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Table 1 Proposed CMO configurations explaining how a wide-scale CQI model in primary health influences care delivery

From: Evaluating the effectiveness of a multifaceted, multilevel continuous quality improvement program in primary health care: developing a realist theory of change

Summary of salient ABCD CQI project inputs Potential contexts Plausible mechanisms Potential outcomes Exemplar quotes
Health center staff participate in annual predominantly paper-based audit processes, interpretation of reports and systems assessment and action planning that use data derived from clinical audit, as a starting point for change Centralized management style; regional board committed and involved in CQI implementation (C1) Collective or shared valuing of clinical data for improvement purposes (M1) Temporary declines and instability as services get used to new systems. Major revision of clinical record keeping; centralized ‘cleaning up’ process to standardize reporting across health centers. ‘Across our region we did a concerted effort for documentation for diabetes services…and so certainly the improvement [in the early years] would just have been about documentation, so having somewhere to write things…I think all was about documentation. But 2006 to 2007 I think there was a concerted effort. The chronic disease strategy really kicked in and that was when, at some point during that period, [name] had her lights on moment. [we understood] the focus of how important doing the right processes at the right time was’.
Marked changes (HC1 & 2 Figure 2E).
Automatic generation of reports from clinical audit through a web-based information system. Local ownership of CQI (devolved management style); competent staff in management roles; managers and clinicians with an interest in chronic disease and in clinical and population health data (C2) Collective or shared valuing of clinical data for improvement purposes (M1) Use of non-core strategies such as follow up of individuals receiving poor care identified in clinical audit, used to highlight clinical relevance of data (HC 7 & 8 Figure 2A). ‘Doctor [name] was always really, really interested in the data…where he saw really big increases in ACRs and that, he would want to know who were the people that were being audited in terms of following those up. So he was very good with that. And then of course [name] is their quality improvement person… they were standardising their filing system right across that region, which she led, and so [the data] were quite easily accessible’
Ability for health centers to adjust reporting (format, indicators etc.) to suit local reporting requirements and accountabilities Sustained high performance or marked change to improvement (HC 3 Figure 2C & 2F).
Engagement of champions and change agents at different levels of the health system to promote uptake of the project Poor management, uncertainty and confusion over role definitions. (C3) Collective or shared valuing of clinical data for improvement purposes (M1) Limited changes in data systems; frustration and confusion about ongoing involvement in CQI. ‘A lot of health workers. Been there for a long time, and I asked them what, sort of asked what their training was. Why aren’t they doing like blood pressures and blood sugars…They said they were not allowed. They’ve been told by management they’re not allowed.…that was part of their training though that, you know, I’m a health worker and that’s part of my training. But yeah, a lot of them have been there for 15 years. They just didn’t have a focus. We actually wondered what their existence was about’.
Ongoing refinement of the project to maximize synergies with major policy initiatives Poor performance or declines in care (HC5 & 6 Figure 2C and 2D).
Processes and tools that brought together different health care professionals and managers to share ideas for service performance and improvement activities Regional or organizational infrastructure supportive of networking for CQI and centralization of some tasks. Positive prior history of collaboration (C4) Collective change efficacy (M2) Appropriate reflection on salient comparison group; formation of networked communities ‘Have good communication systems… share ideas between the different health centers. And a strong focus on education through regional support teams… use video conferencing as well as regular visits.. and its very vibrant, like they are always out there’.
Sustained high performance or marked change to improvement (HC3 Figure 2F and 2C).
Annual planning meetings, meetings, teleconferences and sharing of experiences between health centers Organizational culture unsupportive of collaboration. Health centers see themselves as being in competition (C5) Collective change efficacy (M2) Inappropriate reflection on performance and early fatigue ‘Cause, yeah, when I first started they were really eager, you know, like doctors were all eager to see how, cause there’s three clinics in [name of city]. They were all competing with each other, who’s going to be the best, and who’s going to give the best service, so but it’s just worn off’.
Provision of benchmarking data, allowing health centers to reflect on their performance in relation to that of others Persistent low performance or declines in care (HC5 and HC 6, Figure 2C and 2D).
Application of CQI to a wide range of health outcomes and service populations (diabetes, preventive health, maternal health, child health), and a range of care processes Pre-existing favorable context of patient and community oriented care, supported by stable effective outreach workers and good regional co-ordination for CQI (C6) Organizational change to encompass a population health orientation (M3) Recognition of value and roles of Aboriginal Health Workers in outreach and linking this to service delivery. ‘With [NAME] they had the self management program there, and they get a lot of stuff outside the health center.. it was about promoting good health in the community, working with the store [for supply of healthy food in this remote community], and those places. A lot of health promotion activities were going on with those health workers there. .. Population lists were being improved and a better understanding [in the context of transient populations and population movement]’.
Developing greater consistency in provision of general practitioner services.
Processes that brought different service delivery professionals together to reflect on health center performance (for example, outreach workers and clinic-based staff) High performance and marked change to improvement (HC10 Figure 2C and 2F).
Regionally based co-ordinator positions supported population health planning and multidisciplinary team approaches to chronic disease care Staff who can identify with patients and have the skills to take broad ranging action, including clinical action and action related to data system development and use, coupled by regional support and co-ordination (C7) Organizational change to encompass a population health orientation (M3) Priority-driven resource allocation decisions. ‘P1: Well [NAME] is passionate about making sure all the diabetics [are well cared for] …P2: He was also a diabetic wasn’t he? P1: Yeah. He had a personal drive and he was cardiac nurse, so any cardiac stuff that was related to diabetes, you know, he could tell people when they were being sent to Adelaide and you know, he did all that sort of advice as well…And what he did though was set up the big clean up of the data system. And started extracting reports and cleaning up the population base’.
Mixed patterns (high performance or marked change to improvement in diabetes and low in prevention or vice versa) (HC12 Figure 2B and 2F and HC13 Figure 2C and 2D).