Sarah Larkins, Annette Panzera, Michelle Redman MacLaren, + co authors

Transcription

1 Lessons from the best to better the rest: quality improvement in Indigenous primary health care National Rural Health Alliance Conference, Darwin, May 2015 Sarah Larkins, Annette Panzera, Michelle Redman MacLaren, + co authors sarah.larkins@jcu.edu.au

2 Co-authors Sandy Thompson Jacinta Elston Christine Connors Komla Tsey Ross Bailie Chris Henaway Ru Kwedza Kerry Copley Veronica Matthews Jacki Ward Tania Patrao Annette Panzera Cindy Woods Michelle Redman Maclaren Moana Tane Maxwell Mitropoulos All the generous participants from study sites.

3 Background Continuous quality improvement (CQI) processes appear successful in improving quality of care 175 PHC services in the ABCD National Research Partnership Variation in health centre performance observed (Bailie et al 2011, Si et al, 2010) Need to understand variation before scale-up of benefits from CQI can be achieved

4 Aims 1. Identify those services that have had a consistent improvement over 3 consecutive audits in performance in more than one audit tool (HIMPS) 2. Understand, through comprehensive case studies, the interaction of various contextual factors at different levels and how they interact in facilitating the success of QI

5 AIM1 Identified health services that completed two or more full annual audit cycles (3 audits) Type II diabetes, preventive health, maternal and child health audits Overall health centre quality of care score based on percentage of recommended care delivered Examine trends of change in quality of care score

6 AIM1 For example for Type 2 Diabetes :15 Clinical Indicators Physical examinations: weight, waist circumference, body mass index (BMI), blood pressure, visual acuity Laboratory investigations: microalbuminaemia, glomerular filtration rate, blood lipids, Haemoglobin A1C (HbA1c) Vaccinations: flu, pneumococcal Counselling for risk factors: nutrition, physical activity, tobacco use, alcohol use Similar for maternal, child, and preventive audits

7 Trends of Performance Type 2 Diabetes Performance Score Graphs by Primary Health Care Centre Audit Cycle

8 CONSISTENT HIGH IMPROVER Type 2 Diabetes score Baseline 1 2 Audit Cycle We calculated the gap between the first audit performance score and 100%. A PHC centre was classified as a high improver if it showed consistent ascending performance scores from first to last audit and bridged a certain percentage of the gap depending on the number of audit cycles it had completed.

9 Health Centre Performance Flow Diagram Assessed for eligibility (n=165) Excluded (n=92) Not completed any audit cycles (n=22) Not completed 2 audit cycles (n=70) Completed 2 audit cycles in at least 1 audit tool (n=73) Type 2 diabetes Completed 2 audit cycles (n=61) Preventive Health Completed 2 audit cycles (n=65) Maternal Health Completed 2 audit cycles (n=42) Child Health Completed 2 audit cycles (n=47) Consistent high improvement (n=11) Consistent high improvement (n=10) Trends of performance Consistent high improvement (n=11) Consistent high improvement (n=5) Sustained high performance (n=15) Sustained high performance (n=15) Sustained high performance (n=4) Sustained high performance (n=7) Decline (n=3) Decline (n=6) Decline (n=1) Decline (n=5) Marked Change (n=5) Marked Change (n=4) Marked Change (n=0) Marked Change (n=9) Consistent low performance (n=13) No specific inc or dec (n=14) Consistent low performance (n=10) (n=13) Consistent low performance (n=1) No specific inc or No specific inc or dec (n=20) Consistent improvement in more than dec 1 audit (n=25) tool (n=7) Consistent low performance (n=6) No specific inc or dec (n=16)

10 *45-65% Number State Governance Rurality Population Date started/ cycles HIMP in 1 Qld Govt Remote <= /3 DM, mat 2 Qld Govt Remote <= /3 DM, Prev, child 3 WA Govt Remote >= /5 Mat, almost DM* 4 NT Govt Remote /3 DM, prev 5 NT Comm cont Regional >= /5 Prev and child 6 NT Comm cont Remote /5 Prev and child

11

12 STAGE ONE Results No significant association between being a consistent high improver in an audit tool and: Governance (government, community controlled) Location (rural, remote, urban) Population size (<500, , >1000) Systems Assessment Tool completed Negative association with accreditation status for whole period *Consistent with findings from previous research (Schierhout et al, 2013)

13 A AIM 2 Methodology Cross jurisdictional multiple case studies approach (Yin, 2009) A case is defined as a rural, remote or urban Aboriginal PHC service, including its staff, local governance structure, patients, service provision (including outreach services) and formal partnerships

14 Stage two methods 6 HIMPS chosen from NT, QLD and WA Document review: strategic plans, service numbers, staff retention/turnover; staff participation in the CQI process Semi-structured interviews with health service staff (10), managers (10), Board members and CEOs Focus groups with male/female clients Goal setting and action plans reviewed along with existing audit data and systems assessment tool data Non-participant observation

15 Evaluation of contextual factors Microsystem level (eg. staff stability and experience, local IT systems) Mesosystem level (service governance factors, remoteness/accessibility) Macrosystem level (jurisdictional policy and funding) Considering with annual audit data and Systems Assessment tool scores

16 Data management and analysis Interviews recorded and transcribed in full NVIVO used to manage data Within case analysis using iterative thematic analysis (constant comparison) Cross case analysis not yet complete

17 Site 1 Govt (NT; n=7) Site 2 ACCHS (NT; n=12) Site 3 ACCHS (NT; n=16) Site 4 Govt (Qld; n=5) Site 5 Govt (Qld; n=3) Staff Managers Users of service Number Aboriginal or TSI 2 Nurses 1 AHP 2 Doctors 1 Data staff 4 Nurses 4 AHPs 3 Data staff 2 Doctors 3 Nurses 1 AHP 2 Data staff 1 Doctor 3 Nurses 1 Doc 1 data staff/visiting CQI 2 (1 Manager/RN) Nurses 1 0 0

18 Themes emerging Importance of regular discussion about CQI Working in partnership important Ability to use results to impact change Competing demands System challenges Workforce stability important but not everything

19 Importance of regular discussion about CQI We go through a report sort of after the audits are done and sort of you know, brainstorm as to why it s not in there. How can we improve it to make it you know, become part of everyone s routine when they re screening clients. Male Aboriginal Health Practitioner, ACCHS, NT

20 Working in partnership team support We have two computers. One person sits on the other one going through the notes and one enters the data. We do as much as we can. Try to do like seven to ten each so- And then we get the reports at the end of- oh probably the week after and then it s all filtered to an all clinical meeting as to what we re lacking in. Male RN, ACCHS, NT

21 Ability to use results to impact change They re good actually because they show us you know... what we haven t been concentrating on. Kinda makes us push a bit harder to get all that done. So it s good looking at the graphs. Female Aboriginal Health Practitioner, ACCHS, NT on the local level, yeah. Anything that we can control will be done. But things that require bigger system stuff, forget it. Female RN, Govt Health service, QLD

22 Competing demands Yeah like today. I m the only practitioner at work, so- in my area. So I ve had to run a clinic, work with a doctor and screen clients, take telephone calls and then come here for a meeting while I could be over there screening clients. Male Aboriginal Health Practitioner, ACCHS, NT

23 System challenges what was happening is that there wasn t a strong feedback loop. So the auditors would come in and they d be in the clinic for days, um...and then they d go. And that was as much as we got out of it. At some date later, you know, we d be told, oh, you ve got to make sure you measure people s waists. Female RN, Govt Health Service

24 Workforce stability important but not everything Sometimes when you get an injection of new staff- we ve got a new staff member here and it was like, oh do you think we could do that? Yeah. Can t see why we can t do that. So it s like- throws new ideas at you. Male RN, ACCHS

25 Conclusions Response to CQI is multifactorial and difficult to predict Understanding factors that are important in supporting CQI may help funders, peak bodies and support agencies work with services to improve quality of care

26 This work is supported by NHMRC Project grant ( ) Thank You Health centre staff, managers and patients CQI coordinators One21seventy and ABCD National Research Partnership CRE Integrated Quality Improvement in Indigenous PHC

27 References Bailie R, Si D, Connors C, et al. Variation in quality of preventive care for well adults in Indigenous community health centres in Australia. BMC Health Services Research. 2011;11(1):139. Gardner K, Bailie R, Si D, et al. 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. Australian Journal of Rural Health. 2011;19(3): Larkins S, Woods C, Matthews V, et al. Responses of Aboriginal and Torres Strait Islander primary health care services to Continuous Quality Improvement (CQI) initiatives: identification of patterns of performance and characteristics of services with positive and negative response to CQI over time. BMJ Quality and Safety Under review. Rumbold A, Bailie R, Si D, et al. Assessing the quality of maternal health care in Indigenous primary care services. Medical Journal of Australia. 2010;192(10). Schierhout G, Hains J, Si D, Kennedy C, Cox R, Kwedza R, O Donoghue L, Fittock M, Brands J, Lonergan K, et al: Evaluating the effectiveness of a multifaceted, multilevel continuous quality improvement program in primary health care: developing a realist theory of change. Implement Sci 2013, 8(1):119. Si D, Bailie R, Dowden M, et al. Assessing quality of diabetes care and its variation in Aboriginal community health centres in Australia. Diabetes/Metabolism Research and Reviews. 2010;26(6): Yin, R. K. (2009). Case Study Research: Design and Methods. Thousand Oaks, California, Sage Publications Inc.