A qualitative exploration of priorities for quality improvement amongst Aboriginal and Torres Strait Islander primary health care services

Abstract

Background Achieving quality improvement in primary care is a challenge worldwide, with substantial gaps between best practice and actual practice. Within the context of Australia, Aboriginal and Torres Strait Primary Health Care (PHC) services have great variation across settings, structures and context. Research has highlighted how these contextual differences can critically influence the success of Quality Improvement (QI) interventions and outcomes. Less understood is the interaction between local context and other factors, which may impact the implementation of QI interventions. This paper aims to explore the strengths and challenges in QI for Aboriginal and Torres Strait Islander PHC services and their priorities for improvement. Methods A multiple case study design was adopted, working with eight Aboriginal and Torres Strait Islander PHC services in Northern Territory, Queensland and Western Australia. Data were collected via a health service survey, semi-structured interviews with health service staff and service users and researcher observations, to explore QI and perceptions of care quality at the service level. Data reported here were analysed using an iterative thematic technique, within-case and across-case. Results A total of 135 interviews were conducted with health service staff, service users and community members. Participants emphasised the centrality of resilient community, committed workforce and valued Aboriginal and Torres Strait Islander team members in delivering care. A shared purpose around improving the health of community was a significant driver. Key challenges included staff turnover and shortages, a complex and overwhelming acute and chronic care workload, building relationships and trust between health services and the community. Service-suggested priority areas for improvement were categorised into five themes: i) cultural safety (community driving health and planning for culturally safe services); ii) community engagement (through clinical activities in the community); iii) shared ownership and a team approach around QI; iv) strengthening systems and consistent ways of doing things in the health service; and v) strengthening local workforce (and resources for a culturally safe workforce). Conclusions These findings advance understandings of relational, community and cultural factors which are identified priorities for the delivery of quality care in Aboriginal and Torres Strait Islander PHC services across varied contexts.

“The world is so white”: improving cultural safety in healthcare systems for Australian Indigenous people with rheumatic heart disease

“…To facilitate cultural safety being embedded and sustained within organisations despite staff turnover, our primary recommendation is to include cultural safety measures into CQI processes. These recommendations are in line with findings in similar recent research 30,31 but provide specific actions that broaden the cultural measures for CQI and show that work within ‘turbulent waters’ has been attempted. Cultural safety actions derived from the research reported in this paper are described here as measures for CQI processes for clinical services (see Box 1).…”

Effective primary care management of type 2 diabetes for indigenous populations: A systematic review

“…CHWs (finding 1) reduce health system barriers against primary care access (finding 2) through their role in case management. CHWs further reduce health system barriers by reassuring patients that the health system will understand them, rather than making assumptions based on untrue stereotypes [ 43 , 44 ]. Finding 3 also works to negate health system barriers (finding 2) by empowering Indigenous people to self-manage their diabetes and not rely on the health system.…”

“…McDermott et al demonstrated improvements in some health behaviours (dietician referral and blood glucose self-monitoring) in intervention group, but deterioration in others (smoking and dyslipidaemia), making it difficult to correlate Indigenous Health Workers to health behaviours in this study. A recent qualitative analysis of Aboriginal and Torres Strait Islander health services found staff and community members valued Aboriginal and Torres Strait Islander team members in delivering care [ 44 ]. Pratte et al also demonstrated an improvement in clinical and behavioural outcomes with case management being a main component of intervention [ 35 ].…”

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“…54 This question is difficult to answer when Indigenous status is hard to determine from the content and metadata of an article. Recently, several publications denoted Indigenous cultural identity of authors as: first name, last name (Indigenous Nation), [5][6][7] thus signalling the importance of cultural authority.…”

“…The notation of cultural provenance was variable. It appeared in the byline of both the webpage header and in the pdf, 5–7 researcher positionality, 8 acknowledgements section, 9 ethics section, 10 methods section, 11 materials and methods section, 12 the introduction and preceding the methods, 13 citation format, 5 front page of author information on preprint, 14 and was indicated with additional author information symbols (*, †, ‡, §) 15 …”