Continuous Quality Improvement - Advancing Understanding of Design, Application, Impact and Evaluation of CQI Approaches

Editorial

23 November 2017

Editorial: Continuous Quality Improvement (CQI)—Advancing Understanding of Design, Application, Impact, and Evaluation of CQI Approaches

Ross Bailie

Jodie Bailie

Sarah Larkins

and

Edward Broughton

16,567 views

14 citations

Editors

Ross Bailie

The University of Sydney

Sarah Larkins

James Cook University

Edward I Broughton

Bristol Myers Squibb (United States)

Impact

Inclusion criteria of Aboriginal and Torres Strait Islander client records to examine cardiovascular risk assessment (CVRA) as primary prevention strategy. *A preventive care audit excludes clients with a record of diabetes, hypertension, coronary heart disease, rheumatic heart disease, and chronic kidney disease.

Original Research

04 September 2017

Integrated Clinical Decision Support Systems Promote Absolute Cardiovascular Risk Assessment: An Important Primary Prevention Measure in Aboriginal and Torres Strait Islander Primary Health Care

Veronica Matthews

, 7 more and

Ross Bailie

5,365 views

14 citations

Original Research

24 March 2017

Exploring Systems That Support Good Clinical Care in Indigenous Primary Health-care Services: A Retrospective Analysis of Longitudinal Systems Assessment Tool Data from High-Improving Services

Cindy Woods

, 5 more and

Ross Bailie

4,854 views

17 citations

Theory of change for how socially accountable health professional education (SAHPE) institutions collaborating under THEnet contribute to health equity (28).

Perspective

27 February 2017

Improving Community Health Using an Outcome-Oriented CQI Approach to Community-Engaged Health Professions Education

Amy Clithero

, 3 more and

Andre-Jacques Neusy

4,208 views

9 citations

Perspective

22 February 2017

Enabling Continuous Quality Improvement in Practice: The Role and Contribution of Facilitation

Gillian Harvey

and

Elizabeth Lynch

Facilitating the implementation of continuous quality improvement (CQI) is a complex undertaking. Numerous contextual factors at a local, organizational, and health system level can influence the trajectory and ultimate success of an improvement program. Some of these contextual factors are amenable to modification, others less so. As part of planning and implementing healthcare improvement, it is important to assess and build an understanding of contextual factors that might present barriers to or enablers of implementation. On the basis of this initial diagnosis, it should then be possible to design and implement the improvement intervention in a way that is responsive to contextual barriers and enablers, often described as “tailoring” the implementation approach. Having individuals in the active role of facilitators is proposed as an effective way of delivering a context-sensitive, tailored approach to implementing CQI. This paper presents an overview of the facilitator role in implementing CQI. Drawing on empirical evidence from the use of facilitator roles in healthcare, the type of skills and knowledge required will be considered, along with the type of facilitation strategies that can be employed in the implementation process. Evidence from both case studies and systematic reviews of facilitation will be reviewed and key lessons for developing and studying the role in the future identified.

Example facilitation strategies [adapted from Ref. (35)].

11,308 views

57 citations

Original Research

04 May 2016

System-Level Action Required for Wide-Scale Improvement in Quality of Primary Health Care: Synthesis of Feedback from an Interactive Process to Promote Dissemination and Use of Aggregated Quality of Care Data

Jodie Bailie

, 2 more and

Ross Bailie

Introduction: There is an enduring gap between recommended practice and care that is actually delivered; and there is wide variation between primary health care (PHC) centers in delivery of care. Where aspects of care are not being done well across a range of PHC centers, this is likely due to inadequacies in the broader system. This paper aims to describe stakeholders’ perceptions of the barriers and enablers to addressing gaps in Australian Aboriginal and Torres Strait Islander chronic illness care and child health, and to identify key drivers for improvement.

Methods: This paper draws on data collected as part of a large-scale continuous quality improvement project in Australian Indigenous PHC settings. We undertook a qualitative assessment of stakeholder feedback on the main barriers and enablers to addressing gaps in care for Aboriginal and Torres Strait Islander children and in chronic illness care. Themes on barriers and enablers were further analyzed to develop a “driver diagram,” an improvement tool used to locate barriers and enablers within causal pathways (as primary and secondary drivers), enabling them to be targeted by tailored interventions.

Results: We identified 5 primary drivers and 11 secondary drivers of high-quality care, and associated strategies that have potential for wide-scale implementation to address barriers and enablers for improving care. Perceived barriers to addressing gaps in care included both health system and staff attributes. Primary drivers were: staff capability to deliver high-quality care; availability and use of clinical information systems and decision support tools; embedding of quality improvement processes and data-driven decision-making; appropriate and effective recruitment and retention of staff; and community capacity, engagement and mobilization for health. Suggested strategies included mechanisms for increasing clinical supervision and support, staff retention, reorientation of service delivery, use of information systems and community health literacy.

Conclusion: The findings identify areas of focus for development of barrier-driven, tailored interventions to improve health outcomes. They reinforce the importance of system-level action to improve health center performance and health outcomes, and of developing strategies to address system-wide challenges that can be adapted to local contexts.

6,722 views

29 citations

Variation in percentage delivery of eye and vision assessments to Aboriginal and Torres Strait Islander patients across participating primary health centers. Polygons represent the proportion of primary healthcare services delivering services at that percentage rate; box limits indicate the 25th and 75th percentiles; and whiskers extend 1.5 times the interquartile range from the 25th to 75th percentiles.

Original Research

19 December 2016

Delivery of Eye and Vision Services in Aboriginal and Torres Strait Islander Primary Healthcare Centers

Anthea M. Burnett

, 4 more and

Ross Bailie

4,184 views

7 citations

Phases of the ESP project. Note: this process is repeated for each area of care (e.g., child health, chronic illness care). Source: Matthews et al. (26). PHC, primary health care; CQI, continuous quality improvement; ESP, “Engaging Stakeholders in Identifying Priority Evidence-Practice Gaps, Barriers and Strategies for Improvement (ESP)” Project.

Perspective

03 May 2016

Interactive Dissemination: Engaging Stakeholders in the Use of Aggregated Quality Improvement Data for System-Wide Change in Australian Indigenous Primary Health Care

Alison Laycock

, 2 more and

Ross Bailie

Background: Integrating theory when developing complex quality improvement interventions can help to explain clinical and organizational behavior, inform strategy selection, and understand effects. This paper describes a theory-informed interactive dissemination strategy. Using aggregated quality improvement data, the strategy seeks to engage stakeholders in wide-scale data interpretation and knowledge sharing focused on achieving wide-scale improvement in primary health-care quality.

Methods: An iterative process involving diverse stakeholders in Australian Aboriginal and Torres Strait Islander health-care delivery uses aggregated audit data collected across key areas of care. Phases of reporting and online feedback are used to identify: (1) priority areas for improvement; (2) health center, system, and staff attributes that may be important in addressing the identified priority evidence-practice gaps; and (3) strategies that could be introduced or strengthened to enable improvement. A developmental evaluation is being used to refine engagement processes and reports as the project progresses.

Discussion: This innovative dissemination approach is being used to encourage wide-scale interpretation and use of service performance data by policy-makers, managers, and other stakeholders, and to document knowledge about how to address barriers to achieving change. Through the developmental evaluation, the project provides opportunities to learn about stakeholders’ needs in relation to the way data and findings are described and distributed, and elements of the dissemination strategy and report design that impact on the useability and uptake of findings.

Conclusion: The project can contribute to knowledge about how to facilitate interactive wide-scale dissemination and about using data to co-produce knowledge to improve health-care quality.

8,830 views

22 citations

Original Research

30 March 2016

Improving Health Promotion Using Quality Improvement Techniques in Australian Indigenous Primary Health Care

Nikki Percival

, 3 more and

Ross Stewart Bailie

Although some areas of clinical health care are becoming adept at implementing continuous quality improvement (CQI) projects, there has been limited experimentation of CQI in health promotion. In this study, we examined the impact of a CQI intervention on health promotion in four Australian Indigenous primary health care centers. Our study objectives were to (a) describe the scope and quality of health promotion activities, (b) describe the status of health center system support for health promotion activities, and (c) introduce a CQI intervention and examine the impact on health promotion activities and health centers systems over 2 years. Baseline assessments showed suboptimal health center systems support for health promotion and significant evidence-practice gaps. After two annual CQI cycles, there were improvements in staff understanding of health promotion and systems for planning and documenting health promotion activities had been introduced. Actions to improve best practice health promotion, such as community engagement and intersectoral partnerships, were inhibited by the way health center systems were organized, predominately to support clinical and curative services. These findings suggest that CQI can improve the delivery of evidence-based health promotion by engaging front line health practitioners in decision-making processes about the design/redesign of health center systems to support the delivery of best practice health promotion. However, further and sustained improvements in health promotion will require broader engagement of management, senior staff, and members of the local community to address organizational and policy level barriers.

The health promotion continuous quality improvement model [adapted from Bailie et al. (10)].

10,197 views

54 citations

Percentage delivery of preventive service items by jurisdiction.

Original Research

10 March 2016

Determinants and Gaps in Preventive Care Delivery for Indigenous Australians: A Cross-sectional Analysis

Christopher Bailie

, 8 more and

Ross Stewart Bailie

Background: Potentially preventable chronic diseases are the greatest contributor to the health gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians. Preventive care is important for earlier detection and control of chronic disease, and a number of recent policy initiatives have aimed to enhance delivery of preventive care. We examined documented delivery of recommended preventive services for Indigenous peoples across Australia and investigated the influence of health center and client level factors on adherence to best practice guidelines.

Methods: Clinical audit data from 2012 to 2014 for 3,623 well adult clients (aged 15–54) of 101 health centers from four Australian states and territories were analyzed to determine adherence to delivery of 26 recommended preventive services classified into five different modes of care on the basis of the way in which they are delivered (e.g., basic measurement; laboratory tests and imaging; assessment and brief interventions, eye, ear, and oral checks; follow-up of abnormal findings). Summary statistics were used to describe the delivery of each service item across jurisdictions. Multilevel regression models were used to quantify the variation in service delivery attributable to health center and client level factors and to identify factors associated with higher quality care.

Results: Delivery of recommended preventive care varied widely between service items, with good delivery of most basic measurements but poor follow-up of abnormal findings. Health center characteristics were associated with most variation. Higher quality care was associated with Northern Territory location, urban services, and smaller service population size. Client factors associated with higher quality care included age between 25 and 34 years, female sex, and more regular attendance.

Conclusion: Wide variation in documented preventive care delivery, poor follow-up of abnormal findings, and system factors that influence quality of care should be addressed through continuous quality improvement approaches that engage stakeholders at multiple levels (including, for example, access to care in the community, appropriate decision support for practitioners, and financial incentives and context appropriate guidelines).

9,441 views

23 citations