Indigenous health: effective and sustainable health services through continuous quality improvement

A recent editorial in the Bulletin of the World Health Organization called for international agencies and ministries of health to work together to implement integrated quality improvement processes in clinical practice, with the aim of scaling up delivery of health interventions to meet the Millennium Development Goals.1 The current Australian Government program, Healthy for Life,2 provides a mechanism for doing this in primary care services for Aboriginal and Torres Strait Islander peoples. With funding of $102.4 million over 4 years, the program aims

In addition to other experience and resources, the Healthy for Life program has drawn on the tools, processes and principles developed through an action–research project in the Northern Territory — the ABCD project. “ABCD” originally stood for Audit for Best practice in Chronic Disease. It has come to represent a structured collaborative approach to improving health services, with potential application in a variety of primary care contexts. The ABCD research project is a collaborative initiative of the Cooperative Research Centre for Aboriginal Health, initially funded by the Australian Health Ministers’ Advisory Council, which brought together federal, state and territory government health agencies; Indigenous community-controlled health organisations; and research agencies. The project commenced in 12 Indigenous community health centres in the Top End of the Northern Territory in 2003. Its commencement was independent of, but more or less in parallel with, various other initiatives contributing to the development of the Healthy for Life program.

Here, we discuss some of the key strengths of the approach we have developed, and the evidence and values base for continuous quality improvement (CQI) in this context.

In general, CQI aims to facilitate ongoing improvement by using objective data to analyse and improve processes.3,4 Emphasis is placed on efficient and effective functioning of organisational systems.5,6 CQI involves an ongoing cycle of gathering data on how well organisational systems are functioning, and developing and implementing improvements. An essential starting point is systematic and objective assessment of performance and of the systems supporting good performance.7 Good quality information is needed, so that goals can be set and strategies developed for improving key areas. An emphasis on participation by the people being studied, and flexibility in the approach, makes modern CQI very similar to action research, both being characterised by “cyclical activities involving examination of existing processes, change, monitoring the apparent effects of the change and further change”.8

Features of the ABCD CQI approach (Box 1) include:

• Assessing clinical performance across the scope of best-practice services for chronic illness care rather than selected (“indicator”) services. This is done by auditing records of service delivery and clinical and laboratory findings in a sample of patient records. For example, the diabetes audit covers over 20 services specified in widely accepted best-practice guidelines, and the preventive services audit covers about 10 services specified in guidelines for preventive care for a generally well adult (eg, the 2-yearly Adult Health Check for Aboriginal and Torres Strait Islander people).9,10

• Structured assessment of health centre systems to support best practice. This is based on the Assessment of Chronic Illness Care scale,10,11 which analyses the status of key aspects of primary care service systems (eg, design of work flow and staff roles and responsibilities; arrangements for working with other agencies and community members; information systems; systems to support clinical best practice (including the availability of guidelines and access to specialist advice).

• Emphasising participation in all aspects of the approach. The ABCD approach is guided by widely accepted principles of community-based research, which stress the importance of partnerships (Box 2).12

Trends over two ABCD CQI cycles to date have shown improvements in primary care systems (eg, business plans specifying roles, responsibilities and goals for diabetes care); in adherence to best-practice clinical guidelines (eg, an increased proportion of people with diabetes having regular testing of glycated haemoglobin [HbA1c] levels); and in intermediate health outcomes (eg, normalisation of HbA1c levels).13

Evidence of the effectiveness of modern CQI approaches in the manufacturing,14,15 service16 and health care17,18 industries abound. The most substantial experience of CQI is in the manufacturing and business sectors, and research in these areas highlights leadership, people management and customer focus as components of CQI interventions that strongly predict performance.19 People management appears to be particularly important in the service sector,17 including a commitment to increasing employees’ knowledge of, and empowerment to engage in, CQI processes.15,16 The intensity of interventions has been shown to explain a significant proportion of the variation in performance,16 with greater benefit likely if interventions are implemented as designed.17 Furthermore, international comparisons suggest a degree of culture specificity in what works where.15

In the clinical context, research suggests CQI approaches are most effective when they focus on organisational priorities; there is good engagement of high-level managers; the intervention is clearly formulated; the organisation is ready for change; there is a relationship of trust with practitioners; there is revision of professional roles; there are adequate information systems; and the external environment is supportive.19,20

The strength of the evidence of the effectiveness of CQI is limited by the quality of research study designs, the extent to which confounders are measured and controlled for in data analysis, and the heterogeneous nature and varying intensity of CQI interventions.20 However, the CQI concept has intuitive appeal. Proponents of CQI believe that while the language may change, the tools and vision of CQI will persist because they are adaptive.18 It is this positive view of the promise of CQI that is perhaps most supportive of the call for leading international and national health agencies to implement integrated CQI processes in clinical practice.1

Key features of modern CQI approaches make them well suited to the Indigenous Australian setting and to the principles of Indigenous research and service delivery. The participatory approach and the customer focus of CQI, and the combination of scientific and humanistic professional values,15,16,19 adhere to the principles and values of Aboriginal and Torres Strait Islander peoples, as expressed in recent national statements on research21,22 and cultural respect.23 In these same statements, the emphasis given to tackling underlying causes (eg, human resource capacity and social conditions, including unemployment), to capacity building (including, specifically, community capacity to understand and use data), and to improving outcomes is also central to CQI,18,19 as is the development of positive models and a culture of self-evaluation rather than blame.1 CQI also provides a structure to refine and re-invigorate programs to promote sustainability.13

Early evidence of the acceptability of CQI approaches and their impact on Indigenous primary care services is emerging from our recent and ongoing research.10,13 Comments by stakeholders reinforce our perceptions (Box 3).

Notwithstanding this, there remain significant challenges for the engagement of health services in CQI activities. These include ongoing heavy demands for acute care services (and service orientation towards acute care), a preoccupation of middle-level management with staffing and budgets ahead of service quality and outcomes, and limited human resources in primary care services. The Healthy for Life program should assist in overcoming some of these challenges. Ongoing CQI initiatives for health improvement in Aboriginal and Torres Strait Islander communities should be strengthened by applying participatory-action principles, providing strong clinical and managerial leadership for a CQI culture at all levels of health service organisation and management, and developing capacity to support community-level service organisations.

1 Outline of the ABCD approach