Applying lessons learnt from CQI implementation

Part III has shared findings and messages from implementing CQI in key areas of clinical PHC over more than a decade, using an innovative approach developed and refined through rigorous research and a commitment to long-term research-policy-service partnerships in PHC. The approach was implemented at scale and involved 175 PHC services and centres in five Australian jurisdictions.

There is limited literature reporting the effectiveness of CQI for improving PHC. Available studies tend to focus on single CQI interventions. What sets the work presented here apart from other CQI programs was the opportunity to study what happened when comparable CQI tools and processes were implemented across varied PHC settings over time. The ABCD CQI research program provided evidence that the sustained use of CQI can improve the delivery of evidence-based PHC. It showed that participatory CQI approaches can be adapted for identifying and acting on improvement priorities across settings. The program also demonstrated the benefits of sustained policy, training and system support for CQI (summarised in Chapter 9, Table 9.1). Further, a participatory approach with diverse PHC stakeholders was used to review and synthesise the findings and identify lessons from this extensive CQI program in comprehensive PHC.1

Consistent themes

Some consistent themes emerged from the experiences of implementing CQI across key areas of clinical PHC, particularly the importance of these actions:

• adhering to evidence-based best-practice clinical guidelines
• increasing follow-up of abnormal clinical results in all areas of care
• inquiring about behavioural risks to each client’s health, and providing brief interventions as required
• ascertaining social and emotional risk factors and, when risks are identified, providing brief intervention and support (for example, around living environment, family relationships)
• improving documentation of care provided
• establishing better referral systems (within services and externally) and service options
• overcoming barriers to the delivery of high-quality care that occur in these areas:
  • clinical information systems (for example, improving the ability to generate data for client follow-up and recall)
  • the PHC workforce (for example, strategies to reduce high staff turnover)
  • staff skills and training (for example, recruiting teams with the right mix of roles and skills, providing professional development, supervision and support)
  • community engagement (for example, in service delivery design, CQI).

Implementing improvement

Important lessons have been learnt about implementing CQI in PHC. Improvement efforts need to focus on strengthening systems at different levels of the health system.

At the PHC centre service or practice level, these are the essential actions:

• accurately recording care delivery in client records – a pre-requisite for high-quality data about clinical performance
• ensuring PHC teams, managers and community members participate in CQI – they are more likely to see its benefits and to take ownership of the processes; CQI needs to be everybody’s business
• making improvement strategies context-specific – that is, responsive to social, cultural economic and environmental context
• allocating time and resourcing staff at all levels and in all roles in PHC services and practices to participate in CQI training and activities
• keeping on going with CQI in PHC. Teams that implemented consecutive CQI cycles observed measurable improvements in the data: the quality of care improved.

The integrated nature of PHC can extend the benefits of improvement interventions, because system changes targeting one group of clients frequently flow on to benefit other groups. Changes targeting one aspect of care can contribute to holistic, client-centred care overall. Some individual and team experiences of implementing CQI are shared in Part II.

At the district and regional level, these are the essential actions:

• using CQI tools and processes to enable PHC services and practices to identify and act on local priorities for improvement, in addition to meeting reporting requirements
• using CQI to strengthen systems for tackling the social, cultural, structural and environmental determinants of health
• working with communities to incorporate client perspectives on care into the measures of quality used in CQI
• allocating funding for CQI roles or functions and for staff working at different levels to participate in CQI training and activities
• investing in data literacy and data analysis skills at all levels of the health system to build understanding and capacity in generating and using data to inform improvement
• investing in resources to improve data quality and to monitor trends in best-practice care, the effect of CQI and whole-of-systems responses to quality issues.

The CQI approach described in Chapters 9–19 reflects internationally accepted principles for the effective implementation of CQI and responds to PHC improvement challenges that prevail across countries and populations, such as the provision of high-quality maternal and child health care and the prevention and management of chronic diseases. The findings and messages from this innovative CQI work in Aboriginal and Torres Strait islander PHC may have ongoing relevance for improving the quality of PHC in other settings.

References