Continuous quality improvement across a South Australian health service and the role it plays in a learning health system: a qualitative study

Abstract

Introduction: Continuous quality improvement (CQI) initiatives are commonly used to enhance patient safety and quality of care. A novel South Australian Local Health Network (SALHN) Continuous Improvement Program (CIP009) has integrated a top-down model of executive-directed change initiatives, with a bottom-up approach of clinician designed interventions to address an organisational-wide goal of improved patient flow. This study evaluated the strengths and challenges of CIP009 implementation from the perspective of participants and deliverers.

Methods: A qualitative study was conducted in 2023/2024 to evaluate the implementation of CIP009 and 12 associated quality improvement projects. Semi-structured interviews and focus groups were conducted with key stakeholders (executives, coaches and CIP009 fellows) and guided by the Consolidated Framework for Implementation Research (CFIR). A document review and observations of CIP009 team meetings were also conducted. Data were analysed inductively using thematic analysis, then deductively mapped against the five CFIR domains.

Results: Thirty-one participants were interviewed individually or in focus groups, two presentation days and six team meetings were observed, and 78 documents were reviewed. Seven key themes were identified highlighting key challenges and strengths of CIP009 implementation within the SALHN setting. These included four key strengths: the CIP framework and culture (the flexible framework, common language, training, and a culture of flattened hierarchy); the benefits of support from a dedicated, internal improvement Faculty (wrap around support from coaches); the advantages of an enthusiastic team member disposition and incentives (vested interests to enhance workflow and patient outcomes); and effective teams and team composition (teams comprised of senior clinician change agents). Three key challenges included: workforce and organisation-level challenges (individual workloads, workforce capacity, and data access); team cohesion, logistics and stakeholder engagement challenges (issues in the way teams worked together); and training and support shortcomings (the training course, and the top-down nature of CIP009).

Conclusion: This evaluation identified that CIP009 was considered an effective multifaceted CQI program. The strengths of CIP009 support a learning health system (a data driven model, utilising systematic frameworks, with commitment from leadership, and a culture of continuous learning). Further integration of implementation science principles may support the program to overcome the key challenges identified. These findings will inform and guide improvement efforts within future iterations of CIP.

Keywords: Ambulance ramping; Capacity building; Consolidated framework for implementation research; Continuous quality improvement; Implementation science; Learning health system; Patient flow; Qualitative research; Quality improvement; Thematic analysis.

Fig. 1

Key attributes of the SALHN CIP009 program