Informing implementation of quality improvement in Australian primary care

The Australian primary health care system was initially designed to deliver acute care services but has been modified over twenty five years to better address preventive health and chronic disease management. This evolution started in 1992 with the release of “National Health Strategy: the Future of General Practice” [1]. The strategy promoted development of general practice standards, accreditation and integration with health services outside general practice. In 2010 the first national Primary Healthcare strategy was launched identifying a focus on integration, information technology, access, quality, and safety as some of the key building blocks and priority areas [2].

Despite this evolution from reactive to more proactive health care, large gaps are evident in the quality of care received. CareTrack, an Australian study conducted during 2009–2010, reported only 57% of patients with chronic conditions in primary care encounters received appropriate care [3]. Barriers that prevent the adoption of best practice often appear to overwhelm clinicians and managers working in primary health care [4].

Quality Improvement (QI) initiatives in primary care have the potential to improve uptake of evidence based practices, but have been difficult to implement and sustain [5]. QI is a multi-dimensional concept which, in the healthcare context, can be defined as having a systematic approach to making changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning) [6]. Bataldan et al. postulate that by defining QI in this way, it allows people to have a measureable approach to the concept of improving healthcare. There are a number of ways to intentionally implement QI initiatives, and one such approach is the establishment of Quality Improvement Collaboratives (QIC). QICs actively bring together groups of practitioners from different organisations to meet and learn about a specific aspect of health service quality and to share experiences about making changes in their local settings. The process specifically supports practitioners to use QI tools such as Plan, Do, Study, Act (PDSA) cycles to achieve improvements.

There has been mixed evidence of success using QICs in health care. A systematic review of 64 QIC programs in 2018 reported significant improvements in 83% of targeted clinical processes and patient outcomes [7]. The authors noted that enthusiasm for these findings must be tempered by reflection on the limitations in design and reporting in many QIC’s, as well as likely publication bias. Evidence suggests that implementation processes for each QIC may be critical drivers of program success with up to 66 contextual factors identified in a 2014 study as associated with improved outcomes [8].

In Australia the Improvement Foundation (IF) has administered a series of QICs called the Australian Primary Care Collaboratives (APCC) since 2004 ([9]). The program was designed in collaboration with the United Kingdom National Primary Care Development Team [10]. The IF was initially commissioned by the Australian Federal government to assist primary care practices in five priority areas; coronary heart disease, diabetes, chronic obstructive pulmonary disease, chronic disease prevention and self-management, and health care access and care redesign. APCC offered General Practices and Aboriginal health services financial incentives to participate in a QIC wave over 18 months. A wave (Fig. 1) comprised an orientation session to the principles of QI, followed by a series of learning workshops (delivered either face-to-face or online). The goal was for each primary care practice to complete requirements of one “wave” during which time Practice staff would each develop a knowledge of QI, understand the principles of measuring for improvement, the use of data in QI, the application of QI tools as well as identify ways to build a team culture and develop effective communication skills to facilitate QI. Clinical and administration staff were expected to attend workshops and submit monthly data to monitor their progress. One thousand one hundred and eighty five primary care health services (16% of all Australian General Practices) and 83% of PHCO’s enrolled in the APCC program between 2004 and 2012 [11]. Practice characteristics varied enormously from solo clinician to large multi-disciplinary group practices including Aboriginal Community health centres.

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Participants in the APCC program included GPs, practice nurses and practice managers.

These staff were encouraged and supported to introduce small, manageable changes in specific areas during the activity periods between workshops. By 2014 over 1800 practices across Australia had participated in at least one program wave (approximately 20% of registered primary care practices in the country) [9]. A before-after evaluation of seven APCC waves involving 743 practices and 150,000 patients over the period 2004–2009 showed improvements in four of the five program areas, with the exception of health care access [5].

For over eight years IF provided QI support to practices directly, however in 2012 the funding contract changed and required them to provide support to government-funded, meso-tier primary health care organisations (PHCO) (previously called Medicare Locals and now called Primary Health Networks (PHN)) who would in turn provide direct support to practices. A review of the program by Knight et al. in 2014 suggested that further institutionalising the QIC from within a PHCO had potential to improve program utilisation, sustainability and spread [4]. The new PHN contracts in 2016 provide an opportunity to capitalise on this potential with the specific inclusion of quality improvement activity to assist in increasing and improving the efficiency and effectiveness of medical services for patients [12]. From 2019 PHN’s will be required to support general practices undertake QI programs and to offer assistance in oversight and management of practice data. General Practices will be offered an incentive payment to share their data with an external organisation such as a PHN.

In this paper we report on a qualitative study that sought to identify enablers and barriers to implementation of sustainable QI programs in the primary care setting.

Fifteen people were invited via email and all agreed to participate in the study.

The identified QI implementation enablers and barriers were grouped into five thematic areas: Leadership, organisational culture, funding, data and clinical systems. These thematic areas are described below.

The APCC program has provided a rich context for identification and analysis of enablers and barriers for QI in the Australian setting. Participants of the program provided useful insights into possible future implementation strategies.

Health systems internationally are investing in primary care meso-tier organisation to reduce fragmentation and improve system performance. Whilst there is substantial variation in the specific roles they play in the system, ranging from commissioning (Clinical Commissioning Groups in England [15]), financial accountability and provision of financial incentives (Accountable Care Organisations in United States of America [16]), direct service provision (Primary Health Organisations in New Zealand [17]), engagement in quality improvement activities is a common element and therefore the themes found in this study are likely to be relevant in an international context.

Primary Health care is a complex environment that benefits from structured systems of care to assist the adoption of best practice. The privatised model of Australian general practice acts as financial and philosophical barrier to widespread adoption of QI programs. Primary Health Networks (PHN) have an opportunity to assist in countering these barriers and implement solutions that are tailored to local health care needs.

Studies regarding the role of meso-level organisations in primary health care in UK, Canada and New Zealand suggest that such organisations can play an important role in facilitating a more integrated health system and promoting peer collaboration with resultant improvements in efficiency and quality of care [18, 19, 20, 21]. The impact of PHCO’s such as PHNs could be optimised by emphasising relationship building between the external facilitators and general practices. Trusted relationships have been demonstrated to play a key role in assisting adoption of evidence based improvements in the healthcare environment [22, 23]. Ideally these trusted relationships will be established at both the individual and organisational level.

The process of GP clinical decision making that assists the adoption of evidence based guidelines is complex. Gabbay and le May coined the term “mindlines” to describe the GP process of internalising tacit guidelines, informed by professional reading and social interactions (opinion leaders, patients, colleagues), resulting in a socially constructed response to guidelines rather than a rigid protocol [26]. Peer networks can assist GPs in the active formulation of these “mindlines”. A PHCO-facilitated network could provide an evidence-based, social and professional platform for these interactions and establish trust between both the PHCO and individual practice teams and GPs. An example would be a group of GPs meeting to network about QI topics, once a month at a time and venue of their choice, facilitated by the PHCO.

PHCOs may also assist GPs in the philosophical adoption of system change within their workplace. For instance, the change in emphasis to systematised team based care has not been widely adopted in the Australian general practice setting and this is likely to be related to a perceived loss of individual GP clinician’s autonomy such as described by Hall in 2009 regarding professional cultures as barriers to interprofessional teamwork [27]. PHCOs can share stories of change from other local general practices that illustrate the benefits of team based care such as improved time management and decreased stress via the peer networks.

To engage individual practitioners long term, it is important to recognise the role of both practice structures and financial incentives. Under the current Australian payment model, lack of direct financial incentives for quality improvement is a significant barrier for many GPs and practice managers. This can affect practice teams’ ability to quarantine sufficient time and resources to implement QI programs. PHCOs are well-positioned to assist practice teams through provision of staff and IT tools. Long term engagement in QI programs will also require modification to the fee-for-service funding models. The Australian government is currently trialling a new model of payment for patients with chronic and complex disease where practices will receive a bundled payment to manage patients whom agree to be enrolled in a “healthcare home” [28] .This is a substantive health reform that has potential to shift primary care remuneration to a more outcomes focussed payment model, and there may be important opportunities for PHCOs to engage clinicians and practice teams in making this transition.

We note the following study limitations. Firstly the interviewees did not include those from general practices with no contact with APCC. While this sampling aligned with the study goals of eliciting lessons from participants’ experience of the APCC, their views may reflect a potential bias toward philosophical alignment with QI. Further study among non APCC participants may identify additional barriers to QI implementation. We also note that the first author was known to all the interviewees due to her involvement in APCC from 2008 until 2012 as a participant and clinical lead. While this allowed potential for some degree of social desirability bias, it was apparent from the interviews that the study participants felt comfortable to report and discuss both positive and negative experiences of the APCC program.

PHCOs such as the Australian PHNs are well poised to facilitate transformation of primary care through a range of mechanisms identified in this study. However, the challenges to achieving this in the current policy environment are important to recognise and should not be minimised. In developing QI programs and policies, such organisations ought to invest their efforts in: (1) identifying and mentoring local leaders; (2) fostering QI culture via development of local peer networks; (3) developing and advocating for alternative funding models to support and incentivise these activities; (4) investing in data and audit tool infrastructure; and (5) facilitation of systems implementation within primary care practices. If these opportunities are maximised the PHCOs will be well positioned to make a major contribution to improved delivery of health outcomes in the primary care arena.