives to rely on local service managers and clinicians, as their efforts are strongly mediated by higher system-level influences.

Using CQI data for wide-scale improvement

Despite developments in CQI theory and practice, there is little evidence about how to engage stakeholders in wide-scale CQI processes to inform system strengthening. Yet bringing together CQI data from multiple PHC centres has scope to engage stakeholders in identifying common priorities for improving care, and interventions that target change at different health-system levels. To this end, our CQI research network conducted an interactive data dissemination process targeting people in diverse PHC roles at different levels of the health system. The CQI data had been collected over 10 years and represented more than 60,000 de-identified clinical audits of client records and 492 systems assessments from 175 PHC centres across five Australian jurisdictions.23

• Aggregated CQI data reports were distributed by email through the existing ABCD National Research Partnership network (described in Chapter 9) and a snowballing recruitment technique was used to invite wider participation.
• Stakeholders were invited to use aggregated CQI data reports to identify the evidence-to-practice gaps, barriers and enablers most critical to improving health outcomes in key areas of clinical care, and to suggesst improvement strategies.
• Feedback was obtained through online surveys. A phased reporting and feedback process was used, culminating in a final report and other outputs (for example, journal articles, summaries) (see Figure 20.1).
• The process was used to generate findings for child health, maternal health, preventive care, chronic illness, mental health, and acute rheumatic fever and rheumatic heart disease care. (Key findings are reported in Part III.24)

People who responded to the project surveys included Aboriginal and Torres Strait Islander health practitioners, nurses, doctors and other health practitioners, CQI facilitators, policymakers, PHC managers, governing board members and researchers.25

The commonly identified evidence-to-practice gaps across all the data could be grouped into five categories:

• follow-up of abnormal findings
• assessment and counselling for lifestyle risk factors
• emotional wellbeing screening and support
• treatment adherence (for example, taking medications) and self-management
• physical checks and investigations.

Synthesising the findings to identify messages for greater impact

When the priority evidence-to-practice gaps in each area of PHC (for example, child health, chronic illness care) were mapped according to these five categories, three improvement needs were common to all areas:

• follow-up of abnormal findings
• risk factor inquiry and provision of brief interventions
• social and emotional wellbeing support.

This finding suggested that improving these care processes would improve the quality of care for clients with a range of health conditions and care needs. Survey data about system barriers to improving the three gaps were analysed; these data reflected participants’ contextual and professional knowledge and their experience working in Aboriginal and Torres Strait Islander PHC. Pareto analysis was used to identify the “vital few” system barriers to improvement in each of the categories. (For an explanation of Pareto analysis, see Chapter 5). The findings are summarised in Figure 20.2.

As illustrated in Figure 20.2, the “vital few” barriers to improvement were identified as clinical information systems, workforce, staff skills and training, financial resources and community engagement. The findings suggested that focusing improvement efforts on these aspects of PHC would increase the effect for improving people’s health.

The analysis also reinforced the importance of multi-level action across the health system to improve PHC performance, and the need to bring communities, policymakers and practitioners together to plan system improvement. As project participants reflected:

Summary

This chapter has provided examples of a systems approach to CQI in PHC. The varied examples illustrate the benefit of people in complementary roles and at different system levels being involved in quality improvement. High-level policy support and action for CQI help to build sustainability of CQI processes at the health service and community level. Concurrent action at different system levels and across sectors has more potential to create synergy for change than efforts that are narrow in focus, due in large part to the interconnectedness of the systems that affect health. Strengthening systems in one area of health can reduce pressure on other systems; bridging a common evidence-to-practice gap can improve the quality of clinical care for clients with a range of health conditions.

A systems approach to CQI is situated within a broader systems approach to health services and health services research. It is important to acknowledge that not all system improvements are amenable to a classic CQI approach. Health systems research is a diverse and innovative field of research, and a range of mechanisms are required to improve health systems and other systems that affect health, such as legislation, justice, education, food production and social welfare. CQI is one key element in the coordinated and sustained action required to achieve improvement in population health outcomes and health equity.

References