Table 3

Summarised within case analyses: factors affecting continuous quality improvement (could be supplementary material)

LevelThemeSite (1)Site (2)Site (3)Site (4)Site (5)Site (6)
MacroLinkages/partnerships with external organisations*
‘So (name) comes around quite frequently and gets an update on health because he’s on the Hospital Board. He goes around all the different agencies in the community for updates so he’s very proactive in that way.’
*
‘The partnership recognises that other agencies also contribute, so there is Mental Health, there is (name) Paediatrics that provides services, there’s also United First Peoples of Australia who provide services.’
*
‘You know we need really good relationships with services like (ACCHS) to sort it out. I know we’ve got some students that have organised with their Clinic to be able to get their medication while they’re here.’

‘AMSANT did one of their collaborative workshops in Katherine and the focus was on anaemia…I know that we’ve shared data with the ABCD partnership stuff.’

‘There are very good relationships with stakeholders in Central Australia ……. from clinical working on a daily basis, we need to strengthen those relationships.’
Supportive external health service policies
‘So just because of the stability and the belonging and the Health Workers, in the communities, it’s more ideal to invest and give them the appropriate training.’

‘…there’s a huge shift in the way Primary Healthcare is delivered and it’s coming from the top. Before it was more acute. Executives have finally realised that…’
*
‘There was a really concerted effort to try and get people on fixed term contracts rather than agency. Or swap them over from agency to fixed term.’
*
‘We have received a lot of support from central – from N.T. Health. We are able to access the CQI coordinator if we need to, to get some advice.’
*
‘we probably find a lot of our support from the N.T. Health Government as well.’
Understanding and responding to historical and cultural context*
‘people need to, before they go and talk to people, they really need to sit back and understand their ways first. They need to know their audience.’
*
‘Find out the story of the people that you’re working for… that’ll give you a rough indication of where things are… It gives you a bit more understanding of them.’
*
‘We have a pretty big focus on cultural safety and cultural security in the organisation. People get hammered at cultural orientation. If an issue arises we’ll nip it in the bud pretty well straight away.’
*
‘I’m a full supporter of Aboriginal Health Services and as a community we need to get behind them …Our health is not improving and in fact… it’s actually gone downhill since the intervention in the Territory’
Community driving health (care)*
‘The Health Committee in the community, introduced that because that was where we needed to be working and that was our support system. We’d all agree that we’ll be coordinating and that was the beginning of the direction of our future health’
*
‘consumer input into the governance of care …that makes a big difference…but anything new that comes to us is provided in terms of a cultural and security framework and…that does help with engagement in care and participation, and some of the self-management stuff.’
MesoCQI systems and supports at health service level
‘They do yearly checks on a few things and the healthcare staff here are quite good at monitoring – controlling who’s coming in and who’s going out.’
*
‘The CQI is something which is best done when someone’s interested in it and hopefully passionate. …when they get the feedback that they’re improving things, they can see the difference that it’s making.’
*
‘So we have quite a tight structure around quality improvement. We do actively have a quality approach to the way that we deliver our health service and we actually announce that- we say that.’
*
‘We have embraced the process a lot more than what was in place before then. It’s a regular process now’
Teamwork and collaboration: shared focus*
‘We support each other.' ‘We’re pretty tight as a unit.’
*
‘It’s the communication here, it’s just really open and (lack of experience) isn’t held against me so to speak. I suppose coz I’m fresh eyes as well. And I have been asked you know, ‘if you see anything that you think is missing.’
*
‘We are a team and using the computer system while you’re triaging a mother for …pain, ‘oh look she’s overdue, 6 week check.’ ‘Let’s just have a look at baby in the pram. He’s 2 months overdue his needles!’ That’s the kind of things that we’re trying to strive for.’
*
‘They’ve got staff who really understand about how to deliver primary healthcare programmes and they really think about and they have to think hard about how they do that for both an Indigenous population and a non-Indigenous population’
*
‘When we think about why are we here? We’re here for our people out in our communities and how do we provide the service best we can… we respond to their needs and wants.’
*
‘They would work with a Health Practitioner usually…So they got to work in ways that they don’t normally work. So there was all this team-building type stuff, you know, and relationship type stuff, in a different way, which was good.’
Prepared and stable workforce for CQI*
‘it’s better to have one that’s here coz they- they build a rapport with the locals and they get to understand a full history of the patient, which is good.’
*
‘The Health Service runs smoothly because the continuity has always been there. So (name) knows the system and what kind of programmes to deliver.’
*
‘I honestly think local personnel and a fresh outlook has made a big difference (to the partnership) and that’s continuity. Stopped this…churn of agency through this hospital.’
*
‘The advantage they have is that they have a more stable staff and going right through from their reception staff to their clinical staff.’
*
‘I think the benefit that we have here is a very stable Leadership Group. So all of the people …have been here for at least 5 years…and some of us for ten. I see in terms of staffing, I see stability now that I’ve never seen in the past.’
*
‘I think that they have consistent staff which makes a difference. A lot of the other health centres that you go to every time you go there’s a different staff member there that makes it difficult. So having consistent staff is one of the big keys.’
‘Two way learning’ for CQI (Indigenous culture and health)*
‘I always like to use the word tuning in – tuning in to people. Different frequencies. Listen to them. Understanding them and I can use my knowledge with their knowledge to bring a level of half understanding between (us).’
*
‘What was working really well, through the partnership is the Family Approach programme. The first step was to introduce the doctor to the traditional owners of that place, then meeting the chairperson, explaining the Family Approach to them and the Council and the community.’
*
‘We go out yearly and hold open community meetings…Management staff will go out, put ourselves in front of the community…give an update on what we’ve done for the last twelve months…open that up to the community and our performance review begins at that point. You tell us from a grass roots perspective, …and if we’ve got challenges then (they) will certainly let us know.’
*
‘I think having the Aboriginal health workers on board? It’s that two-way learning and I’m a believer of two-way learning and that is between health workers and the doctors.’
Micro User/community engaged with the service*
‘We have regular women’s nights where we can promote friendship, getting together and support.’
*
‘People seem to trust and follow-up on their own health, instead of people having to go out and collect them, which is quite interesting as well. Like the health behaviour here is I think a bit different than the type of places I’ve been’
*
‘One of the ‘hooks’ for Aboriginal people to get involved in the health services was the Aboriginal and Torres Strait Islander health checks – just around the engagement with the families getting families in, getting them engaged.’
*
‘The people that do come to the clinic, they come when they’re called in general and they engage. They try and do what you ask them to do. They’re very actively managed by the clinic in terms of getting them in here and they get good service when they come in…and they come back.’
*
‘We have a client population that is I suppose, regularly interacting with the health system.’
*
‘I feel comfortable and every time I come here, everybody’s just laid back. Then they’ve got all these different little changes that happen now and then with the office and stuff it makes you feel really - could you say, ‘at home’.’
‘Going the extra mile’ and staff caring, commitment*
‘They go that little extra mile I think to do those extra things like the afterhours events.’
*
‘(name) has been there for a number of years and has gained the trust of many community members. (name) is part of community.’
*
‘You know, it’s respectful and they listen to you if you got a problem. You know, a lot of health centres don’t listen to their community people when they go in and some are very hard to talk to, but you can go up any time and talk to them about anything if you need to.’
*
‘I had bleeding so we rang up the clinic and a Health Worker she got a hold of the nurse. Well by the time I got to the clinic, she rang and apologised. She even pulled her kids out of the bath to get over to me. So I mean that’s real dedication.’
*
‘…well they’re doing everything all alright. They get along with the community people. They go around, they have a yarn to people. If they need to chase someone down, they go and do that.’
*
‘I enjoy coming in here you know. Have a talk with them and that. They’re always happy, no sad faces or anything. They always greet you with a smile. And they ask me questions too you know. Where they’re going wrong.’
  • *Clearly present.

  • †Present to some degree.

  • ‡Not clearly present.

  • ACCHS, Aboriginal Community Controlled Health Services; AMSANT, Aboriginal Medical Services Alliance, Northern Territory; CQI, continuous quality improvement; N.T., Northern Territory, Australia.