Sustaining quality improvement in indigenous primary health care : a sociological analysis

Abstract

Sustaining the delivery of effective chronic disease care is a major imperative for health systems worldwide. As the prevalence of chronic conditions continues to rise, health systems struggle to provide high quality care that meets the standards set out in practice guidelines. Reorientation of primary health care systems to support the delivery of prevention and management over long timeframes is required. Continuous quality improvement programs are increasingly being used to make and monitor progress towards meeting these objectives. They use participatory action methods to stimulate changes to clinical practice and to the systems that support it. Although research has demonstrated that these programs can be effective, little is known about how they are implemented and sustained, the mechanisms that underpin their impacts, or the influence of implementation processes and context on outcomes. There is a need for research approaches that are better informed by theory to help identify mechanisms and explain change processes or lack of them in different settings. This thesis uses a case study design to investigate factors associated with the sustainability of a large scale CQI program in Indigenous primary health care services in Australia. Drawing on sociological approaches, the study develops and applies a complexity perspective to conceptualise sustainability as the dynamic outcome of interactions between elements of programs and the broader health system and stakeholder environments. It brings together concepts from complex adaptive systems and actor network theory to conduct an in-depth examination of the processes through which participants were engaged in CQI, their use of the audit tools and processes and development of strategies to enact and sustain change. The study demonstrates that despite initial enthusiasm and a complex but broadly conducive environment for developing CQI, using the tools and processes was intensive and time consuming and changing practices to support improvement priorities required services to adapt and realign clinical and administrative processes within and between service systems. Processes of change were reflexive, operating in loops and feedbacks that produced results which were not always intended or predictable. Changes in one part of the system inevitably led to impacts in another. Partial engagement among the stakeholders, workforce shortage and turnover, inter{u00AD}professional relations, poorly aligned patient information systems, bureaucracy and competing priorities in the service environment impeded efforts. Services that were better able to address the impediments they faced had: organisational buy-in; supportive clinical and managerial leadership; someone at the health centre level to coordinate and drive CQI; resources to support team involvement and facilitation; internal communication and feedback; and decision making processes that allowed managers to enact change at the service level. The thesis makes recommendations for changes in practice at the local and regional levels, and in policy at the national level, that will be required to support the widespread adoption and sustained practice of CQI. These practical conclusions are founded in an enhanced theoretical repertoire developed by this thesis that furthers an understanding of implementation processes, and of the relationship between context and programme, in order to improve the sustainability of CQI programmes.