Abstract. Introduction

Review Article

Reorienting primary health care for addressing chronic

conditions in remote Australia and the South Pacific: Review

of evidence and lessons from an innovative quality

improvement process

Karen Gardner,

_{Ross Bailie,}

_{Damin Si,}

_{Lynette O’Donoghue,}

_{Cath Kennedy,}

Helen Liddle,

_{Rhonda Cox,}

_{Ru Kwedza,}

_{Marea Fittock,}

_{Jenny Hains,}

Michelle Dowden,

_{Christine Connors,}

_{Hugh Burke}

_{and Carol Beaver}

1_{Australian Primary Health Care Research Institute, Australian National University, Acton, ACT,} 2_{Menzies School of Health Research,} 3_{University of Queensland, Brisbane, Queensland,}4_{Maari Ma,}

Broken Hill, New South Wales,5_{Curtin University of Technology, Perth, Western Australia, and}

6_{Queensland Government Department of Health, Cairns, Australia,} 7_{Ngalkanbuy Health Service, Elcho}

Island, Northern Territory,8_{Northern Territory Department of Health & Families,}9_{Charles Darwin}

University, Darwin

Abstract

This paper reviews what is known about the challenges of implementing quality improvement programs and draws on data from a systematic continuous quality improvement (CQI) project in remote communities in Australia and Fiji, known as Audit and Best practice for Chronic Disease, to synthesise lessons and discuss the potential for broader application in low and middle income countries, including Pacific Island countries and territories. Although a number of systematic reviews have indicated that quality improvement programs can be effective in changing professional practice and improving the quality of care and patient outcomes, little is known about the key ingredients for change or how services use and implement different strategies to achieve improvements. We identify key features of an innovative CQI model and factors related to implemen-tation that support improvement in diabetes service delivery and intermediate outcomes. Requirements for supporting CQI are identified and the potential for wider application discussed. It is argued that the par-ticipatory action research approach supports innovation and broad-based change and the evidence it has pro-duced extends the current knowledge base and

facilitates the translation of knowledge into action, for both policy and practice.

KEY WORDS: chronic disease, continuous quality improvement,plan-do-study-act,primary health care.

Introduction

As the tide of chronic conditions continues to rise worldwide, many health systems in both developed and developing countries fall short of providing effective chronic disease care.1 _{Research consistently}

demon-strates a gap between what is seen to be best practice and actual care,2_{and a well-recognised need to enhance}

knowledge transfer.3 _{The World Health Organization}

(WHO) Regional Committee of the Western Pacific Region recognises that much remains to be carried out to reorient health systems to a stronger primary health care model4_{and in response to this, has recommended}

the development of Innovative models for Chronic Illness Care. In remote disadvantaged communities in Australia and in Fiji, experimentation with a continuous quality improvement (CQI) approach, known as Audit and Best Practice for Chronic Disease (ABCD), has dem-onstrated that positive changes can be made to service systems, care delivery and intermediate client outcomes and is proving to be an effective means of strengthening and reorienting primary health care to an evidence-based chronic care model.

Our aim in this paper is to review what is known about the challenges of implementing quality improve-ment programs to improve diabetes care and drawing Correspondence:Karen Gardner, Australian Primary Health

Care Research Institute, Australian National University, Cnr Mills & Eggleston Roads, Acton, ACT 0200, Australia. Email: [email protected]

Competing interests: None.

on our experiences of using a systematic CQI approach, synthesise lessons and discuss potential for broader application in low and middle income countries, includ-ing Pacific Island countries and territories (PICTs).

The scale and nature of the problem

of chronic conditions in our region

In Australia, the prevalence of diabetes for Aboriginal and Torres Strait Islander people is two to four times that for non-Indigenous people and the death rate for those aged 35–45 years is up to 35 times higher.5_These

figures reflect deficiencies in prevention and manage-ment of diabetes at various levels of the health system. Similarly, in PICTs non-communicable diseases (NCDs) are a major cause of death, accounting for approxi-mately 75% of deaths annually.6_NCD-related

compli-cations such as end-stage renal disease, diabetes-related sepsis and associated amputations are major problems, reflecting limited access to best practice chronic disease care in the community. While systems to monitor per-formance of primary care in prevention and manage-ment of chronic disease are not well established in Australia, in under-resourced PICTs such systems are virtually non-existent.

The service sector for Indigenous health in Australia is complex, involving community controlled, state and ter-ritory funded primary health care services and private general practice. Most services participating in ABCD operate under a regional service delivery model and are funded through a series of commonwealth and state government arrangements. Health care is free at the point of delivery and is provided in a multidisciplinary environment staffed by nurses and Aboriginal health workers with medical general practice services either resident or available on a rostered or fly-in basis. In remote areas high turnover and shortage of staff, prob-lems of geographic isolation, a high burden of disease and illness in the community, and overwhelming demands for acute care contribute to the complexity of improving systems and service delivery.

Similarly, in PICTs services are primarily funded and managed by government and are either free at point of delivery or incur a small co-payment.

Current state of knowledge about

quality improvement as a method

for improving care

Quality improvement is a promising, although poorly tested, method for monitoring performance and stimu-lating improvements in the prevention and management of chronic disease in primary health care. These pro-grams aim to facilitate improvements in patient care by

using objective information to analyse systems and service delivery against explicit criteria. By using differ-ent strategies to implemdiffer-ent changes at an individual, team or service level and monitoring these to assess improvements, organisations seek to shift underlying patterns of behaviour and adapt delivery systems to support best practice.

Systematic reviews have demonstrated that quality programs can be effective in changing professional prac-tice,7_{improving the quality of care}8–10_{and patient}

out-comes11_{for some conditions and in some circumstances.}

However, evidence is limited and often of poor quality12–14_{and little is known about the key ingredients}

for change or how services use and implement different strategies to achieve improvements.14_{Many health}

ser-vices use a combination of strategies which include activities as diverse as audit and feedback, evidence-based guidelines, provider education, academic detail-ing, disease management, financial incentives and team work.15 _{While no interventions consistently produce}

large improvements, those producing modest improve-ments tend to be active and multifaceted.15 _Studies

have suggested that impacts are greater when baseline performance is low and feedback is delivered more intensively.15–17

In diabetes care, most quality improvement strategies can produce small to modest improvements in glycemic control and of a range of strategies that have been examined in a recent systematic review, team changes and case management showed more robust improve-ments, especially for interventions in which case man-agers could adjust medications without awaiting physician approval.18_{Providing healthcare professionals}

with data about their performance in the form of audit and feedback might also help improve practice,18,19_but

in the trials included in a recent review, the effects varied widely, from an apparent negative to a very large posi-tive effect. When effecposi-tive, the effects were mainly small to moderate. The extent to which evidence from diabe-tes studies can be used to inform practical decisions about how to use audit and feedback to improve care is limited and a recent systematic review concluded that variation in outcome between studies might reflect dif-ferent methods of providing feedback or other factors, such as which behaviours are targeted or which profes-sional group provides feedback.9

Greater attention to understanding why particular interventions work, and to the factors that enhance or interfere with their success in different settings is there-fore needed. While high quality evidence on how to conduct quality improvement is lacking, evidence is accruing that organisational environments in which structured quality improvement processes are made a priority at the board level,20_{and where audit data from}

aggregated level,21_{appear to be delivering the conditions}

required to support ongoing efforts. Teamwork and a culture of strong clinical leadership also appear to be important. Most recently, community-based participa-tory research approaches are being touted as promising for supporting quality and translational research.22,23

These involve the engagement of patients, individual clinicians and staff, as well as the operational and administrative leaders of health systems in the research planning, implementation and evaluation process, and increase the likelihood that research questions will be relevant, interventions sustainable and research findings translated into systematic action.

Key features of an innovative

continuous quality

improvement model

The ABCD approach to CQI utilises an action research design to test the feasibility, acceptability, effectiveness and sustainability of CQI in the Australian Indigenous primary health care setting. The approach draws on key principles relating to values and ethics in Indigenous health24 _{and action learning principles.}25 _{The project}

began in 2002 in 12 remote Aboriginal and Torres Strait Islander community health centres and has since spread through an extension phase from 2005 to 2009, to 63 health centres in four Australian states and territories. An additional 60 services are using the project QI tools and processes, including three centres in Fiji, without being formally enrolled in the research project. Key features of the ABCD model include: assessing clinical performance across the scope of best practice for chronic disease care; conducting a structured assessment of health centre systems to support best practice; facili-tating a dialogue with health centre staff for interpreting results, determining priorities, setting goals and plan-ning action. This enables health services to systemati-cally review and improve the care they provide by focusing on the way they organise and deliver services to better meet the needs of their population. The approach is implemented through an annual plan-do-study-act cycle (Fig. 1) and engagement of the range of health centre staff (managers, clinicians, admin and other staff) in the CQI cycle is a critical component of the change process. At the broader project level, the engagement of policy and program managers, researchers, clinicians and service providers into a broader CQI network is enabling the sharing of resources and expertise to support the practical application and research effort and for feeding back information to the project participants. A range of process, impact and intermediate outcome data are collected routinely by the project participants and entered into a web-based data system which pro-vides real-time analysis of health centre performance

and allows them to compare it with other de-identified services in the region. These data are also used for research purposes to examine the effectiveness and level of engagement with the quality improvement process over time. The data include qualitative data collected through structured reports on health centre progress through the steps in the cycle, and clinical audit and systems development data which are used to assess changes in the quality of health centre systems and clinical indicators. More information on the study methods is available from the study protocol.26

Overview of progress in

achieving outcomes

Audit and Best practice for Chronic Disease research has shown that during the first phase of the project from 2002 to 2005 participants had achieved improvements in health centre systems (as measured by a structured Systems Assessment Tool);27,28_{improvement in delivery}

of care in accordance with best practice (e.g. HbA1c testing at least once every 6 months improved from 41% to 74%, and overall delivery of guideline sched-uled diabetes services improved from 31% to 54%);29

and improvement in intermediate health outcome indi-cators (for example % of clients with HbA1c <7% increased from 19% to 28%).30

Interim results from the extension phase suggest that of the health centres which went on to complete at least two CQI cycles, about 60% had achieved more than 10% improvement in overall delivery of diabetes guide-line scheduled services and in the proportion of clients with HbA1c controlled at <7%. Similarly, 64% had FIGURE 1: Audit and Best Practice for Chronic Disease annual plan do study act cycle.

achieved improvement of 10% or more in overall deliv-ery of guideline scheduled services for general preventive care for adults (including standard screening and moni-toring for cervical cancer and blood pressure). Twelve of the 14 health centres which had completed the systems assessment at baseline and at the end of two subsequent CQI cycles had clear evidence of improvement in the health centre systems required to support best practice care. A number of participating services reported that they use the approach to support a system-based change management process for reorienting primary health care from an episodic acute care model to a chronic care model.

Supporting uptake

As with other research, the ABCD experience has dem-onstrated that CQI is a complex intervention and the organisational tasks associated with adopting, imple-menting and sustaining it have much in common with other change management processes.31,32_{We have found}

that implementation is complex and messy, resource intensive and time-consuming. Organisations which developed a clear internal vision and purpose for which the ABCD quality tools and processes would be used and which adopted a strong regional approach to sup-porting services in data analysis and response to prob-lems that lie beyond the capacity of individual services to solve, appeared to be more successful in implemen-tation.33_{Services have limited capacity to address issues}

of staff turnover, poorly aligned data capture systems, lack of appropriate services for referral and other fea-tures of the external environment which impede QI efforts. Unanticipated events in the local or broader policy environment can obstruct or enhance capacity for achieving improvements. Progress is therefore iterative, rather than linear or steady and might happen in fits and starts over time. Services that were part of a strong network for CQI were more greatly insulated from bar-riers that might otherwise have obstructed efforts.

Supporting learning

We also found that the facilitation of the ABCD audit tools and processes was essential for assisting staff and teams to develop new skills and ways of evaluating their practice. The structured dialogue that is built in to the tools and processes at each step in the plan-do-study-act cycle offers a ‘no-blame’ experience-based learning approach that appears to be critical for stimulating change. When this occurred, staff reported that partici-pation in the data collection, feedback and interpreta-tion processes provided an important reference point for best practice and for building understanding of the importance of health centre systems for optimal service

delivery. Success in translating this experience into improvements in the quality of care appeared to be dependent on the extent to which organisations were able to support these changes through the adaptation of service routines and by developing structures and link-ages to improve communication and draw on resources needed to support change.33

Promoting and sustaining change

Some services were able to support planned changes through incorporating new practices into services’ rou-tines or by adapting pre-existing rourou-tines and structures. Where there was supportive clinical leadership, a stable team, and someone at the local level to assume respon-sibility for negotiating the agreed changes, services dem-onstrated they could achieve improvements. Efforts were made to update patient registers, recall and reminder systems and to improve data capture and the quality of data entry. At the team level, clinical reviews, attention to handover and team discussions to improve follow-up such as by providing education or greater support for clients with poor clinical profiles were strat-egies developed and implemented through weekly team meetings. Some regions introduced new models of care to enhance follow-up of medical care. Teams that per-ceived they had limited autonomy to make decisions that could change the way they provided care seemed less likely to maintain motivation.

Discussion

The ABCD experience has shown that efforts to imple-ment CQI benefit from an increimple-mental approach and organisation-wide commitment to stimulate learning, adapt systems and motivate action to support improved practice. While services with committed teams and local leadership can make good progress at a health centre level, they have limited capacity to address the variety of challenges in their environment which can impede improvement. Good leadership and management at all levels, efficient administrative and information systems, as well as strong internal and external linkages appear to be important requirements for successful take up, implementation and sustainability of CQI processes in primary health care services.

Strong regional management played an important role in legitimating activity, providing resources and advocating for improved systems at all levels. Where regional bodies took an advocacy role and strengthened networks to address problems in the local environment that impeded efforts for change, motivation could be better maintained at the service level. However, creating teams and supporting changes to practice across organi-sational or cultural boundaries is difficult and adapting

systems does not happen quickly. In this respect, the participatory action research approach appears to have played an important part in the development of a network that can support a broader process of change over the longer term. Its role in supporting regional coordination, developing expertise and providing review and feedback of project data to the network seems to have played a key role in facilitating and advo-cating change across the system. Not only has it enabled services to mobilise resources and expertise required to support implementation, it has also provided a means for pooling data which allows services to review their performance in relation to others. At the broader level

the network has helped to drive the alignment of various performance measures and processes.

Table 1 outlines our findings in relation to system wide requirements for supporting CQI.

Relevance to Pacific Island countries

and other settings

The lessons learned from implementing the ABCD approach in Aboriginal and Torres Strait Islander com-munities are not just relevant to Australian primary health care settings but also to near neighbours in the Pacific. Participants at the WHO/NCD workshop in TABLE 1: Requirements for supporting continuous quality improvement (CQI)

Enabling policy environment for CQI

• Ensure institutional commitment to a systematic rather than ad hoc approach

• Support the development of practice-based quality networks that can develop and share expertise and resources for implementing CQI

• Support the development of information systems and data development to support CQI capacity • Ensure staff development and training commitment relevant to CQI

• Align performance reporting and CQI activity through the development of commonalities between datasets Preparing for CQI

• Define objectives for taking part and assess capacity to benefit from CQI

• Identify clinical, Indigenous, management and policy champions to influence opinion and encourage engagement of different groups

• Define roles and responsibilities regarding CQI and make clear what is expected

• Ensure a quality coordinator is available to provide training to staff and support health centres to implement the steps in the CQI cycle

• Allocate resources to provide backfill support for health centre staff to participate in audits, systems assessment, feedback and action planning workshops

• Establish a quality committee with senior clinical and management staff who can support implementation, review performance results at a service and regional level and respond to challenges

• Define objectives for using clinical performance and systems data in quality reporting structures at local, regional, state and national levels

• Adopt an incremental approach to implementation and build on small successes over time Supporting learning

• Encourage all staff to participate in at least one clinical audit and the annual facilitated group systems assessment, feedback and action planning processes

• Emphasise a no-blame, systems-oriented and experience-based learning approach to dialogue to achieve mutual learning rather than teaching

• Ensure teams have achievable targets

• Appoint someone at the health centre to negotiate implementation of action plans during the course of the year • Support health centre managers to use CQI processes to underpin business planning

Sustaining changes

• Adapt service routines to incorporate follow-up activities into clinical and administrative team meetings

• Ensure duty statements contain quality improvement roles and responsibilities and embed requirements for reporting on CQI into performance processes

• Motivate and empower teams to continue to address challenges, particularly in teams where staff turnover is high • Work to ensure the alignment of data for service reporting at all levels

• Work towards the development of IT capacity to support automated information system functions to specifically support CQI

August 2009 identified that key activities in relation to strengthening and reorienting national health systems to promote NCD surveillance and research to enhance the evidence for policy and measure the effectiveness of NCD population interventions34_{are essential}

contribu-tions in a process to bring about change. The ABCD program has demonstrated success in a variety of Aus-tralian settings in this regard and lessons from this expe-rience might be useful for PICTs to assist them to meet this objective.

While the percentage of health expenditure attributed to NCDs in PICTs is high, the current resources avail-able at national and regional levels are neither in pro-portion to the incidence of NCDs nor adequate to address the challenge.6_{This means that what resources}

are available need to be used in the most effective and efficient manner to improve the quality of health inter-ventions (no waste) at the primary health care level. The PICTs are well placed to provide the kind of integrated innovative care proposed by WHO as services are primarily funded and managed by government and are either free at point of delivery or incur a small co-payment. While implementing a sector-wide CQI program has resource implications, preliminary analysis indicates that the return on investment over time will far outstrip the required financial input. The ABCD expe-rience suggests that a participatory action research approach to CQI can provide a sound methodological framework for supporting innovation and broad-based change, and that the evidence it has produced extends the current knowledge base and has facilitated the trans-lation of knowledge into action, for both policy and practice.

Acknowledgements

The authors would like to acknowledge the many par-ticipating services and members of the ABCD team. The project would not be possible without the active support, enthusiasm and commitment of staff and man-agement of the participating health services and the contribution made by the wider ABCD project team. The ABCD project was supported by funding from the Cooperative Research Centre for Aboriginal Health and the Australian Government’s Commission for Safety and Quality in Health Care. The work of a number of people with key roles in the project is supported by their employing organisations, including State and Territory governments and community controlled health organi-sations. K.G.’s work is supported by an Australian Post-graduate Award. D.S.’s work is supported by a National Health and Medical Research Council (NHMRC) Capacity Building in Population Health Grant and NHMRC Postdoctoral Fellowship. RB’s work is sup-ported by an NHMRC Research Fellowship.

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