Stoneman Alice, Atkinson David, Davey Maureen, Marley Julia V
Launceston Clinical School, University of Tasmania, Locked Bag 1377, Launceston, TAS 7250, Australia.
BMC Health Serv Res. 2014 Oct 7;14:481. doi: 10.1186/1472-6963-14-481.
Management of chronic disease, including diabetes, is a central focus of most Aboriginal Community Controlled Health Services (ACCHSs) in Australia. We have previously demonstrated that diabetes monitoring and outcomes can be improved and maintained over a 10-year period at Derby Aboriginal Health Service (DAHS). While continuous quality improvement (CQI) has been shown to improve service delivery rates and clinical outcome measures, the process of interpreting audit results and developing strategies for improvement is less well described. This paper describes the evaluation of care of patients with type 2 diabetes mellitus (T2DM) and features of effective CQI in ACCHSs in the remote Kimberley region of north Western Australia.
Retrospective audit of records for Aboriginal and Torres Strait Islander primary care patients aged ≥15 years with a confirmed diagnosis of T2DM at four Kimberley ACCHSs from 1 July 2011 to 30 June 2012. Interviews with health service staff and focus group discussions with patients post audit.
diabetes care related activities, clinical outcome measures and factors influencing good diabetes related care and effective CQI.
A total of 348 patients from the four ACCHSs were included in the study. Clinical care activities were generally high across three of the four health services (at least 71% of patients had cholesterol recorded, 89% blood pressure, 84% HbA1c). Patients from DAHS had lower median cholesterol levels (4.4 mmol/L) and the highest proportion of patients meeting clinical targets for HbA1c (31% v 16% ACCHS-3; P = 0.02). Features that facilitated good care included clearly defined staff roles for diabetes management, support and involvement of Aboriginal Health Workers, efficient recall systems, and well-coordinated allied health services. Effective CQI features included seamless and timely data collection, local ownership of the process, openness to admitting deficiencies and willingness to embrace change.
Well-designed health care delivery and CQI systems, with a strong sense of ownership over diabetes management led to increased service delivery rates and improved clinical outcome measures in ACCHSs. Locally run CQI processes may be more responsive to individual health services and more sustainable than externally driven systems.
慢性病管理，包括糖尿病管理，是澳大利亚大多数原住民社区控制卫生服务机构（ACCHSs）的核心工作重点。我们之前已经证明，在德比原住民健康服务中心（DAHS），糖尿病监测及相关成果在10年期间内可以得到改善并维持。虽然持续质量改进（CQI）已被证明能提高服务提供率和临床结果指标，但解读审核结果并制定改进策略的过程却鲜有描述。本文描述了对西澳大利亚州西北部偏远金伯利地区ACCHSs中2型糖尿病（T2DM）患者护理情况的评估以及有效CQI的特点。
对2011年7月1日至2012年6月30日期间在金伯利地区四家ACCHSs确诊为T2DM的15岁及以上原住民和托雷斯海峡岛民初级护理患者的记录进行回顾性审核。审核后对卫生服务人员进行访谈，并与患者进行焦点小组讨论。
糖尿病护理相关活动、临床结果指标以及影响良好糖尿病相关护理和有效CQI的因素。
来自四家ACCHSs的348名患者纳入研究。四家卫生服务机构中的三家临床护理活动总体水平较高（至少71%的患者记录了胆固醇水平，89%记录了血压，84%记录了糖化血红蛋白）。DAHS的患者胆固醇中位数水平较低（4.4毫摩尔/升），达到糖化血红蛋白临床指标的患者比例最高（31%对ACCHS - 3的16%；P = 0.02）。促进良好护理的特点包括明确界定糖尿病管理的工作人员职责、原住民健康工作者的支持与参与、高效的召回系统以及协调良好的联合卫生服务。有效的CQI特点包括无缝且及时的数据收集、对该过程的本地自主权、承认不足的开放性以及接受变革的意愿。
精心设计的医疗服务提供和CQI系统，以及对糖尿病管理的强烈主人翁意识，使得ACCHSs的服务提供率提高，临床结果指标得到改善。本地运行的CQI流程可能比外部驱动的系统对个别卫生服务机构更具响应性且更具可持续性。
