Cited by 67Health Policy Implementation ScienceHealthcare Quality and ManagementPrimary Care and Health Outcomes

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

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Schierhout, Gill, Hains, Jennifer, Si, Damin, Kennedy, Catherine, Cox, Rhonda, Kwedza, Ru, O’Donoghue, Lynette, Fittock, Marea +4 more·2013·Implementation Science

Abstract

BACKGROUND: Variation in effectiveness of continuous quality improvement (CQI) interventions between services is commonly reported, but with little explanation of how contextual and other factors may interact to produce this variation. Therefore, there is scant information available on which policy makers can draw to inform effective implementation in different settings. In this paper, we explore how patterns of change in delivery of services may have been achieved in a diverse range of health centers participating in a wide-scale program to achieve improvements in quality of care for Indigenous Australians. METHODS: We elicited key informants' interpretations of factors explaining patterns of change in delivery of guideline-scheduled services over three or more years of a wide-scale CQI project, and inductively analyzed these interpretations to propose fine-grained realist hypotheses about what works for whom and in what circumstances. Data were derived from annual clinical audits from 36 health centers operating in diverse settings, quarterly project monitoring reports, and workshops with 12 key informants who had key roles in project implementation. We abstracted potential context-mechanism-outcome configurations from the data, and based on these, identified potential program-strengthening strategies. RESULTS: Several context-specific, mechanism-based explanations for effectiveness of this CQI project were identified. These were collective valuing of clinical data for improvement purposes; collective efficacy; and organizational change towards a population health orientation. Health centers with strong central management of CQI, and those in which CQI efforts were more dependent on local health center initiative and were adapted to resonate with local priorities were both favorable contexts for collective valuing of clinical data. Where health centers had prior positive experiences of collaboration, effects appeared to be achieved at least partly through the mechanism of collective efficacy. Strong community linkages, staff ability to identify with patients, and staff having the skills and support to take broad ranging action, were favorable contexts for the mechanism of increased population health orientation. CONCLUSIONS: Our study provides evidence to support strategies for program strengthening described in the literature, and extends the understanding of mechanisms through which strategies may be effective in achieving particular outcomes in different contexts.

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  1. Hedstrom PSR Social mechanisms: an analytic approach to social theory 1998 Cambridge, UK: Cambridge University Press

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Authors
Schierhout, G., Hains, J., Si, D., Kennedy, C., Cox, R., Kwedza, R., O’Donoghue, L., Fittock, M., Brands, J., Lonergan, K., Dowden, M., & Bailie, R.
Affiliations
  • Menzies School of Health Research (AU)
  • Queensland Health (AU)
  • Maari Ma Health (AU)
  • Curtin University (AU)
Corresponding author
Schierhout, Gill
Venue
Implementation Science
Published
2013-10-08
Volume
8
Issue
1
Pages
119-119
ISSN
1748-5908 (ISSN-L)
OpenAlex
W2021954893
Cited by
67
References
21
Citations by year
2025: 3 · 2023: 4 · 2022: 2 · 2021: 6 · 2020: 4 · 2019: 9 · 2018: 10 · 2017: 9 · 2016: 7 · 2015: 9 · 2014: 2 · 2013: 1
FWCI
11.41
Type
journal article
Language
en
Open access
Locations
  • Implementation Science (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • CDU eSpace Institutional Repository (Charles Darwin University) (submittedVersion)
  • eSpace (Curtin University) (submittedVersion)
Funders
  • Australian National University
  • Lowitja Institute
  • Medical Research Council
  • Australian Research Council (FT100100087)
  • National Health and Medical Research Council (545267, ID No.545267)
Topics
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
  • Health Sciences › Health Professions › Health Information Management › Healthcare Quality and Management
  • Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
Keywords
continuous quality improvement, primary care, Indigenous Australians, context-mechanism-outcome configurations, collective efficacy, organizational change, program strengthening, health centers, community linkages
MeSH terms
Australia, Humans, Models, Theoretical, Organizational Innovation, Primary Health Care, Total Quality Management

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