Developing a model for primary care quality improvement success: a comparative case study in rural, urban and Kaupapa Māori organisations
Jane Cullen
1 * , Paul Childerhouse 2 , Nihal Jayamaha 1 , Lynn McBain 3
1 Massey University, Palmerston North, New Zealand.
2 Royal Melbourne Institute of Technology, Melbourne, Australia.
3 Department of Primary Care, University of Otago, Wellington, New Zealand.
Abstract
Primary care is under pressure to achieve accessible, equitable, quality health care, while being increasingly under resourced. There is a need to understand factors that influence quality improvement (QI) to support a high-performing primary care system. Literature highlights the impact of context on QI but there is little primary care research on this topic.
This qualitative case study research seeks to discover the contextual factors influencing QI in primary care, and how the relationships between contextual factors, the QI initiative, and the implementation process influence outcomes.
The Consolidated Framework for Implementation Research was used to frame this qualitative study exploring primary care experiences in depth. Six sites were selected to provide a sample of rural, urban and Kaupapa Māori settings. Qualitative data was collected via semi-structured interviews and compared and contrasted with the organisational documents and data provided by participants.
Cases reported success in achieving improved outcomes for patients, practices, and staff. Strong internal cultures of ‘Clan’ and ‘Adhocracy’ typologies supported teamwork, distributed leadership, and a learning climate to facilitate iterative sensemaking activities. To varying degrees, external network relationships provided resources, knowledge, and support.
Organisations were motivated by a combination of patient/community need and organisational culture. Network relationships assisted to varying degrees depending on need. Engaged and distributed leadership based on teamwork was observed, where leadership was shared and emerged at different levels and times as the need arose. A learning climate was supported to enable iterative sensemaking activities to achieve success.
Keywords: case study, context, distributed leadership, general practice, implementation, learning climate, network relationships, quality improvement.
References
1 Dixon-Woods M, Bosk CL, Aveling EL, et al. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q 2011; 89(2): 167-205.
| Crossref | Google Scholar |
2 Charlesworth K, Jamieson M, Davey R, et al. Transformational change in healthcare: an examination of four case studies. Aust Health Rev 2016; 40(2): 163-7.
| Crossref | Google Scholar |
3 Dixon-Woods M, Leslie M, Tarrant C, et al. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci 2013; 8(1): 70.
| Crossref | Google Scholar |
4 Crabtree BF, Nutting PA, Miller WL, et al. Primary care practice transformation is hard work: insights from a 15-year developmental program of research. Med Care 2011; 49(Suppl): S28-35.
| Crossref | Google Scholar |
5 Braithwaite J, Glasziou P, Westbrook J. The three numbers you need to know about healthcare: the 60-30-10 Challenge. BMC Med 2020; 18(1): 102.
| Crossref | Google Scholar |
8 Rifkin SB. Alma Ata after 40 years: Primary Health Care and Health for All—from consensus to complexity. BMJ Glob Health 2018; 3(Suppl 3): e001188.
| Crossref | Google Scholar |
9 Subramanian L, Elam M, Healey AJ, et al. Context matters—but what aspects? The need for evidence on essential aspects of context to better inform implementation of quality improvement initiatives. Jt Comm J Qual Patient Saf 2021; 47(11): 748-52.
| Crossref | Google Scholar |
12 Coles E, Anderson J, Maxwell M, et al. The influence of contextual factors on healthcare quality improvement initiatives: a realist review. Syst Rev 2020; 9(1): 94.
| Crossref | Google Scholar |
13 Imison C, Curry N, Holder H, et al. Shifting the Balance of Care: Great Expectations. 2017. Available at https://www.nuffieldtrust.org.uk/research/shifting-the-balance-of-care-great-expectations [11 November 2017]
14 Kaplan HC, Froehle CM, Cassedy A, et al. An exploratory analysis of the Model for Understanding Success in Quality. Health Care Manage Rev 2013; 38: 325-38.
| Crossref | Google Scholar |
15 Lau R, Stevenson F, Ong BN, et al. Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews. Implement Sci 2016; 11(1): 40.
| Crossref | Google Scholar |
16 Brennan SE, Bosch M, Buchan H, et al. Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments. Implement Sci 2012; 7(1): 121.
| Crossref | Google Scholar |
17 Lanham HJ, McDaniel Jr RR, Crabtree BF, et al. How improving practice relationships among clinicians and nonclinicians can improve quality in primary care. Jt Comm J Qual Patient Saf 2009; 35(9): 457-66, AP1–2.
| Crossref | Google Scholar |
18 Lanham HJ, Palmer RF, Leykum LK, et al. Trust and reflection in primary care practice redesign. Health Serv Res 2016; 51(4): 1489-514.
| Crossref | Google Scholar |
19 Pfadenhauer LM, Gerhardus A, Mozygemba K, et al. Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework. Implement Sci 2017; 12(1): 21.
| Crossref | Google Scholar |
20 Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4(1): 50.
| Crossref | Google Scholar |
21 Coles E, Wells M, Maxwell M, et al. The influence of contextual factors on healthcare quality improvement initiatives: what works, for whom and in what setting? Protocol for a realist review. Syst Rev 2017; 6(1): 168.
| Crossref | Google Scholar |
22 Keith RE, Crosson JC, O’Malley AS, et al. Using the Consolidated Framework for Implementation Research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation. Implement Sci 2017; 12(1): 15.
| Crossref | Google Scholar |
23 Kowalski CP, Veeser M, Heisler M. Formative evaluation and adaptation of pre-and early implementation of diabetes shared medical appointments to maximize sustainability and adoption. BMC Fam Pract 2018; 19(1): 109.
| Crossref | Google Scholar |
24 Ilott I, Gerrish K, Booth A, et al. Testing the Consolidated Framework for Implementation Research on health care innovations from South Yorkshire. J Eval Clin Pract 2013; 19(5): 915-24.
| Crossref | Google Scholar |
25 Skela-Savič B, Macrae R, Lillo-Crespo M, et al. The development of a consensus definition for healthcare improvement science (HIS) in seven European countries: a consensus methods approach. Slovenian J Public Health 2017; 56(2): 82-90.
| Crossref | Google Scholar |
26 Cullen J, Childerhouse P, McBain L. Contextual antecedents of quality improvement: a comparative case study in rural, urban and Kaupapa Māori general practice. J Prim Health Care 2022; 14: 179-86.
| Crossref | Google Scholar |
29 Darling M, Guber H, Smith J, et al. Emergent learning: a framework for whole-system strategy, learning, and adaptation. Found Rev 2016; 8(1): 59-73.
| Crossref | Google Scholar |
30 Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014; 12(6): 573-6.
| Crossref | Google Scholar |
31 Casalino LP. Technical assistance for primary care practice transformation: free help to perform unpaid labor? Ann Fam Med 2018; 16(Suppl 1): S12-5.
| Crossref | Google Scholar |
32 Miller WL, Crabtree BF, Nutting PA, et al. Primary care practice development: a relationship-centered approach. Ann Fam Med 2010; 8(Suppl 1): S68-79.
| Crossref | Google Scholar |
33 Larkins S, Carlisle K, Turner N, et al. ‘At the grass roots level it’s about sitting down and talking’: exploring quality improvement through case studies with high-improving Aboriginal and Torres Strait Islander primary healthcare services. BMJ Open 2019; 9(5): e027568.
| Crossref | Google Scholar |
34 Harding T, Oetzel J. Implementation effectiveness of health interventions for indigenous communities: a systematic review. Implement Sci 2019; 14(1): 76.
| Crossref | Google Scholar |
35 Beaton A, Manuel C, Tapsell J, et al. He Pikinga Waiora: supporting Māori health organisations to respond to pre-diabetes. Int J Equity Health 2019; 18(1): 3.
| Crossref | Google Scholar |
36 Donahue KE, Halladay JR, Wise A, et al. Facilitators of transforming primary care: a look under the hood at practice leadership. Ann Fam Med 2013; 11(Suppl 1): S27-33.
| Crossref | Google Scholar |
37 Crabtree BF, Howard J, Miller WL, et al. Leading innovative practice: leadership attributes in LEAP practices. Milbank Q 2020; 98: 399-445.
| Crossref | Google Scholar |
38 Bailie R, Matthews V, Brands J, et al. A systems-based partnership learning model for strengthening primary healthcare. Implement Sci 2013; 8: 143.
| Crossref | Google Scholar |
39 Avby G, Kjellström S, Andersson Bäck M. Tending to innovate in Swedish primary health care: a qualitative study. BMC Health Serv Res 2019; 19(1): 42.
| Crossref | Google Scholar |
41 Maitlis S, Christianson M. Sensemaking in organizations: taking stock and moving forward. Acad Manag Ann 2014; 8(1): 57-125.
| Google Scholar |
42 Edmondson AC, Lei Z. Psychological safety: the history, renaissance, and future of an interpersonal construct. Annu Rev Organ Psychol Organ Behav 2014; 1(1): 23-43.
| Crossref | Google Scholar |
43 Carroll JS, Edmondson AC. Leading organisational learning in health care. Qual Saf Health Care 2002; 11(1): 51-6.
| Crossref | Google Scholar |
44 Kiran T, Ramji N, Derocher MB, et al. Ten tips for advancing a culture of improvement in primary care. BMJ Qual Saf 2018; 28: 582-7.
| Crossref | Google Scholar |
