Continuous Quality Improvement Framework Research Articles

A Continuous Quality Improvement Framework for Sustainable Action and Advancement of Diversity, Equity, Inclusion, and Belonging in Physical Therapy.

To address racial and ethnic disparities, physical therapy organizations, educational institutions, and clinical practices seek to advance diversity, equity, inclusion (DEI), and social justice in health care. Although our professional organizations have crafted proclamations, resource lists, developed new accreditation standards, and strategic plans, we lack a unifying framework and action tools for substantial and sustained progress. In addition, the DEI acronym is missing the essential element of belonging (B), that is, sharing a sense of purpose and feeling safe to contribute opinions as a valued member of an organization. Therefore, the purpose of this position paper is to propose the utilization of a continuous quality-improvement (CQI) framework using Plan-Do-Study-Act (PDSA) cycles to advance DEI-B in physical therapy education and practice. The CQI framework and PDSA cycles are data-driven, iterative approaches for identifying areas for improvement, implementing interventions, collecting data, analyzing outcomes, and taking evidence-based next action steps. Application of this framework can enhance sustainability of DEI-B goals and foster progress toward the proposed accreditation criteria of the Commission on Accreditation in Physical Therapy Education in this critical area. Tenants for PDSA team success are presented, and PDSA cycles are described. Addressing racism and advancing DEI-B efforts in the physical therapy profession requires bold, sustained, and intentional action that incorporates standards, strategies, and methods for measuring change. Examples of PDSA DEI-B initiatives, interventions, and outcomes are provided to illustrate how this approach can be implemented within a physical therapy education program. Using this CQI framework provides our profession with a DEI-B roadmap for advancing incremental and sustained progress.

The 5C model: A proposed continuous quality improvement framework for volunteer dental services in remote Australian Aboriginal communities.

Aboriginal and Torres Strait Islander communities in remote parts of Australia are some of the most underserviced communities in regard to oral health care. These communities rely on volunteer dental programmes such as the Kimberley Dental Team to fill the gaps in care, however, there are no known continuous quality improvement (CQI) frameworks to guide such organizations to ensure that they are delivering high-quality, community-centred, culturally appropriate care. This study proposes a CQI framework model for voluntary dental programmes providing care to remote Aboriginal communities. Relevant CQI models wherein the (i) behaviour of interest was quality improvement, and (ii) the health context was volunteer services in Aboriginal communities were identified from the literature. The conceptual models were subsequently augmented using a 'best fit' framework and the existing evidence synthesized to develop a CQI framework that aims to guide volunteer dental services to develop local priorities and enhance current dental practice. A cyclical five-phase model is proposed starting with consultation and moving through the phases of data collection, consideration, collaboration and celebration. This is the first proposed CQI framework for volunteer dental services working with Aboriginal communities. The framework enables volunteers to ensure that the quality of care provided is commensurate with the community needs and informed by community consultation. It is anticipated that future mixed methods research will enable formal evaluation of the 5C model and CQI strategies focusing on oral health among Aboriginal communities.

Geospatial analysis of patients' social determinants of health for health systems science and disparity research.

Geospatial analysis of patients' social determinants of health for health systems science and disparity research.

Content and process: using continuous quality improvement to teach and evaluate learning outcomes in quality improvement residency education

BackgroundPsychiatry has not prioritised quality improvement and patient safety (QIPS) to the same degree as other medical specialties. Professional capacity building in QIPS through the education of residents is essential...

Systems analysis and improvement approach to optimize outpatient mental health treatment cascades in Mozambique (SAIA-MH): study protocol for a cluster randomized trial

BackgroundSignificant investments are being made to close the mental health (MH) treatment gap, which often exceeds 90% in many low- and middle-income countries (LMICs). However, limited attention has been paid to patient quality of care in nascent and evolving LMIC MH systems. In system assessments across sub-Saharan Africa, MH loss-to-follow-up often exceeds 50% and sub-optimal medication adherence often exceeds 60%. This study aims to fill a gap of evidence-based implementation strategies targeting the optimization of MH treatment cascades in LMICs by testing a low-cost multicomponent implementation strategy integrated into routine government MH care in Mozambique.MethodsUsing a cluster-randomized trial design, 16 clinics (8 intervention and 8 control) providing primary MH care will be randomized to the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) or an attentional placebo control. SAIA-MH is a multicomponent implementation strategy blending external facilitation, clinical consultation, and provider team meetings with system-engineering tools in an overall continuous quality improvement framework. Following a 6-month baseline period, intervention facilities will implement the SAIA-MH strategy for a 2-year intensive implementation period, followed by a 1-year sustainment phase. Primary outcomes will be the proportion of all patients diagnosed with a MH condition and receiving pharmaceutical-based treatment who achieve functional improvement, adherence to medication, and retention in MH care. The Consolidated Framework for Implementation Research (CFIR) will be used to assess determinants of implementation success. Specific Aim 1b will include the evaluation of mechanisms of the SAIA-MH strategy using longitudinal structural equation modeling as well as specific aim 2 estimating cost and cost-effectiveness of scaling-up SAIA-MH in Mozambique to provincial and national levels.DiscussionThis study is innovative in being the first, to our knowledge, to test a multicomponent implementation strategy for MH care cascade optimization in LMICs. By design, SAIA-MH is a low-cost strategy to generate contextually relevant solutions to barriers to effective primary MH care, and thus focuses on system improvements that can be sustained over the long term. Since SAIA-MH is integrated into routine government MH service delivery, this pragmatic trial has the potential to inform potential SAIA-MH scale-up in Mozambique and other similar LMICs.Trial registrationClinicalTrials.gov; NCT05103033; 11/2/2021.

An Inter-professional Framework for Quality Improvement of School Gardening Programming

Background: School gardens are exemplary learning environments for providing hands-on nutrition and health education, promoting time outdoors, and developing collaborative skills. However, randomized controlled trials of school gardening programming to provide evidence of the robust benefits to child health can be time consuming and costly. We therefore sought to develop an inter-professional framework for continuous quality improvement (QI) of school gardening programming to improve health outcomes while limiting program implementation and evaluation costs. Methods: This QI cohort study took place in two elementary schools and served 75 students in Palm Beach County, Florida during the 2019-2020 academic year. Students participating in a non-profit sponsored after-school gardening club completed investigator-designed pre- and post-assessments from which unique lessons pertaining to health and food literacy were developed to target knowledge deficits. We present a lesson pertaining to harvesting, preparing, and sampling foods as an exemplar for this framework. Paired and independent samples t-tests and chi-squared tests were used to compare student learning outcomes. Results: Twenty-seven students (36%) participated in the harvest lesson, which led to marginal improvement in overall food literacy compared to non-participants (X2=3.6, P=0.057).Considering cumulative garden club activities, club participation improved students’ likelihood to individually prepare fresh fruits and vegetables (P=0.002). Conclusion: This project provides an important framework for inter-professional collaboration to engage in QI of small-scale school gardening programs. Future work should focus on the creation and implementation of further lessons to develop a full, individualized, health-oriented curriculum that optimizes learning outcomes, and thereby health, for elementary-aged children.

Evaluation of an ankylosing spondylitis education and self-management program: Beneficial effects on ankylosing spondylitis specific outcomes.

Self-management programs have demonstrated significant health benefits in people with musculoskeletal diseases. To examine the benefits of a tailored ankylosing spondylitis self-management program (ASSMP) delivered by trained health professionals for people with ankylosing spondylitis (AS) relative to health status, quality of life and disease activity. ASSMP was developed within a continuous quality improvement framework following a needs assessment and focus group discussions. Formal feedback from the group after each 6week program cycle group by questionnaire helped refine the ASSMP. Patient health status, quality of life and disease activity were assessed at multiple time points up to 12months. Fifty-five percent were female; mean age 48.5±15.2years. Median time to AS diagnosis was 4years (interquartile range: 1-10). AS disease activity Bath Ankylosing Spondylitis Global Score scores improved at 3, 6 and 12months (P<.001). Bath Ankylosing Spondylitis Disease Activity Index improved at 6weeks and was sustained at 3, 6 and 12months (P<.001). The Ankylosing Spondylitis Quality of Life improved at 3, 6 and 12months (P<.001). Bath Ankylosing Spondylitis Functional Index improved by 12months (P<.001). Participants reported less nocturnal back pain at 6months and was sustained at 12months (P<.001). Patients Global Disease Activity improved by 6months (P=.012), Multi-Dimensional Assessment of Fatigue and a Global Fatigue Index at 6months (P=.003), Hospital Anxiety and Depression Scale - Anxiety at 12months (P=.001), Evaluation Ankylosing Spondylitis Quality of Life at 6months (P=.001) and Pain Self-Efficacy Questionnaire at 12months (P=.002). This ASSMP demonstrated significant and sustained benefit in symptoms, disease activity measures and quality of life in a condition that results in significant impairment, disability and poorer quality of life. The cost effectiveness and benefit of this program should be tested.

A continuous quality improvement framework for electrowinning current efficiency

SYNOPSIS Electrowinning consumes a substantial amount of electrical energy, and owing to the ever-increasing unit cost of electrical power there is a need to improve current efficiency in the process. This research was carried out to design a continuous quality improvement framework for improving electrowinning current efficiency by applying statistical process control (SPC) on an online industrial copper electrowinning operation. A sequential mixed research methodology was applied and a statistical software package utilized for analysing data. It was concluded that metallurgical short-circuits (hotspots) had the most significant effect on current efficiency. Bringing hotspots under statistical control resulted in a 5.40% improvement in current efficiency, which is equivalent to approximately 74 t of 99.999% pure grade A copper cathode production over a period of 1.5 months. Keywords: quality, continuous improvement, continuous quality improvement, statistical process control, and current efficiency.

A framework of healthy ageing for the Torres Strait: A grassroots approach to dementia risk reduction

AbstractBackgroundOlder Aboriginal and Torres Strait Islander Australians play a crucial role in the health of their communities, holding the cultural rights and responsibilities for maintaining connections to Country, caring for extended family members, and providing leadership and support in their families and within communities. Maintaining the health of older adults is crucial not only for their quality of life but also the cohesiveness of the community they live in. Dementia is a key health priority in Indigenous communities given their increased risk of dementia compared to the general population. At present, there is a lack of evidence around what healthy ageing means in the Torres Strait or how older adults can be supported through the health care system to remain in their communities. In this paper, a study protocol will be presented for review. The aim of the study is to develop a culturally appropriate framework of Healthy Ageing for Torres Strait Communities that will include dementia risk reduction strategies to enable older persons to remain living within their communities for as long, and as healthily, as possible.MethodThis project will use Participatory Action Research to enable Torres Strait communities to identify environmental, cultural, spiritual and other priorities to achieve a fulfilling and positive approach to living well as they age. Using a Continuous Quality Improvement framework, primary health care centres will develop quality improvements based on priorities identified by the community.ResultsPrimary health care centres will implement best practice screening, culturally appropriate assessments, and targeted interventions to support their people to age well and remain on country and implement dementia risk reduction strategies.ConclusionResults will inform a culturally appropriate framework of Healthy Ageing for Torres Strait Communities to enable older persons to remain living well at home, and on Country for as long as possible with reduced dementia risk.

An automated continuous quality improvement framework for failing student outcomes based on mathematics weaknesses

In this paper, we present a detailed action plan under continuous quality improvement (CQI) exercise of outcomes based education framework related to Mathematics concerns highlighted by the Electrical Engineering (EE) Department. Failing and low performed student learning outcomes (SOs) and course learning outcomes (COs) in range of core EE courses were observed to be linked with weak Mathematics basis of students. This feedback was achieved through an automated CQI system in EvalTools under Faculty Class Assessment Report (FCAR) tab, where each instructor is required to make reflections about failing as well as low performed SOs and COs. Feedback was reviewed comprehensively, and mathematical concepts which significantly affect the performance of students in the core EE courses were derived. Moreover, a high level of Mathematics pre-requisite covering required mathematical concepts is identified for the range of core EE courses. Consequently, well-defined tasks were assigned to continuously evaluate and monitor improvement in required Mathematics concepts to ensure SOs and COs achieved in core EE courses. Results are given to exhibit the effectiveness of continuous improvement management system (CIMS).

LO41: The development of a standardized provincial massive hemorrhage protocol with a built-in continuous quality improvement framework

Background: Massive hemorrhage protocols (MHPs) streamline the complex logistics required for prompt care of the bleeding patient, but their uptake has been variable and few regions have a system to measure outcomes from these events. Aim Statement: We aim to implement a standardized MHP with uniform quality improvement (QI) metrics to increase uptake of evidence-based MHPs across 150-hospitals in Ontario between 2017 and 2021. Measures &amp; Design: We performed ongoing PDSA cycles; 1) stakeholder analysis by surveying the Ontario Regional Blood Coordinating Network (ORBCoN), 2) problem characterization and Ishikawa analysis for key QI metrics based on areas of MHP variability in 150 Ontario hospitals using a web-based survey, 3) creation of a consensus MHP via a modified Delphi process, 4) problem characterization at ORBCoN for the design of a freely available toolkit for provincial implementation by expert working groups, 5) design of 8 key QI metrics by a modified Delphi process, and 6) identification of process measures for QI data collection by implementation metrics. Evaluation/Results: PDSA1-2; 150-hospitals were surveyed. 33% of hospitals lacked MHPs, mostly in smaller sites. Major areas for QI were related to activation criteria, hemostatic agents, protocolized hypothermia management, variable MHP naming, QI metrics and serial blood work requirements. PDSA3; 3 Delphi rounds were held to reach 100% expert consensus for 42 statements and 8 CQI metrics. Major areas for modification were protocol name, laboratory resuscitation targets, cooler configurations, and role of factor VIIa. PDSA4; adaptable toolkit is under development by the steering committee and expert working groups. Implementation is scheduled for Spring 2020. PDSA5; the 8 CQI metrics are: TXA administration &lt; 1 h, RBC transfusion &lt; 15 min, call to transfer for definitive care &lt; 60 min, temp &gt;35°C at end of protocol, Hgb kept between 60-110g/L, transition to group-specific RBC by 90 min, appropriate activation defined by ≥6 units RBC in the first 24 hours, and any blood component wastage. Discussion/Impact: MHP uptake, content, and tracking is variable. A standardized MHP that is adaptable to diverse settings decreases complexity, improves use of evidence-based practices, and provides a platform for continuous QI. PDSA6 will occur after implementation; we will complete an implementation survey, and design a pilot and feasibility study for prospective tracking of patient outcomes using existing prospectively collected inter-hospital and provincial databases.

Abstract WP189: Application of a Continuous Quality Improvement Framework: Longitudinal Results From Year 1 of the Stroke Survivor to Survivor Program

In 2018, the Mission Lifeline North Dakota (ND) initiative adopted and began to implement Stroke Survivors Empowering Each Other, Inc.’s (SSEEO’s) Stroke Survivor to Survivor (SS2S) program. The SS2S program is a post-stroke support program that aims to facilitate survivors’ efforts to recover after stroke. Volunteers, who are themselves survivors, call participants monthly at least twice following discharge from the hospital and provide them with stroke-related resources and support. The adaptation and implementation of the Chicago-borne SS2S program in ND was embedded within a continuous quality improvement framework to ensure ongoing performance monitoring data could inform programmatic improvements as needed. Key questions: • How has the Chicago-borne SS2S program been adapted to fit the unique characteristics and environment of ND, while maintaining fidelity? • What are performance monitoring findings from the first three quarters of implementation? Between Oct 2018- Feb 2019, four of the six ND tertiary hospitals implemented the SS2S program. These hospitals provide monthly quantitative and qualitative data on program implementation. From Oct 2018 to May 2019, SS2S volunteers made 153 calls to survivors, with 57% (n = 87 of 153) of calls answered by a prospect, including stroke survivors (n=74) and their caregivers (n=13). Thirteen percent (n = 9 of 69) of stroke survivors calls required additional follow-up by hospital staff. SS2S volunteers mailed additional resources to stroke survivors for 48% percent of the calls where the prospect was reached (n= 33 of 69). Seventy percent (n = 48 of 69) of survivors reached were able to identify at least one sign of stroke. Preliminary results suggest that both volunteers and stroke survivors may benefit from the program. Importantly, performance monitoring data also identified opportunities for programmatic improvements. For example, these data informed edits to the volunteers’ phone scripts to clarify signs-of-stroke patient-education. Ongoing feedback from the hospitals have also informed improvements to the performance monitoring processes.

MANAGING HIGH-RISK PATIENTS IN THE COMMUNITY

Participants will be able to appreciate the benefits of using a continuous quality improvement framework to develop and evaluate evidence-based quality care to meet the needs of their patient population.

The co-design of timely and meaningful information needed to enhance social participation in community aged care services: Think tank proceedings.

To determine what information from community aged care social participation and quality of life assessments needs to be captured, and meaningfully utilised as part of an integrated information and communication technology system. Two think tank sessions comprised of community aged care staff and researchers (n=9) were conducted over 5weeks. The sessions were guided by the Continuous Quality Improvement framework. Thematic analysis was used to categorise the think tank data. To monitor progress over time, participants needed more contextual information captured in the assessment forms, such as client goals and outcomes of assessments. The aged care provider agreed to embed outcome measure score and action following assessment into its information and communication technology system. Collaboration between aged care staff and researchers resulted in adjustments to the aged care provider's information and communication technology system to better target the monitoring and planning of its clients' psychosocial needs.

A modified Continuous Quality Improvement approach to improve culturally and socially inclusive care within rural health services.

The sickest Australians are often those belonging to non-privileged groups, including Indigenous Australians, gay, lesbian, bisexual, transsexual, intersex and queer people, people from culturally and linguistically diverse backgrounds, socioeconomically disadvantaged groups, and people with disabilities and low English literacy. These consumers are not always engaged by, or included within, mainstream health services, particularly in rural Australia where health services are limited in number and tend to be generalist in nature. The aim of this study was to present a new approach for improving the sociocultural inclusivity of mainstream, generalist, rural, health care organisations. This approach combines a modified Continuous Quality Improvement framework with Participatory Action Research principles and Foucault's concepts of power, discourse and resistance to develop a change process that deconstructs the power relations that currently exclude marginalised rural health consumers from mainstream health services. It sets up processes for continuous learning and consumer responsiveness. The approach proposed could provide a Continuous Quality Improvement process for creating more inclusive mainstream health institutions and fostering better engagement with many marginalised groups in rural communities to improve their access to health care. The approach to improving cultural inclusion in mainstream rural health services presented in this article builds on existing initiatives. This approach focuses on engaging on-the-ground staff in the need for change and preparing the service for genuine community consultation and responsive change. It is currently being trialled and evaluated.

Does Clinical Governance influence the quality of medical records?

Clinical Governance (CG) is a validated framework for continuous quality improvement in health care settings. Quality medical records may reflect the quality of care delivered and are a viable tool to implement CG skills. Aim of this study is to investigate the correlation between the level of implementation of CG dimensions and the quality of medical records. A cross-sectional study was carried out in an Italian Teaching Hospital. CG implementation levels were quantified through a systematic methodology (OPTIGOV©). The overall quality of medical records was measured through a revised version of a National-validated scale. A multiple linear regression model was used to test the likely influence of all the variables constituting the OPTIGOV evaluation on the quality of medical records. 47 hospital wards and 1458 medical records were assessed. A significant and positive association between the quality of medical records and the accountability score (β = 0.15; p < 0.01) and the clinical audit score (b = 0.11; p = 0.02), was found. Conversely, the risk management score shown a negative and significant correlation (b = -0.17; p < 0.01). This study confirms that CG plays a central role in driving quality improvement and advocates a systematic implementation of such an approach within healthcare organizations.

Effective implementation of the UNCRPD by Thailand State Party: challenges and potential remedies

BackgroundThe Thai government ratified the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2008, and the first progress report by the State Party was issued in 2012. This study assesses and identifies gaps in the Government’s implementation of the Convention.MethodsUsing the Deming Plan-Do-Check-Act Cycle as an analytical framework for continuous quality improvement, we reviewed five documents which are: the 2012 State Party report; the list of issues by the Committee on the Rights of Persons with Disabilities; the 2015 replies to the list of issues by the Thai government; an alternative report produced by Civil Society Organizations (CSOs); and an alternative report produced by the National Human Rights Commission of Thailand. Content analysis is applied to generate the emerging gaps in implementation.ResultsThailand’s main advantage is the evolving legal frameworks operating in compliance with the convention, although further amendment is still needed, including effective law enforcement. Conflicting information between the Government’s and alternative reports reflects the shortcomings in the information system that intends to support rigorous monitoring and evaluation. Lacking of concrete measures and outcome indicators on certain articles reflects the State Party’s limited understanding of the concept of human rights and participatory approaches and insufficient institutional capacities for effective implementation.ConclusionsTo rectify these implementation gaps, a few actions are suggested. This includes amending the laws which violate the rights of persons with psychosocial disability; reforming governance where the monitoring bodies are truly independent from implementing agencies; strengthening cross-sectoral actions; and improving information systems which facilitate monitoring and evaluation where Disabled People’s Organizations and Civil Society Organizations are recognized as true equal partners. Implementation research can provide evidence for further effective implementation.

Improvement in quality of hospital care during accreditation: A nationwide stepped-wedge study.

To assess changes over time in quality of hospital care in relation to the first accreditation cycle in Denmark. We performed a multi-level, longitudinal, stepped-wedge, nationwide study of process performance measures to evaluate the impact of a mandatory accreditation programme in all Danish public hospitals. Patient-level data (n=1 624 518 processes of care) on stroke, heart failure, ulcer, diabetes, breast cancer and lung cancer care were obtained from national clinical quality registries. The Danish Healthcare Quality Programme was introduced in 2009, aiming to create a framework for continuous quality improvement. Changes in week-by-week trends of hospital care during the study period of 269 weeks prior to, during and post-accreditation. The quality of hospital care improved over time throughout the study period. The overall positive change in trend odds ratio (OR) = 1.002 per week; 95% confidence interval (CI: 0.997-1.006) observed when comparing the period during accreditation with the period prior to accreditation was not significant. However, when restricting the analyses to processes of care where the performance did not meet target values for satisfactory quality prior to accreditation, we found a significant positive change in trend (OR = 1.006 per week; 95% CI: 1.001-1.011). When comparing the post-accreditation period with the period during accreditation, we found a significantly reduced trend (OR = 0.994 per week; 95% CI: 0.988-0.999), indicating the improvement in quality of care continued but at a lower rate than during accreditation. These findings support the hypothesis that hospital accreditation leads to improvements in patient care.

Drivers of Dashboard Development (3-D): A Curricular Continuous Quality Improvement Approach.

Undergraduate medical education (UME) programs are seeking systematic ways to monitor and manage their educational performance metrics and document their achievement of external goals (e.g., Liaison Committee on Medical Education [LCME] accreditation requirements) and internal objectives (institution-specific metrics). In other continuous quality improvement (CQI) settings, summary dashboard reports have been used to evaluate and improve performance. The Stony Brook University School of Medicine UME leadership team developed and implemented summary dashboard performance reports in 2009 to document LCME standards/criteria compliance, evaluate medical student performance, and identify progress in attaining institutional curricular goals and objectives. Key performance indicators (KPIs) and benchmarks were established and have been routinely monitored as part of the novel Drivers of Dashboard Development (3-D) approach to curricular CQI. The systematic 3-D approach has had positive CQI impacts. Substantial improvements over time have been documented in KPIs including timeliness of clerkship grades, midclerkship feedback, student mistreatment policy awareness, and student satisfaction. Stakeholder feedback indicates that the dashboards have provided useful information guiding data-driven curricular changes, such as integrating clinician-scientists as lecturers in basic science courses to clarify the clinical relevance of specific topics. Gaining stakeholder acceptance of the 3-D approach required clear communication of preestablished targets and annual meetings with department leaders and course/clerkship directors. The 3-D approach may be considered by UME programs as a template for providing faculty and leadership with a CQI framework to establish shared goals, document compliance, report accomplishments, enrich communications, facilitate decisions, and improve performance.

'There's only one enabler; come up, help us': staff perspectives of barriers and enablers to continuous quality improvement in Aboriginal primary health-care settings in South Australia.

This paper presents the findings from a qualitative study, which sought to investigate the barriers and enablers to implementation of a continuous quality improvement (CQI) program by health-care professionals in Aboriginal primary health-care services in South Australia. Eighteen semi-structured interviews across 11 participating services were conducted alongside CQI implementation activities. Multiple barriers exist, from staff perspectives, which can be categorised according to different levels of the primary health-care system. At the macro level, barriers related to resource constraints (workforce issues) and access to project support (CQI coordinator). At the meso level, barriers related to senior level management and leadership for quality improvement and the level of organisational readiness. At the micro level, knowledge and attitudes of staff (such as resistance to change; lack of awareness of CQI) and lack of team tenure were cited as the main barriers to implementation. Staff identified that successful and sustained implementation of CQI requires both organisational systems and individual behaviour change. Improvements through continuing regional level collaborations and using a systems approach to develop an integrated regional level CQI framework, which includes building organisational and clinic team CQI capacity at the health centre level, are recommended. Ideally, this should be supported at the broader national level with dedicated funding.