Part IV Summary

Continuous quality improvement (CQI) is generally viewed as an opportunity to reflect on the success of an activity and how it could be improved. As documented here and elsewhere, there have been significant successes in implementing CQI in primary health care (PHC). These successes include measurable improvements in population health outcomes, the adaptation of CQI methodologies to diverse primary healthcare settings, the development of new CQI tools and processes, and recognition of CQI as a core skill for the PHC workforce. New knowledge has emerged for improving the quality of clinical PHC and for tackling the social, cultural and environmental determinants of health through CQI.

When considering the CQI question “How can we do better?”, we might first look to core primary healthcare concepts: the place-based context-specific nature of PHC, the right of all individuals, families and communities to health and social justice, the recognition of health as a multi-sectoral social and economic construct, and the empowerment of communities with respect to health services.1 We can implement CQI in ways that uphold these core concepts: focusing on equity, engaging clients, carers and local communities in CQI processes, and working with agencies in other sectors to improve outcomes.

It is almost half a century since the 1978 Declaration of Alma-Ata identified community-driven, affordable, accessible, safe PHC as key to attaining health for all.2 Despite remarkable progress in global health, technologies and health care, quality PHC is not universally available, and millions of people die from conditions that should be treatable by health systems.3 The 2018 Global Conference on PHC4 reinforced the critical ongoing role of PHC in adapting health systems to respond to our rapidly changing world, addressing the causes and risks for poor health, handling emerging health challenges, and achieving the health-related Sustainable Development Goals.5 Evidence now confirms climate change as the single biggest health threat facing humanity, and the people whose health is most at risk from the climate crisis are those who contribute least to its causes, and who are least resourced to protect against it: people in low-income and vulnerable communities, displaced people, Indigenous communities, people in places where economies and health infrastructure are weak, and people with underlying health conditions.6 Health challenges will increase as exposure to threats such as extreme temperatures and weather events, poor air and water quality, food insecurity and disease increase. CQI and quality improvement research have an increasingly important role in strengthening primary healthcare systems and community capacity to adapt to and mitigate these challenges.

There are several significant emerging challenges and opportunities:

• A continuing emphasis on holistic approaches, systems thinking and collaboration for CQI. These competencies will be increasingly important for taking the multi-level, cross-sector approaches needed to meet increasingly complex quality improvement challenges.
• Building skills and relationships to harness the context-specific and diverse knowledges required to achieve high-quality systems, including the lived experiences of primary healthcare clients and Indigenous knowledges about living equitably and sustainably. Definitions of quality need to reflect client and community perspectives, and quality improvement knowledge and practices need to be shared in ways that respect people’s rights, sovereignty and dignity.
• Keeping a focus on measuring, reporting and acting on performance against evidence-based best-practice clinical guidelines and best-practice processes.
• Considering the climate crisis when we tackle quality challenges in PHC (for example, through research, by advocating for resources and approaches that protect health, by designing improvement strategies that reduce the environmental footprint of primary healthcare delivery, by modelling sustainable practices).
• Improving the quality of health literacy, health promotion and prevention programs, as a measure to reduce health costs and suffering.
• Prioritising CQI activities and research to reflect the changing needs of service populations. CQI tools and processes will need to respond to emerging health risks and priorities, to meaningfully engage clients and communities, and incorporate the complex social, cultural political and environmental determinants that affect health.
• Effective knowledge translation: putting improvements into practice and sustaining high-quality care; sharing learning in ways that are appropriate to different settings and audiences; and leveraging success to change systems and policies.

This book has aimed to provide an accessible guide to implementing CQI in primary healthcare settings. It has drawn on practical experience and established leadership in this field, the collective learning of many people involved in CQI, and published evidence and resources. It has included stories and findings specific to CQI in Aboriginal and Torres Strait Islander health that are grounded in core PHC, CQI principles and widely accepted CQI approaches. The book shares important learning for implementing quality improvement in primary healthcare settings, but there is much more to learn if we are to truly achieve more equitable people-centred health care.

References