Research Stream 2: Improving safety and quality in primary healthcare

The aims of Research Stream 2 are to improve the quality and safety of primary healthcare by:

• Measuring the performance and organisational development of practices participating in the Collaboratives

• Identifying the characteristics of high performing practices and how to spread high performance

Knowledge gap and research questions

Quality Improvement: Internationally, Collaboratives are the most common means for improving the quality of healthcare. The APCC Program, managed by Improvement Foundation Australia (IFA), is the Australian national initiative. After five years, 16% of general practices have demonstrated improved outcomes for their patients (1), but we know very little about the organisational processes of practices participating in the Collaboratives (2-4). For example, clinical leadership and teamwork have been recognised as crucial for the improvement of clinical outcomes (5,6). Yet there has been no systematic analysis at general practice or divisional level of the organisational development required to optimise leadership and teamwork. There is little understanding of the organisational development occurring among successful participants, or in their general practices.

Safety and Governance: The identification and reduction of harm has become a major priority for healthcare providers. The Australian Commission on Safety and Quality in Health Care (ACSQHC) has recognised (7)  that little is known about safety in general practices even though general practice is the usual point of entry into the healthcare system. Standards for general practice set by the Royal Australian College of General Practitioners (RACGP) support quality improvement activities and the development of a clinical risk management system. Australian General Practice Accreditation Limited (AGPAL) accredits 85% of general practices by surveyor site visits assessing against the standards.

We propose eight research questions:

1. What are the characteristics of general practices that have a high performance in accreditation with AGPAL, particularly in safety and quality procedures?
2. What is the contribution of the Collaboratives to team dynamics within general practice?
3. What is impact of the Collaboratives on the role of practice nurses?
4. What are enablers and barriers to uptake, utilisation and spread of the Collaboratives?
5. What is the contribution of the Collaboratives to patient outcomes, especially imputed reduction in cardiovascular events?
6. What are the leadership and cultural characteristics associated with high performance in general practice, particularly in relation to safety and quality?
7. What is the effectiveness of an implementation program designed to provide a framework to improve patient safety in general practice?
8. What are the patient and consumer perspectives of safety and quality in general practice?

Methods

Several studies in Stream 2 will investigate the proposed research questions by using the clinical microsystem approach. Practices will be stratified by their performance in quality and safety by quality score based on data from Australian Primary Care Collaboratives Program (APCC) database for clinical performance and Australian General Practice Accreditation Limited (AGPAL) database for safety and governance. Three samples will be chosen for in-depth interviews.

The first sample is a national sample of general practices and medical Aboriginal services to identify the characteristics of high-performing general practices through interviews with general practitioners, practice nurses and practice managers.

The second sample is regional patients and consumers residing within the Greater Green Triangle region of South East Australia to gather their views and experiences on quality and safety.

The third sample is key informant interviews and case studies of Medicare Locals and general practices to examine the utilisation and spread of the Collaboratives.

IMPACT modelling will be used to assess the contribution of the Collaboratives to patient outcomes, especially imputed reduction in cardiovascular events.

Outcomes

1. Identification of general practices that have high performance in quality and safety.
2. Development and evaluation of an implementation program for a governance framework to improve patient safety and quality in general practice.
3. Understanding the leadership and team dynamics related to successful application of collaborative methodology, and how this knowledge can be translated into clinical leadership and team training.
4. Understanding the role of practice nurses, and how this knowledge can be translated into recruitment and training.
5. A strategy for improved uptake, utilisation and spread of Collaboratives in Australia.
6. The imputed reduction in the risk of cardiovascular events for patients of practices participating in the Collaboratives.
7. A safety collaborative.
8. Patient and consumers perspectives of safety and quality in general practice.

Research Team includes:

• Prof James Dunbar, GGT UDRH, Flinders & Deakin Universities
• Prof Paul Batalden, Dartmouth Medical School Assoc
• Prof Julie Johnson, University of New South Wales
• Prof Jeffrey Fuller, Flinders University

Associate Investigators

• Dr Dale Ford, Improvement Foundation Australia
• Prof Erkki Vartiainen, National Institute of Health and Welfare, Finland
• Sir John Oldham, Department of Health, England
• Dr Steve Clark, Australian General Practice Accreditation Limited
• Prof Alan Wolff, Wimmera Health Care Group
• Dr Christine Walker, Chronic Illness Alliance
• Prof Stuart Emslie, University of Loughborough, UK
• Prof Susan Dovey, Dunedin School of Medicine, NZ

Postdoctoral Fellows & Students

Improving the safety and quality of primary healthcare through performance measurement and organisational development.

Dr Amr Abou Elnour, MB BCh, PhD, Grad Dip PHC
Postdoctoral Research Fellow, Flinders University & Deakin University
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Aims

1. To identify the characteristics of Australian general practices performing highly in safety and quality

2. To develop a safety collaborative manual to improve patient safety in Australian primary care

3. To investigate the Australian Primary Care Collaborative (APCC) Program impact on CVD outcomes.

Methodology

1. In-depth interviews with a national sample from Australian general practices with high scores in safety and quality

2. Literature review and interviews with highly experienced surveyors who are involved in accreditation of Australian general practices and consultations with national and international experts on patient safety

3. A cohort study to follow up the CHD patients in the APCC program register for one year.

Outcomes

1. Characteristics of high performing Australian general practices in safety and quality

2. Safety Collaborative manual and a trigger tool

3. Measuring APCC Program impact on CVD outcomes

Significance

This project will develop:

1. Indicators to assess quality improvement, safety, and governance in the Australian primary healthcare system

2. A patient safety framework for Australian primary care

3. Optimal strategies to minimise CVD events in Australian primary care

The enablers and the barriers for the uptake, utilisation, sustainability and spread of Primary Health Care Collaboratives in Australia.

 
Aims

The main aim is to improve our understanding of primary health Care Collaboratives in terms of:

• How collaboratives are accessed (uptake)

• How collaboratives are implemented and employed (utilisation)

• How improvements are maintained (sustainability)

• How we can promote the uptake of Collaboratives to other General Practices (spread)

Methodology

A qualitative study is being conducted using individual face-to-face interviews with members of General practices and key informants from the Collaborative program. The interview questions will be specifically designed to ellicit responses on four different themes of uptake, utilisation, sustainability and spread.

Outcomes

It is predicted that the perceived enablers and barriers may be influenced by the demographic and structural characteristics of the practices (ie., rural vs urban locations or size of the practice) and possible the discipline and the role of ther person being interviewed.

Significance

If we can fully understand what makes Collaborative programs work, and what prevents them from working, then we have a greater hope of spreading improvement programs like Collaboratives throughout the remaining 80% of general practices in Australia. The significance of this will be greatly improved, sustainable primary health care for citizens across Australia.

The feasibility of Facebook-based interventions on increasing physical activity in postpartum women.

Dr Siew Lim, BSc (Biomedical), MND, PhD
Postdoctoral Research Fellow, Flinders University & Deakin University
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Aims

To determine the feasibility and short-term effectiveness of a Facebook-based intervention on increasing physical activity in postpartum women (6 months) with a history of gestational diabetes.  

Methodology

20 postpartum women (6 months postpartum) who had gestational diabetes will be recruited from Tasmania, Warrnambool, and Brisbane. Inclusion criteria include women who are 6 months postpartum, have a history of gestational diabetes, have private access to the internet, currently sedentary but willing to increase physical activity, and able to atten the initial in-person session. Exclusion criteria include those who are currently pregnant, currently diagnoses with diabetes mellitus, or currently exercise at moderate intensity for more than 30 minutes a day, 5 days a week. Subjects will receive and initial face-to-face consultation, followed by online support through Facebook messages. Subjects will be encouraged to provide and receive peer support through a designated Facebook group.  

Outcomes

Frequency (the number of days per week) that participants reported at least 30 minutes of moderate to vigorous physical activity (MVPA) or walking for exercise, the total duration (min/week) of MVPA and walking for exercise (measured using the Australian Women's Activity Survey, AWAS), frequency of responding to weekly goal checks, perceived intervention usefulness.  

Significance

This study will provide important information on the feasibility and effectiveness of delivering lifestyle intervention through social networking websites to women with a history of gestational diabetes. Such programs are much needed for those who could not attend regular, in-person sessions as required by conventional programs. This is particularly relevant in the rural and remote setting, but may also apply to other postpartum mothers who could not attend in-person group sessions due to childcare duties, time constraints, cultural barriers or other reasons.

Developing a framework for teaching quality and safety core competencies in primary care microsystems.

Anne Sinclair, MEd, Grad Cert Health Management, RN
PhD Student, University of New South Wales
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Aims

The aim of this study is to explore general practice microsystems from a learning organisation perspective. The focus will be on general practice in New South Wales.

Methodology

A mixed methods study will be conducted. Quantitative data will include collection of demographics and completion of a Learning Organisation Questionnaire (Marsick et al. 2003) by staff in the practices. Qualitative data will include analysis of one on one interviews exploring responses to the Learning Organisation Questionnaire and patient survey responses.

Outcomes

This study will identify features of learning organisations demonstrated by the practices studied. It will contribute to our understanding of how learning needs are identified and addressed within a primary care setting.

Significance

With the emphasis continuing to move to preventive health it is imperative that Australia has contemporary and effective clinical microsystems that deliver high quality services. Learning organisations encourage learning, innovations and improvement, which increases the organisation's capacity to adapt to changing environments. In the business world, entities that have demonstrated excellence as learning organisations have also demonstrated innovation, market dominance and economic viability. Adoption and cultivation of the characteristics of the learning organisation has the potential to improve the quality and safety of care provided, benefiting health care delivery systems, consumers of primary healthcare, and the community. 

Patient and consumer perspectives of safety and quality in general practice.

Andrea Hernan, BPH&HP
Masters Student, Flinders University & Deakin University
Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it.

Aims

This study aims to investigate patient and consumers' perspectives of safety and quality in general practice?

Methodology

• A qualitative focus group undertaken with rural and regional patients and consumers residing within the Greater Green Triangle region of South East Australia.

• Patients and consumers were asked to discuss their experiences of particular aspects of safety and quality in general practice in order to obtain detailed, in-depth, and holistic descriptions of what patients value and the meanings they attach to experiences.

Outcomes

• Patients' identified a range of safety and quality indicators that are considered to be important

• These include but are not limited to:

  • timely access to services,

  • choice in provider,

  • continuity of care,

  • professional and personal competence,

  • referral systems and coordination of care,

  • relationship and communications, and

  • patient engagement in care

Significance

• Little in known specifically about safety and quality in general practice in Australia

• The majority of studies on safety and quality in general practice look at quantitative measures from a provider or organisational perspective

• Little research has focused on patient values, experiences, and satisfaction of safety exclusively within general practice.

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2. Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust 2004;180(6 Suppl):S57-60.
3. Mittman BS. Creating the evidence base for quality improvement collaboratives. Ann Intern Med 2004;140(11):897-901.
4. Ovretveit J. Which interventions are effective for improving patient safety - A review of research evidence. Stockholm: Karolinska Institute, 2005.
5. Mannion R, Davies, H.T.O., Marshall, M.N. Cultures for performance in health care. New York: Open University Press, 2005.
6. Moss F, Garside P, Dawson S. Organisational change: the key to quality improvement. Qual Health Care 1998;7 Suppl:S1-2.
7. Australian Commission on Safety and Quality in Health Care. Patient Safety in primary care. A review of the literature. Adelaide: Joanna Briggs Institute, 2009.