Editorial on the Research Topic
Continuous Quality Improvement (CQI)—Advancing Understanding of Design, Application,
Impact, and Evaluation of CQI Approaches
Continuous quality improvement (CQI) approaches are increasingly used to bridge gaps
between the evidence base for best practice, what actually happens in practice, and
achievement of better population health outcomes. Among a range of quality improvement
strategies, CQI is characterized by iterative use of processes to identify quality
problems, develop solutions, and implement and evaluate changes. Application of CQI
in health care is evolving and evidence of their success continues to emerge (1–3).
Through the Research Topic, “Continuous Quality Improvement (CQI)—Advancing Understanding
of Design, Application, Impact, and Evaluation of CQI approaches,” we aimed to aggregate
knowledge of useful approaches to tailoring CQI approaches for different contexts,
and for implementation, scale-up and evaluation of CQI interventions/programs. This
Research Topic has attracted seven original research reports and three “perspectives”
papers. Thirty-six authors have contributed from eighteen research organizations,
universities, and policy and service delivery organizations. All original research
articles and one perspective paper come from the Australian Audit and Best Practice
for Chronic Disease (ABCD) National Research Partnership (“ABCD Partnership”) in Indigenous
primary healthcare settings (4–6). To some extent, this reflects the interests and
connections of two of the Topic Editors, who were lead investigators on the ABCD Partnership.
This Partnership has made a prominent contribution to original research on CQI in
primary healthcare internationally, with over 50 papers published in the peer-reviewed
literature over the past 10 years.
As most articles in this Research Topic arise from the ABCD Partnership, a brief overview
of the program provides a useful backdrop. The program originated in 2002 in the Top
End of the Northern Territory in Australia, and built on substantial prior research
and evaluation of CQI methods in Indigenous primary healthcare. With substantial growth
and enthusiastic support from service providers and researchers around Australia,
the ABCD Partnership has focused since 2010 on exploring clinical performance variation,
examining strategies for improving primary care, and working with health service staff,
management and policy makers to enhance effective implementation of successful strategies
(4). By the end of 2014, the ABCD Partnership had generated the largest and most comprehensive
dataset on quality of care in Australian Indigenous primary healthcare settings. The
Partnership’s work is being extended through the Centre of Research Excellence in
Integrated Quality Improvement (6).
Several research papers included in this Research Topic illustrate consistent findings
of wide variation in adherence to clinical best-practice guidelines between health
centers (Bailie et al.; Burnett et al.; Matthews et al.). The papers also show variation
among different aspects of care, with relatively good delivery of some modes of care
[Bailie et al.; (7)] and poor delivery of others—such as follow-up of abnormal clinical
or laboratory findings. These findings are evident in eye care (Burnett et al.), general
preventive clinical care (Bailie et al.), and in absolute cardiovascular risk assessment
(Matthews et al.; Vasant et al.). The findings are consistent with other ABCD-related
publications on diabetes care (8), preventive health (9), maternal care (10), child
health (11), rheumatic heart disease (12), and sexual health (13).
Systems to support good clinical care are explored by Woods et al. in five primary
healthcare centers that were identified through ABCD data as achieving substantially
greater improvement than others over successive CQI cycles. Attention to understanding
and improving systems was shown to be vital to the improvements in clinical care achieved
by these health centers. Improved staffing and commitment to working in the community
were standout aspects of health center systems that underpinned improvements in clinical
care.
On a wider scale, engagement by primary healthcare services in the ABCD Partnership
has enabled assessment of system functioning at district, regional, state, and national
levels, as reflected in stakeholders’ perceptions of barriers and enablers to addressing
gaps in chronic illness care and child health, and identifying drivers for improvement
(Bailie et al.). Primary drivers included staff capability, availability and use of
information systems and decision support tools, embedding of CQI processes, and community
engagement. We have also shown how consistent and sustained policy and infrastructure
support for CQI enables large-scale and ongoing improvements in quality of care (3).
Commitment of the ABCD team to promoting effective use of CQI data is reflected in
one “perspective” paper, which describes a theory-informed cyclical interactive dissemination
strategy (Laycock et al.). Concurrent developmental evaluation provides a mechanism
for learning and refinement over successive cycles (14).
The other two perspective articles (not specifically from the ABCD program) highlight
the role of facilitation in CQI and the potential for application of CQI in health
professional education. The emerging evidence on facilitation as a vital tool for
effective CQI should guide resourcing and approaches to CQI (Harvey and Lynch). The
approach builds on the humanistic principles of modern CQI methods—participation,
engagement, shared decision-making, enabling others, and tailoring to context. The
framework for CQI approaches to health professional education described by Clithero
et al. directly addresses a critical need for innovative approaches to health workforce
development that will strengthen community engagement and embed CQI principles into
health system functioning. The scale and scope of need in workforce development is
strongly evident in findings of the ABCD program.
Importantly, CQI methods are proving useful in assessing and potentially improving
delivery of evidence-based health promotion practices (Percival et al.). Percival’s
experience in this field highlights the health facility and wider system challenges
facing effective implementation of CQI methods. In health promotion these barriers
include low priority given to health promotion in the face of heavy demands for acute
clinical care. This work in health promotion complements other research on applying
CQI to social determinants of health more broadly (15), including community food supply
(16), housing (17), and education (18).
The publications in this special issue address many of the “building blocks” of high
performing primary care described by Bodenheimer and colleagues in the US; namely,
four foundational components (engaged leadership, data-driven improvement, empanelment,
and team-based care) that are vital to facilitate the implementation of the other
six elements (patient-team partnership, population management, continuity of care,
prompt access to care, comprehensiveness, and care coordination) (19). They are also
relevant to Australian based work on clinical microsystems and development of CQI
tools for mainstream general practice, such as the Primary Care-Practice Improvement
Tool (with similar components to the ABCD systems assessment tool) (20).
Continuous quality improvement is vital to improving health outcomes through system
strengthening. We anticipate substantial future development of CQI methods. By late
2017, there had been over 20,000 views of this Research Topic, and many articles have
already been cited in peer-review manuscripts. Further research on CQI in primary
healthcare would be well guided by a systematic scoping review of literature summarizing
empirical research on current knowledge in the field, and identifying key knowledge
gaps.
Author Contributions
RB wrote the first draft. JB has revised content and structure. SL and EB reviewed
and edited subsequent drafts. All authors have approved the final version of the manuscript
for publication.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.
RB was the chief investigator on the ABCD National Research Partnership and is the
chief investigator on the Centre of Research Excellence in Integrated Quality Improvement.
All papers published in the Research Topic received peer review from members of the
Frontiers in Public Health Policy panel of reviewers who were independent of named
authors on any given article published in this volume, consistent with the journal
policy on conflict-of-interest.