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Table 2 Barriers and enablers for published studies meeting eligibility criteria

From: Implementation of continuous quality improvement in Aboriginal and Torres Strait Islander primary health care in Australia: a scoping systematic review

  Authors Study approach Changes in Service Systems FPA_PHC Level 2
    Barriers and enablers to implementing CQI Barriers and enablers to implementing improvements in care (evidence - practice gap)
  ABCD Group
A national service support program of annual PDSA cycles involving:
• Manual clinical file audits (n=30 client records) for one or more of vascular and metabolic disease (diabetes, CHD, hypertension, renal disease); maternal health care; child health care, preventive services; mental health; rheumatic heart disease; health promotion;
• Systems Assessment Tool (SAT), generic or specific to the file audit(s), covering the following domains: delivery system design; information systems and decision support; self-management support; links with the community, other health services and other services and resources; organisational influence and integration;
• Web-based data entry and reporting system showing trends over time; comparison with audit data from other de-identified participating services;
• Information feedback to service staff and an action planning workshop.
Program training provided. Processes externally facilitated variably over time. Health service staff were responsible for implementing and documenting action plans.
(*Key activities described in the black literature in Bailie, Si, O’Donoghue et al. (2007) and Bailie, Si, Dowden et al. 2007; and in the study protocol for the extension phase (Bailie, Si, Connors et al. 2008).
13 Bailie, Si, Dowden et al. (2007)
Improving organisational systems for diabetes care in Australian
Indigenous communities
Study period 2002-2005; NT (Top End); purposive sample of 12/53 services in the Top End (mix of community controlled, government, health board); baseline plus 2 annual follow-up cycles. Diabetic clients (total =295) with annual follow up of the same clients. All services completed all cycles.
Comprehensive list reported of examples of improvement strategies implemented across the 12 services categorised according to SAT domains; strategies not linked to services/changes in SAT scores.
  At 2 years, statistically significant improvement in median scores for all 7 SAT domains. Reflections on barriers and enablers to improve care:
Barriers to improved care appeared to be related to inadequate attention to abnormal clinical findings and medication management.
Enablers: Improvement in intermediate outcomes may be achieved by addressing system barriers to therapy intensification through engagement of medical staff in CQI activities and/or
greater use of nurse-practitioners.
15 Si, Bailie, Dowden et al.. (2007)
Delivery of preventive health services to Indigenous adults: response to a systems-oriented primary care quality improvement intervention
Study period 2002-2005; NT (Top End); purposive sample of 12/53 services in the Top End (mix of community controlled, government, health board); baseline plus 2 annual follow-up cycles. Process as for Pub #1 but clinical audits were for random samples (n=30) of clients with no known diagnosis of chronic disease (total = 360) and follow-up audits were new samples. All services completed all cycles.
Some examples of improvements strategies across the 12 services were classified with respect to SAT domains but not linked to services/changes in SAT scores. At 2 years, “Marked improvements across each [SAT] system component over the study period”; statistical significance not reported.
Statistically significant improvements in counselling services were achieved over 2 audit cycles but no change in preventive care such as measurement of waist circumference, blood pressure etc.
  Barriers to improvements in preventive care appeared to be related to a limited focus on improving service systems most likely to influence change eg. “external linkages” (outreach and health promotion type initiatives) and “organisational influence” (use of management processes to demonstrate interest in preventive care and securing new resources)
Enablers for achieving improved counselling in diabetes care were a focus on systems likely to influence change eg. delivery system design (use of interpreters and revision of team roles); decision support (training by visiting specialists).
21 Gardner, Dowden, Togni (2010) Study period: First year of participation in ABCDE for 61 services (35 ACCHSs; 26 Govt) in NT, WA, NSW, QLD over the period 2006-2008. Data included routinely collected regional and service profile data; uptake of tools and progress through the first CQI cycle, interviews with key stakeholders (n=48). Organising framework for data analysis was the Greenhalgh diffusion of complex innovation framework which identifies attributes of the intervention and the change agency; process of diffusion; elements of user system and the outer system context. Enablers: supportive policy environment for CQI; compatibility of CQI tools with MBS incentives; individual motivation for improvement processes; leadership support endorses & provides authority to take up CQI; skills; organisational networks; high level committee oversight within organisations; coordinator position responsible for implementation; clinical staff involvement; information infrastructure; networking, training and facilitation of CQI provided by ABCD team; Indigenous, academic and clinical champions promote understanding of how CQI contributes to organisational, professional and community objectives;
Barriers: high staff turnover & shortage impeded implementation of CQI cycle; lack of leadership; lack of oversight for implementation; few organisational networks; sudden changes in staffing, leadership; community priorities
Not discussed
23 Schierhout, Brands, Bailie (2010) ABCDE Project Final report 2005-2009 investigates acceptability of the ABCD model in 12 Aboriginal Primary Health Services in the NT.
Report draws on the data derived from purposively structured dialogue with hub co-ordinators to explore perceptions of the degree to which key influences on engagement were operating within each health centre in each year of participation; and analysis of more than 48 supplementary in-depth interviews with practitioners, health centre managers and staff, policy makers, hub co-ordinators and researchers conducted as part of a PhD project aligned with the ABCD Extension project (Gardner et al. 2010).
No theory reported in this report but reported in Gardner 2010.
Enablers at: Service level include commitment by senior management; planned implementation that linked CQI to organisational aims and adaptation to local needs; improving record keeping of clinical data; allocating time and resources for staff to participate in CQI; investing in professional development in CQI.
Regional level: High level commitment from health authorities and organisation wide networks
Enablers: Larger and better resourced health services, those under a regional health authority and those with engaged clinical leaders were more likely to achieve improvements. Enablers include regional level management support; adequate levels and stable staffing; involvement of AHWs in clinical care and CQI; completion of CQI processes according to project protocols.
26 Gardner, Bailie, Si etal (2011) Review paper drawing on ABCD papers and other published evidence. Barriers: staff turnover, poorly aligned data capture systems, lack of appropriate services for referral
Enablers: 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 supporting services in data analysis and response to problems that lie beyond the capacity of individual services to solve
 
30 Ralph, Fittock, Schultz et al. (2013) Study period 2008-2010; NT (Top End and Central Australia); 6 services (sampling strategy not reported; jurisdiction not reported); baseline plus 2 annual follow-up cycles. Process as for Pub #1 but audits for all clients with RHD at each cycle (n=154, 145,156) (new samples).All services completed all cycles. Participatory action methods included facilitated discussion with primary care staff aided by Systems Assessment to identify system barriers to high quality care. Improvement strategies such as improved record-keeping, triage systems and strategies for patient follow-up encouraged but strategies for 6 participating centres not reported.   SAT domain organisational influence and integration improved over 3 years, and appeared to be related to performance in BPG prophylaxis. However tests of significance were “not calculated given the somewhat subjective nature of these scores ….”
Variation in contextual characteristics of 6 health centres included population size; geography; accessibility; staffing; record keeping; and governance arrangements; mobile populations; number of RHD deaths; ability to locate files. Wide variation in key performance measures including recording eg.% clients receiving routine injections and % people with documented risk classification.These not discussed specifically in relation to implementation
32 Schierhout, Haines etal (2013) Study period 2002-2012; data obtained from 36 health centers completing 3 or more annual cycles, quarterly project reports, and workshops with 12 key informants who had key roles in project implementation. Aim was to abstract context-mechanism-outcome configurations and from those develop strategies to strengthen the program.   Three mechanisms were identified: collective valuing of clinical data for improvement purposes; collective efficacy; and organizational change towards a population health orientation underpinned “successful CQI” as measured by improvements in the delivery of diabetes and preventive care. Strong central management of CQI and alignment of CQI with local priorities were favourable contexts for collective valuing of clinical data. Positive experiences of collaboration led to collective efficacy. Strong community linkages, staff ability to identify with patients, and staff having the skills and support to take broad ranging action, were favourable contexts for the mechanism of increased population health orientation
33 Bailie, Matthews, Bailie (2014) Study period for audit data 2007-2013; 10,000 clinical audits in 132 centres; NT, QLD, SA,WA, NSW. A 3 phase consensus process was used to identify priority evidence-practice gaps in child health care, based on these data. The purpose was to stimulate discussion and enhance ownership of the development of interventions to address system gaps. Key gaps identified included recording of immunisations; monitoring & recording key measures and abnormal findings; recording advice & brief interventions; recording enquiries on tobacco & alcohol use; systems to support links with communities & regional centres   Barriers and enablers to high quality care include Staffing/workforce support recruitment & retention; staff shortage; development of clinical information systems; community engagement and health literacy; training and development to support skills for provision of best practice care.
34 Matthews, Schierhout, McBroom et al. (2014) Study period 2005-20012; NT, Q, NSW, SA, WA; 132 services participating in One21Seventy/ABCD Program (73% government, remainder community controlled). Clinical audits over 7 years of random samples of clients with diabetes (n=10,674 client records); cycle completion rates: baseline only (32 services) 1-2 cycles (55 services), ≥3 cycles (45 services); audits conducted by services with training and support provided; SAT, feedback workshops and action planning and improvement strategies implemented not discussed.
Process indicators of quality of care for each patient were calculated by determining the proportion of recommended guideline scheduled services that were documented as delivered. Multilevel regression models used to quantify amount of variation in Type 2 diabetes service delivery attributable to health centre or patient level factors and to identify those factors associated with greater adherence to best practice guidelines.
  Health centre factors explained 37% of the differences in level of service delivery between jurisdictions with patient factors explaining only a further 1
Health centre factors that were independently associated with adherence to best practice guidelines included:
• longer participation in the CQI program,
• remoteness of health centres,
• regularity of client attendance.
Significantly associated patient level variables included
• greater age, and
• number of co-morbidities
• disease complications.
36 Bailie, Matthews, Nagel (2015) Study period for audit data 2009-2014; 975 clinical audits & 29 SATs in 21centres; NT, QLD, SA,WA,NSW. A 2 phase consensus process involving 13 stakeholders was used to identify priority evidence-practice gaps in mental health care, based on these data. The purpose was to stimulate discussion and enhance ownership of the development of interventions to address system gaps.   Key evidence practice gaps identified: consistent recording of client health summaries; enquiry & recording of risk factors & brief interventions; consistent recording of scheduled services; follow up of abnormal results; health centre systems, particularly links with the community to inform service and regional planning; organisational commitment for structures and processes that promote safe, high quality care, and team structure and function.
38 Bailie, Schultz, Matthews (2015) Priority evidence-practice gaps and stakeholder views on barriers and strategies for improvement preventive health care   
40 Gibson-Helm, Teede, Rumbold et al. (2015) Study period 2007-20012; NT, QLD, NSW, SA, WA; 76 services participating in One21Seventy/ABCD Program Research Partnership (65% government, remainder community controlled). Clinical audits of clients who had recent pregnancy in up to 4 cycles; audits conducted by trained internal or external personnel with regional support; Systems assessment tool (SAT) externally facilitated; feedback workshops and action planning noted but not discussed. Improvement strategies not linked to SAT.   In 21 services statistically significant associations found between 3/6 SAT scores and diabetes screening; 1/6 SAT scores and B/P first trimester. 0/6 SAT scores and BMI and B/P at any time
Health centre system enablers: more highly developed PHC information systems and decision support enable first trimester BP screening; more highly developed PHC systems for self management support and organisational influence and integration
41 Matthews V, Connors C etal 2015 Study period 2005-13;18,000 clinical records; 160 PHC centres A three phased process engaged 380 stakeholders from Aboriginal and Torres Strait Islander PHC centres and systems in analysing and interpreting, chronic disease audit data. A consensus process was used to identify priority evidence-practice gaps in chronic illness care, barriers and enablers to high quality care; system-wide strategies for achieving improvement based on these data. The purpose was to stimulate discussion and enhance ownership of the development of interventions to address system gaps.   Enablers for improving practice evidence gaps in CD include: follow-up of abnormal findings; adherence to treatment guidelines; assessment and support of emotional well-being for patients with CD; improved vaccination coverage; links between services; workforce recruitment, retention, capacity and training; capacity to provide patient centred care; modification of AHW roles; community involvement and participation in service delivery design; develop CQI culture, health literacy and leadership.
Barriers to high quality care include workforce recruitment and retention; capacity to provide patient-centred care; community engagement and participation in service delivery design; training and development of health centre staff and management.
42 Newham J, Schierhout Getal 2015 18 semi-structured interviews in 11 Aboriginal primary health-care services in South Australia Barriers at the macro level include resource constraints and access to project support; meso level include senior level management and leadership for quality improvement and the level of organisational readiness; at micro level include knowledge and attitudes of staff, resistance to change and lack of team tenure. Enablers include training, someone who drives the CQI process at the service, organisational and individual change, a regional approach,  
48 Bailie, Laycock, Matthews, Bailie 2016 Evidence practice gaps identified using audit data 2012-13 for chronic illness care ( 123 health centres; 6523 patient records and 90 SATs) and for child health care ( 94 health centres; 4011 patient records, 62 SATs) together with data derived from purposively structured dialogue with stakeholders and a survey to rank the relative importance of areas of poor recording, delivery of care and health centre systems   Seven priority evidence-practice gaps were identified for chronic illness care and five for child health Common gaps were related to follow-up of abnormal findings; recording of advice on risks to health; and systems for links between health centers and communities. Respondents felt that health center and system attributes were of greater or equal importance compared to staff attributes in improving quality of care. 5 primary drivers and 11 secondary drivers of high-quality care are identified.
  QAIHC Closing the Gap Collaborative
An ACCHS state affiliate member service support program involving monthly automated extraction from electronic health records of aggregated data for 21 indicators of overall service performance (‘QAIHC core indicators’) with analysis and web-based reporting to participating services. (Additionally, described in the grey literature only, were three quality improvement support coordinators, a network of quality improvement support officers, 2-day learning workshops every 6 months, face-to-face and web-based training seminars, an electronic discussion forum and a monthly electronic newsletter (QAIHC 2011).
57 Panaretto, Gardner, Button et al. (2013) Study period June 2010 - February 2012; QLD; 22 member services of Queensland Aboriginal and Islander Health Council (100% community controlled). Data available for a total of 19,727 regular clients, aggregated data reported for 5 time points.
CQI processes, including state-wide ‘collaboratives’ not described. Improvement strategies implemented by health services not reported.
Not discussed Contextual factors at the service level that may drive variation in improvement on performance:
Clinical activities versus EPC items: One person activity versus team activity
Interservice variation: SEIFA, community size and percentage of indigenous people in catchment. Remoteness
ICAC or SAT scores: available
staffing/workforce. Senior medical officer turnover. Ratio of doctors to patients workload per clinician
Use of data platforms–Pen CAT usage or similar. APCC portal usage.
Use of Plan Do Study Act cycles:
CQI programme/collaborative
Incentives: Staff flat salaries or incentives
Patients: Staff and patients
  Derby Aboriginal Health Service
A study in one health service of diabetes care and outcomes involving a retrospective audit covering a 10 year period during which time the service participated in CQI activities through ABCDE and APCC (time periods for involvement unclear).
58 Marley J, Nelson C, O’Donnell V et al. (2012) Study period 1999-09; WA; 1 service (community controlled). Retrospective audit of records of clients with diabetes (n=254 clients). CQI processes not described; Improvement strategies implemented by health services not reported. Consideration given to enablers for CQI through participant observation. Service level enablers: Stable governance, community elected board, electronic health info system, consistency of senior staff, long term employment of Aboriginal Health Workers and Nurses; CQI approaches based on a culture of organisational appraisal and improvement; encouraging review and reflection among staff at all levels; embracing change in response to gaps; CQI and formalisation of regular internal and external audit; regional support & standardisation of processes Enabling policies identified: reimbursement for health checks and for chronic disease management plans and follow up; access to low/no cost medications in remote areas
  Kimberley Services, 2011-2012
A study in 4 ACCHS in Western Australia of diabetes care involving a retrospective audit of records for Aboriginal and Torres Strait Islander primary care patients aged ≥15 years with a confirmed diagnosis of T2DM at four Kimberley ACCHSs from 1 July 2011 to 30 June 2012. Interviews with health service staff and focus group discussions with patients post audit.
59 Stoneman (2014) Study period 1 July 2011 to 30 June 2012; Kimberley WA; 4 Services (community controlled). Retrospective audit of records for patients aged ≥15 years with a confirmed diagnosis of T2DM (n=348 patients). Interviews with 19 staff (9 AHWs, 7 RNs, 3 GPs) from 4 ACCHSs after seeing audit results. 3 focus groups with 16 patients from 3 ACCHSs. Thematic analysis Seamless and timely data collection; local ownership of CQI process; openness to admitting deficiencies and willingness to embrace change; regional CQI facilitator. Enablers included: clearly defined staff roles for diabetes management; increased role for AHWs in chronic disease management including training in self management approaches, retinal camera & point of care HbA1c; efficient recall systems & involvement of AHW or Aboriginal outreach worker in recall; well-coordinated allied health services; increased staffing to increase focus on chronic disease; guidelines and staff training to use Mmex; whole service involvement interpreting audit results; staff and community involvement in developing improvement strategies.
Barriers include high staff turnover, lack of clarity over responsibility for recall; uncertainty of how to use Mmex for recall.
  Winnunga Nimmityjah Aboriginal Health Service
A study in one health service of Pap smear screening involving a baseline retrospective clinical audit, survey of convenience sample of clients (n=32), focus groups with staff and client Women’s Group, rapid PDSA cycles and follow up clinical audits.
60 Dorrington, Herceg, Douglas et al. (2015)
Increasing Pap smear rates at an urban Aboriginal Community Controlled Health Service through translational research and continuous quality improvement
Study period 2009-2013; ACT; 1 service (community control). Baseline audits for eligible women (n=213), 5 rapid PDSA cycles (4-5 wks duration) in 2012, survey of convenience sample of clients (n=32), follow-up assessment of annual screening rate compared with years 2009-2011. Comprehensive description of CQI processes: 1) Baseline data collection tool implemented as first PDSA 2) Promotional material used to raise client awareness of Pap smear screening. 3) Afternoon clinic for health appointments with a female GP established. 4) Pap smear recall system reviewed and cleaned. 5) Reminder letter updated to include specific information about cervical cancer in Aboriginal and Torres Strait Islander women; mail-outs included a culturally appropriate leaflet. 6) Education provided to the Social Health Team to facilitate discussions with clients about Pap smear screening nil Barriers to screening identified by clients included forgetting, not having time and being too busy; discomfort; not liking smears; fear of results; shyness and embarrassment; not knowing which professional to see; other health issues; chronic conditions consuming consultation time.
Enablers were GP prompts, appointments, reminders (letters; text messages)
STRIVE
65 Hengel, Guy etal 2015 Study period: 36 in-depth interviews in 22 out of 65 health centres across four regions in northern and central Australia participating in a randomised control project on STIs.   Barriers including Aboriginal cultural norms that require the separation of genders and traditional kinship systems that prevent some staff and patients from interacting. Both were exacerbated by a lack of male staff. Other common barriers were concerns about client confidentiality (lack of private consulting space and living in small communities), staff capacity to offer testing impacted by the competing demands for staff time, and high staff turnover resulting in poor understanding of clinic systems. Strategies, such as team work, testing outside the clinic and using adult health checks were used to address these barriers.
66 Allen and Clarke 2013
Evaluation of the NT CQI Investment Strategy
Study period 2009-2013. NT. External evaluation drawing on review of evidence, key informant interviews; five case studies; review of program data and key documents; sense making workshop. Key barriers relate to geographical remoteness; cultural diversity and the influence of social determinants on health outcomes. Other challenges include a high turnover of the health workforce, and significant expansion and reform of the health system.  
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