Indigenous health: effective and sustainable health services through continuous quality improvement

Ross S Bailie, Damin Si, Lyn O'Donoghue and Michelle Dowden
Med J Aust 2007; 186 (10): 525-527. || doi: 10.5694/j.1326-5377.2007.tb01028.x
Published online: 21 May 2007

A recent editorial in the Bulletin of the World Health Organization called for international agencies and ministries of health to work together to implement integrated quality improvement processes in clinical practice, with the aim of scaling up delivery of health interventions to meet the Millennium Development Goals.1 The current Australian Government program, Healthy for Life,2 provides a mechanism for doing this in primary care services for Aboriginal and Torres Strait Islander peoples. With funding of $102.4 million over 4 years, the program aims

In addition to other experience and resources, the Healthy for Life program has drawn on the tools, processes and principles developed through an action–research project in the Northern Territory — the ABCD project. “ABCD” originally stood for Audit for Best practice in Chronic Disease. It has come to represent a structured collaborative approach to improving health services, with potential application in a variety of primary care contexts. The ABCD research project is a collaborative initiative of the Cooperative Research Centre for Aboriginal Health, initially funded by the Australian Health Ministers’ Advisory Council, which brought together federal, state and territory government health agencies; Indigenous community-controlled health organisations; and research agencies. The project commenced in 12 Indigenous community health centres in the Top End of the Northern Territory in 2003. Its commencement was independent of, but more or less in parallel with, various other initiatives contributing to the development of the Healthy for Life program.

Here, we discuss some of the key strengths of the approach we have developed, and the evidence and values base for continuous quality improvement (CQI) in this context.

Continuous quality improvement and action research

In general, CQI aims to facilitate ongoing improvement by using objective data to analyse and improve processes.3,4 Emphasis is placed on efficient and effective functioning of organisational systems.5,6 CQI involves an ongoing cycle of gathering data on how well organisational systems are functioning, and developing and implementing improvements. An essential starting point is systematic and objective assessment of performance and of the systems supporting good performance.7 Good quality information is needed, so that goals can be set and strategies developed for improving key areas. An emphasis on participation by the people being studied, and flexibility in the approach, makes modern CQI very similar to action research, both being characterised by “cyclical activities involving examination of existing processes, change, monitoring the apparent effects of the change and further change”.8

Why continuous quality improvement works

Evidence of the effectiveness of modern CQI approaches in the manufacturing,14,15 service16 and health care17,18 industries abound. The most substantial experience of CQI is in the manufacturing and business sectors, and research in these areas highlights leadership, people management and customer focus as components of CQI interventions that strongly predict performance.19 People management appears to be particularly important in the service sector,17 including a commitment to increasing employees’ knowledge of, and empowerment to engage in, CQI processes.15,16 The intensity of interventions has been shown to explain a significant proportion of the variation in performance,16 with greater benefit likely if interventions are implemented as designed.17 Furthermore, international comparisons suggest a degree of culture specificity in what works where.15

In the clinical context, research suggests CQI approaches are most effective when they focus on organisational priorities; there is good engagement of high-level managers; the intervention is clearly formulated; the organisation is ready for change; there is a relationship of trust with practitioners; there is revision of professional roles; there are adequate information systems; and the external environment is supportive.19,20

The strength of the evidence of the effectiveness of CQI is limited by the quality of research study designs, the extent to which confounders are measured and controlled for in data analysis, and the heterogeneous nature and varying intensity of CQI interventions.20 However, the CQI concept has intuitive appeal. Proponents of CQI believe that while the language may change, the tools and vision of CQI will persist because they are adaptive.18 It is this positive view of the promise of CQI that is perhaps most supportive of the call for leading international and national health agencies to implement integrated CQI processes in clinical practice.1

Continuous quality improvement and Indigenous health

Key features of modern CQI approaches make them well suited to the Indigenous Australian setting and to the principles of Indigenous research and service delivery. The participatory approach and the customer focus of CQI, and the combination of scientific and humanistic professional values,15,16,19 adhere to the principles and values of Aboriginal and Torres Strait Islander peoples, as expressed in recent national statements on research21,22 and cultural respect.23 In these same statements, the emphasis given to tackling underlying causes (eg, human resource capacity and social conditions, including unemployment), to capacity building (including, specifically, community capacity to understand and use data), and to improving outcomes is also central to CQI,18,19 as is the development of positive models and a culture of self-evaluation rather than blame.1 CQI also provides a structure to refine and re-invigorate programs to promote sustainability.13

Early evidence of the acceptability of CQI approaches and their impact on Indigenous primary care services is emerging from our recent and ongoing research.10,13 Comments by stakeholders reinforce our perceptions (Box 3).

Notwithstanding this, there remain significant challenges for the engagement of health services in CQI activities. These include ongoing heavy demands for acute care services (and service orientation towards acute care), a preoccupation of middle-level management with staffing and budgets ahead of service quality and outcomes, and limited human resources in primary care services. The Healthy for Life program should assist in overcoming some of these challenges. Ongoing CQI initiatives for health improvement in Aboriginal and Torres Strait Islander communities should be strengthened by applying participatory-action principles, providing strong clinical and managerial leadership for a CQI culture at all levels of health service organisation and management, and developing capacity to support community-level service organisations.

2 Principles of community-based research guiding the ABCD research project12

3 Stakeholders’ perspectives

Aboriginal Health Worker

“[Generally] when programs come into the organisation, the information goes to management levels [which] have always been responsible for collecting [data collection] and providing the information required. Whereas, the H4L [Healthy for Life] and ABCD processes involved all staff perspectives — all the way from drivers, clinical staff, management and executive — and having input in all stages of the project activities.

The project gave all staff the opportunity to have involvement and participation into a different field of work . . . the way we do our work . . . opening up our eyes to different evaluations when entering data, and to see the results . . . what is happening and where the changes can be made.”

Clinic Coordinator, Wurli Wurlinjang Health Service, Katherine

Health Centre Manager

“The project has been able to give us a gentle nudge to look at the work protocols and practice in the clinic.

Each year the audit feedback showed where our areas of practice were working well and not working so well, and where to set goals/targets for improvements in areas needing more attention to improve services for our clients.”

Barunga Community Health Centre, Sunrise Health Service

Chief Health Officer

“All health practitioners aim to be self-reflective in their practice. In the NT, we know we need to do more to address chronic disease. ABCD has supported health practitioners by providing a framework to think through our approach to chronic disease at a health centre level, information to assess how we are going, and some training and support to make appropriate changes. It has also allowed practitioners to learn from each other. In this way, it has strengthened implementation of the NT Preventable Chronic Disease Strategy and the chronic disease strategies that all health service organisations in the NT have in place. ABCD is a great example of effective researcher–practitioner–manager–policymaker collaboration.”

Northern Territory Department of Health and Community Services

  • Ross S Bailie1
  • Damin Si2
  • Lyn O'Donoghue3
  • Michelle Dowden4

  • Menzies School of Health Research, Charles Darwin University, Darwin, NT.



We thank Gwenda Gless, Peter Wordsworth and Tarun Weeramanthri for providing comments from health professionals. Ross Bailie’s research is funded by a National Health and Medical Research Council Fellowship grant (#283303). The ABCD project is funded by the Australian Health Ministers’ Advisory Council and by the Cooperative Research Centre for Aboriginal Health.

Competing interests:

None identified.

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