Evaluating the effectiveness of a multifaceted, multilevel continuous quality improvement program in primary health care: developing a realist theory of change
Open accessAbstract
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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The analysis utilised a similar approach to Schierhout et al. and Rycroft-Malone et al.
“Utilising a similar approach to those of Schierhout et al. 152 and Rycroft-Malone et al., 153 the analysis involved the following steps:”
From ReseArch with Patient and Public invOlvement: a RealisT evaluation – the RAPPORT study (2015) · cites this paper as [152]
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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)
- PMC
- PMC4124892
- 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
- gold
- doi.org
- Licence
- 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
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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