Systems Change Strategies Research Articles

Pathways for Strengthening Lived Experience Leadership for Transformative Systems Change: Reflections on Research and Collective Change Strategies.

The Activating Lived Experience Leadership (ALEL) project was a South Australian participatory action research project that aimed to improve the ways lived experience is recognised, valued and integrated across mental health and social sector systems. ALEL was completed during 2019-2021, where it engaged 182 participants in generating community action and research knowledge. Our paper discusses the project's processes of building a collective partnership among lived experience leaders and other leaders from within the sector, so that the actions and strategies identified through research could be implemented by systems-level impact. We describe the collaborative process and key learnings that resulted in eight key action areas for transformative systems change in South Australia. The project invited a diverse range of self-identified lived experience and other leaders to be involved in a PAR process featuring formal qualitative research (focus groups, surveys and interviews) as well as community development activities (leaders' summit meetings, consultations, training and community of practice meetings). These processes were used to help us describe the purpose, achievements and potential of lived experience leadership. Project priorities and systems-level analysis was also undertaken with lived experience sector leaders and project advisors across two leaders' summit meetings, integrating research outcomes with sector planning to define high-level actions and a vision for transformational change. Participatory action research as informed by systems change and collective impact strategies assisted the project to generate detailed findings about the experiences and complexities of lived experience leadership, and collective responses of how systems could better support, be accountable to and leverage lived experience perspectives, experience and peer-work approaches. Systems change to define, value and embed lived experience leadership benefits from collective efforts in both formal research and sector development activities. These can be used to generate foundational understandings and guidance for working together in genuine ways for transforming mental health and social sector systems, experience and outcomes. Members of lived experience communities codesigned the project, and contributed to project governance and the development of all findings and project reports.

System change in practice: A report from the EHC Think Tank workstreams on Registries and Patient Agency

Abstract Introduction System change addresses the fundamental causes of persistent, complex problems to achieve large-scale, sustainable solutions at multiple levels. Recognising the need for system change to ensure equitable access to healthcare for people with bleeding disorders and other rare diseases, the European Haemophilia Consortium (EHC) established a Think Tank to work alongside its traditional advocacy initiatives. The Think Tank has mobilised a broad range of healthcare stakeholders to identify challenges and co-create potential solutions through a series of thematic workstreams exploring specific aspects of the healthcare system. This paper reports on outcomes and learnings from the Registries and Patient Agency workstreams. Methodology/Process During a series of online meetings and face-to-face discussions, workstream stakeholders contributed to a three-phase process: 1. Discovery; 2. Strategy; 3. Innovation. Having identified key challenges to system change for Registries and Patient Agency, stakeholders mapped the system in which they were working to refine the challenges, recognise enablers and constraints to progress, and use leverage points to co-create strategies for change. Results The Registries workstream prioritised actions to address challenges around lack of common purpose and data quality, and agreed to move forward with developing a consensus statement to facilitate buy-in from key stakeholders, working on good governance for registries, hosting a network for registry owners, and creating a model for patient data input and feedback. A Registries Roadmap was completed for 2025 and 2030, and a project initiated to align registries in Europe. The Patient Agency workstream agreed actions should focus on challenges related to the role of the patient, recognising the need to elevate patient influence in all aspects of the healthcare system. Actions aimed to address the current stakeholder hierarchy and gaps in patient health literacy, and to optimise the potential of digital tools to enable patient contributions to patient-reported outcome and experience measures (PROMs and PREMs). Projects include developing a patient agency guidebook and a patient experience data (PED) dossier on von Willebrand disease, to provide a one-stop repository for regulators, researchers, clinicians and patients. Conclusions There is a clear need for system change to ensure equitable access to healthcare for people with rare diseases such as bleeding disorders. Bringing together multiple stakeholders with different and complementary knowledge and approaches has facilitated the development of innovative strategies for system change in relation to Registries and Patient Agency. Work has started on pilot projects to move these strategies forward.

Improving communicative access and patient experience in acute stroke care: An implementation journey

IntroductionPatient experience for people with aphasia/families in acute care is frequently reported as negative, with communication barriers contributing to adverse events and significant long-term physical and psychosocial sequelae. Although the effectiveness of providing supported communication training and resources for health care providers in the stroke system is well documented, there is less evidence of implementation strategies for sustainable system change. This paper describes an implementation process targeting two specific areas: 1) improving Stroke Team communication with patients with aphasia, and 2) helping the Stroke Team provide support to families. The project aimed for practical sustainable solutions with potential contribution toward the development of an implementation practice model adaptable for other acute stroke contexts. MethodsThe project was designed to create a communicatively accessible acute care hospital unit for people with aphasia. The process involved a collaboration between a Stroke Team covering two units/wards led by nurse managers (19 participants), and a community-based Aphasia Team with expertise in Supported Conversation for Adults with Aphasia (SCA™) – an evidence-based method to reduce language barriers and increase communicative access for people with aphasia. Development was loosely guided by the integrated knowledge translation (iKT) model, and information regarding the implementation process was gathered in developmental fashion over several years. OutcomesExamples of outcomes related to the two target areas include provision of accessible information about aphasia to patients as well as development of two new products – a short virtual SCA™ eLearning module relevant to acute care, and a pamphlet for families on how to keep conversation alive. Potential strategies for sustaining a focus on aphasia and communicative access emerged as part of the implementation process. ConclusionsThis implementation journey allowed for a deeper understanding of the competing demands of the acute care context and highlighted the need for further work on sustainability of communicative access interventions for stroke patients with aphasia and their families.

Turning rebellion into money? Social entrepreneurship as the strategic performance of systems change

AbstractResearch SummaryCritical scholars recognize a disjuncture between the problems identified by social entrepreneurs and the solutions they propose. Existing theory treats this as a problem to be rectified at the organizational level. In this essay, we widen attention to the macro‐oriented systems change strategies of social entrepreneurs. We develop a dynamic typology showing how strategies are reassembled over time to stimulate or deflect desire for systems change. Deriving inspiration from Goffman, we theorize the ways that different types of systems change actor perform systems change via interaction with their environments. Drawing on illustrative cases on the boundaries of social entrepreneurship, we show how the collective action frameworks developed by systems change actors can be adapted and repurposed by their (systems) audiences: effectively turning rebellion into money.Managerial SummarySocial entrepreneurs often call for systems change to tackle wicked problems such as poverty or climate change. However, the strategies they propose for tackling these problems, such as lending money to poor people are considerably less radical. In this essay, we identify three types of systems change actor distinguished by the degree of systems change they call for. We trace their ideas over time to illustrate how strategies are mediated, and subsequently repurposed through interaction with the systems they seek to change. In conclusion, we call upon researchers and social entrepreneurs to widen their perspectives to incorporate more radical ideas and potentials for systems change, and for greater attention to be devoted to scrutinizing and protecting the integrity of systems change strategies.

25 Years: Looking Back, Looking Forward.

Palliative medicine and the practice of palliative care has disseminated around the world for the past 25 years. In many countries, palliative medicine is a formally recognized specialty of medicine. Yet, there is a high variability, due in part to the variable resources devoted to its development. New research is needed to improve our ability to control symptoms and to know how best to implement the existing science so that the patients who need palliative care can get it easily and equitably. Achieving this level of access requires expertise in organizational structure and system change strategies. Building the evidence base for best practices requires us to forge research collaborations with collegues from all medical subspecialities, including experts from allied health disciplines, and partner closely with patients and families. It also compels us to look critically at ourselves to overcome the barriers we put in our own way to becoming a routine part of standard health care in all countries.

Articulating system change to effectively and justly address the climate crisis

ABSTRACT Activists and world leaders increasingly call for bold climate action. Yet proposals remain far from the transformative systemic changes required. While many remain in denial that system change is necessary, others who call for system change fail to articulate what that change would entail. It is critical that the climate movement identifies and promotes specific strategies for change. Identifying synergistic proposals associated with ecosocialism and degrowth, we describe a set of policies, programs, and strategies that have the potential to justly minimize warming and that could become key demands of climate movement organizations attempting to influence governments in the Global North. While there are stigmas associated with ecosocialism and degrowth, the described strategies can be promoted without using these terms. Articulating specific strategies for system change is necessary to challenge the powerful actors and interests that continue to maintain the status quo and our current climate trajectory.

Policy, Systems, and Environmental Change Strategies in the Supplemental Nutrition Assistance Program-Education (SNAP-Ed)

ObjectiveTo categorize and quantify how states planned to use policy, systems, and environmental (PSE) change strategies in the Supplemental Nutrition Assistance Program-Education (SNAP-Ed). MethodsQualitative content analysis of SNAP-Ed annual plans from all 50 states, District of Columbia, Guam, and the US Virgin Islands between fiscal years 2014 and 2016. ResultsBetween 2014 and 2016, the percentage of states that included PSEs as a statewide goal increased from 25% to 47%, and the percentage that planned to implement at least 1 PSE increased from 56% to 98%. Among states that planned to implement PSEs in 2016, the 3 most common settings were places in which people learn (92%), live (90%), and work (83%). Conclusions and ImplicationsThe increased planned use of PSEs in SNAP-Ed was considerable and encouraging as PSEs are important to use in conjunction with direct education and social marketing to improve nutrition and prevent obesity.

Lost Causal: Debunking Myths About Causal Analysis in Philanthropy

What if philanthropic evaluations told us that changes in the world had occurred, as well as how and why they occurred, including in what ways foundation funding and grantees contributed to those changes? What if evaluations made change pathways more visible, tested hypotheses and assumptions, and generated new insights based on what happened in the “black box” of systems change strategies? This type of learning comes from causal analysis — inquiry that explores cause-andeffect relationships.

Public Health and Health Care Partnerships for Improved Tobacco Cessation.

Tobacco use remains a leading cause of preventable death and disease. While most tobacco users are interested in quitting, few receive professional assistance. This state health department-led project leveraged partnerships to build capacity and support 9 health care organizations in implementing system-level initiatives to improve delivery of tobacco cessation. Participating organizations' initiatives targeted 3 focus areas: implementing best practices for tobacco cessation; quality improvement; and utilization of the electronic health record. A qualitative study was conducted to examine facilitators and barriers to tobacco cession systems change among participating health care organizations. Common barriers included time constraints, staffing issues, and organizational structure. These factors often differed by organization type (eg, large vs small). Facilitators included leadership buy-in, organizational priority, technical assistance, teams/teamwork, and IT support. Initial findings suggest that this type of partnership model can be leveraged to gain organizational support, build capacity, address key barriers, and ensure that systems change strategies align with best practices for tobacco cessation across a diverse set of health care organizations. Findings presented in this report provide insights for other public health and health care organizations looking to implement similar initiatives.

Implementation of Integrated Behavioral Health Care in a Large Medical Center: Benefits, Challenges, and Recommendations.

Integrated behavioral health care (IBHC) models in primary care are positioned to address the unmet needs of traditional behavioral health models. However, research support is limited to specific populations, settings, and behavioral health conditions. Empirical evidence is lacking for expansion to larger health systems and diverse behavioral health conditions. This study examines perspectives on IBHC implementation in a large medical center. Semi-structured interviews were conducted with 24 health providers and administrators in two primary care clinics with IBHC. Thematic analysis demonstrated that participants had an overall favorable perception of IBHC, but also perceived implementation challenges, including difficulties with access, underutilization, team dynamics, and financial and interdepartmental issues. The findings suggest that IBHC implementation barriers in existing large health systems risk diminishing potential benefits and successful adoption. These barriers can be combated by incorporating systems change strategies into implementation frameworks, with a focus on barrier prevention and detection and long-term sustainability.

P90 The Sustainability of Policy, Systems, and Environmental Change Strategies Implemented in Partnership with the South Carolina SNAP-Ed Program

Background SNAP-Ed program implementers are encouraged to engage in sustainability planning with partner sites as a long-term environmental outcome per the SNAP-Ed Evaluation Framework. However, currently no literature exists on the sustainability of policy, systems, and environmental (PSE) change strategies adopted with the guidance of program implementers. Objective The study explored the sustainability of PSE strategies implemented in partnership with the South Carolina SNAP-Ed program. Study Design, Settings, Participants Key informants at SNAP-Ed partner sites where at least one PSE strategy was adopted in FY2017 participated in an interview six to eight months post adoption (n = 31). An interview guide was developed based on a validated program sustainability assessment tool to explore the tool's eight domains of sustainability. Measurable Outcome/Analysis Interview transcripts were qualitatively analyzed using NVIVO. Each domain was coded based on being evidenced or not evidenced for the strategy. Then, categories of “sustained” and “not sustained” were developed based on emergent common storylines of sustainability among sites. Categories were then dichotomized to demonstrate high versus low capacity for future sustainability and comparisons were made between the two groups for each domain. Results Five storylines of sustainability surfaced, including strategies that were: going strong (n = 17); going with site investment but unstable (n = 4); going but lacked site investment (n = 1); going but with site planning to discontinue (n = 2); and not going but with site interest in reviving (n = 7). Strategies that demonstrated high capacity for future sustainability commonly had evidence of environmental support, organizational capacity, and partnerships (81%, 48%, 86%, respectively) as compared to strategies with low capacity for future sustainability (10%, 0%, 20%, respectively). Conclusion Sustainable PSE strategies are crucial for SNAP-Ed to achieve its goal of ensuring low-income people are able to meet dietary guidelines and to maximize program funding. SNAP-Ed implementers should work with sites to ensure the most salient domains for future sustainability are in place during PSE implementation. Funding USDA.

Description and Evaluation of Changes to the Rural Nutrition Environment After Implementation of Community-led Policy, System, and Environment Change Strategies (P04-163-19)

ObjectivesTo assess the nutrition environment in three rural Louisiana parishes (counties) with high rates of poverty (range 25%-41.7%), obesity (>40%), and chronic diseases and to better understand the local nutrition environment in rural, low-income, food insecure areas and to evaluate policy, systems, and environmental (PSE) change strategies aimed at improving the rural food environment. MethodsHealthy Access, Behaviors, Communities was a community-participatory, multi-level approach to obesity prevention in Louisiana. This evaluation used a descriptive, mixed methods design that focused on 1st and 3rd year project data. Nutrition environments were assessed using the reduced Nutrition Environment Measurement Survey (NEMS) for food stores and restaurants. Pre and post NEMS scores were compared to determine if PSE interventions were effective in improving the nutrition environment. ResultsOverall, 48 food stores and 39 restaurants were assessed at baseline, while 45 food stores and 36 restaurants were assessed at follow-up. Different numbers between baseline and follow-up assessments are due to store closures/openings. Except for the grocery store and fast food environments in Madison parish, the food environments were poor across the targeted parishes, with NEMS scores indicating a lack of healthy grocery items (stores) or a lack of healthy menu options (restaurants). With few exceptions, average NEMS scores generally increased slightly over the assessments, which is a positive trend; however, these positive changes did not result in the food retail environment moving from unhealthy to healthy. Five stores were targeted by the coalition to implement PSE changes. Of the partner stores, the average number of healthy foods available increased in all categories, except skim or low-fat milk, from baseline to post-intervention. ConclusionsFindings from baseline indicate that the nutrition environment in these poor, rural parishes can present challenges to individuals attempting to meet preventative health recommendations. PSE interventions can improve the nutrition environment in these locations. Funding SourcesCenters for Disease Control High Obesity 1416 Cooperative agreement.

Use of Policy, Systems, and Environmental Change Strategies Within Supplemental Nutrition Assistance Program Education (SNAP-Ed), 2014–2016 (P04-160-19)

ObjectivesSNAP-Ed is the nutrition education and obesity prevention component of the Supplemental Nutrition Assistance Program, the nation’s largest nutrition assistance program for eligible low-income households. The 2010 Child Nutrition Act directed SNAP-Ed to include multi-level and public-health approaches, which was operationalized through policy, systems, and environmental change strategies (PSE). This analysis examines how states incorporated and planned to use PSEs in SNAP-Ed programming. MethodsData were collected from all 50 states, District of Columbia, Guam and the U.S. Virgin Islands (collectively described as “states”) for fiscal years 2014 through 2016. The data sources were state SNAP-Ed plans, annual reports, and administrative data. Qualitative methods were used to abstract the textual information from state plans and annual reports. Numerical data were collected from administrative data sets. Both textual and numerical data were categorized, counted, and relative frequencies were calculated. ResultsBetween 2014 and 2016, the percentage of states that included PSEs as a statewide goal for SNAP-Ed increased from 25 to 47 and the percentage that planned to implement at least one PSE increased from 56 to 98. Among states that planned to implement PSEs in 2016, the 3 most common settings were places where people learn (e.g., schools) (92%), live (e.g., local communities) (90%), and work (e.g., worksites) (83%). States partnered with a wide range of organizations to deliver PSEs, with the 3 most common being government programs or agencies (77%), agricultural organizations (58%), and others non-specified (e.g., food alliances, wellness committees) (48%). Between 2014 and 2016, the percentage of states that planned to target environmental settings from the SNAP-Ed evaluation framework increased from 31 to 78. ConclusionsStates increasingly planned to use and were using PSEs across a range of settings and partners in SNAP-Ed between 2014 and 2016. This increase is encouraging as PSEs are important to use in conjunction with direct nutrition education and social marketing to improve nutrition and prevent obesity. Funding SourcesU.S. Department of Agriculture, Food and Nutrition Service.

The payer's role in addressing the opioid epidemic: It's more than money

Background and objectiveCounty, State, and Federal agencies are addressing the public health opioid crisis. Ohio's 51 county-based Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Boards finance and regulate opioid treatment services within their jurisdictions. This three-year comparative trial collaborated with ADAMHS Boards (n = 14) to test the Advancing Recovery Framework, a suite of organizational and system change strategies designed to promote use of buprenorphine for opioid agonist therapy. MethodsA multi-level intervention directed payers and treatment agencies to leverage their roles in increasing the use of buprenorphine. Half of the boards partnered with local substance use disorder treatment providers using the partnership strategies recommended by the Advancing Recovery (AR) framework. The comparison boards did not use the partnership strategies. Results and conclusionA logistic regression analysis detected increases in the number of patients receiving buprenorphine in both conditions. Buprenorphine use, as a percentage of patients with an opioid use disorder diagnosis, was significantly greater among the boards using the Advancing Recovery strategies during the three-year experimental period (odds ratio (OR) 1.63, 95% CI, 1.50 to 1.76, p < .001) and a one-year maintenance period (OR 2.13, 95% CI, 1.85 to 2.46, p < .001). Boards in both groups provided similar levels of financial support to implement and maintain buprenorphine prescribing. Strategy differences between the study conditions existed in use of a committee that facilitated payer-provider partnering and the ADAMHS boards setting expectations for using buprenorphine. Payer-provider partnerships achieved greater improvements and maximized the effectiveness of funding in increasing access to buprenorphine.

Engaging Fathers in Early Obesity Prevention During the First 1,000 Days: Policy, Systems, and Environmental Change Strategies.

Fathers are critical stakeholders in childhood obesity prevention but are difficult to engage. This review presents a new approach to engaging fathers in obesity prevention during the first 1,000days. The review focuses on five existing health and social service programs, including prenatal care, pediatric care, the Special Supplemental Nutrition Program for Women, Infants, and Children, home visiting, and Early Head Start. For each program, the obesity prevention services provided, evidence of father engagement, and barriers thereto are outlined. Subsequently, policy, systems, and environmental strategies are outlined to address the noted barriers and promote father engagement. Although the programs hold great promise in bringing obesity prevention services to fathers, barriers to their engagement are present in the inner (e.g., limited hours of operation, lack of father-specific materials and programming) and outer (e.g., lack of model programs, best practice models, and consistent funding) settings of programs. Policy, systems, and environmental strategies to increase father engagement focus on earmarked funding, changes to national practice guidelines and practitioner training requirements, and the establishment of father-engagement performance metrics. Increasing father involvement in the specified programs will likely increase their engagement in early obesity prevention in an efficient and sustainable manner.

Evaluating foundational professional development training for trauma-informed approaches in schools.

Trauma-informed schools reflect a national movement toward implementing organizational practices and systems-change strategies that support trauma-exposed individuals. Although frameworks for trauma-informed schools delineate key features for navigating implementation processes, methods of installing these features in schools require additional study. Although foundational professional development (FPD) training is often utilized to prepare schools for implementing trauma-informed approaches, few researchers have examined whether such training influences factors known to promote implementation success: staff knowledge of and perceptions of acceptability for these approaches. The current study utilized a pre-post design to evaluate a 2-day FPD training as a tool for enhancing teacher knowledge of trauma-informed approaches prior to implementation. The study also examined whether gains in knowledge following the training were associated with teacher perceptions of acceptability of trauma-informed approaches and whether perceived alignment of trauma-informed approaches with existing school norms and practices, or system fit, moderated that relationship. Participants included 183 teachers from six schools who completed the training. Knowledge was assessed at pre- and posttraining, and perceptions of acceptability and system fit were assessed at posttraining. Results indicated significant knowledge growth following the training. Among teachers who perceived better system fit, knowledge growth was associated with increased acceptability for trauma-informed approaches. However, among teachers perceiving less system fit, knowledge growth was associated with decreased acceptability. Implications for the installation and implementation of trauma-informed approaches in schools are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Still ‘skiing their own race’ on New Public Management implementation? Patient choice and policy change in the Finnish and Swedish health-care systems

This article applies an agenda-setting approach to the impact of New Public Management on health-care reform in Sweden and Finland (1993–2016). A system-level view of agenda setting and New Public Management implementation is used to order the historical data derived from literature reviews of each health reform process. New Public Management is viewed as a hybrid concept rooted in the search for efficiency gains and cost containment but, here, generating system preservation and system change strategies, characterised as ‘public competition’ and ‘choice and marketisation’. Sweden and Finland are viewed as ‘pragmatic modernisers’ in the public management literature. Health-care system reform in each country was based on similar problems and similar policy ‘solutions’, and was promoted by similar actors, while the implementation of choice and marketisation again saw windows of opportunity open in a similar manner in each. Policy divergence nevertheless occurred. We identify three key reasons for this, relating to the site and pervasiveness of conflict, the impact of party systems, and administrative openness to outside ideas. Sweden’s conflictual politics produced stalemate while consensual Finland produced radical policy change.Point for practitioners• Finland and Sweden wanted to modernise rather than overturn the traditional welfare settlement with New Public Management implementation. • Similar policy problems emerged and similar solutions were forwarded, often by similar actors and for similar reasons. • In both countries, powerful centre-right government correlates with the promotion of fundamental ‘choice and marketisation’ policies. • National differences in New Public Management implementation remain.

Impacts of urban living labs on sustainability transitions: mechanisms and strategies for systemic change through experimentation

ABSTRACTUrban Living Labs (ULL) are considered spaces to facilitate experimentation about sustainability solutions. ULL represent sites that allow different urban actors to design, test and learn from socio-technical innovations. However, despite their recent proliferation in the European policy sphere, the underlying processes through which ULL might be able to generate and diffuse new socio-technical configurations beyond their immediate boundaries have been largely disregarded and it remains to be examined how they contribute to urban sustainability transitions. With this study, we contribute to a better understanding of the diffusion mechanisms and strategies through which ULL (seek to) create a wider impact using the conceptual lens of transition studies. The mechanisms of diffusion are investigated in four distinct ULL in Rotterdam, the Netherlands and Malmö, Sweden. The empirical results indicate six specific strategies that aim to support the diffusion of innovations and know-how developed within ULL to a broader context: transformative place-making, activating network partners, replication of lab structure, education and training, stimulating entrepreneurial growth and narratives of impact.

Impacts of continuous quality improvement in Aboriginal and Torres Strait islander primary health care in Australia

PurposeContinuous quality improvement (CQI) programmes have been taken up widely by indigenous primary health care services in Australia, but as yet there has not been a systematic assessment of their focus and achievements. A scoping review of the literature from studies of CQI in indigenous primary health care services was undertaken to explore impacts on service systems, care and client outcomes with the aim of providing guidance on future evaluation efforts. The paper aims to discuss these issues,Design/methodology/approachSearches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews to December 2016 and handsearching of key websites and publications. Studies of CQI programs or activities in Indigenous primary health care services which demonstrated some combination of CQI characteristics, as described by Rubenstein (2013) were included. A two-stage approach to analysis was undertaken. Stage 1 identified the range and scope of literature, and Stage 2 investigated impacts to service systems, care and client outcomes. The Framework for Performance Assessment in Primary Health Care was used to frame the Stage 2 analysis.FindingsThe majority of Aboriginal community controlled health services have been involved in CQI but there are gaps in knowledge about uptake in general practice and government clinics. There are as many baseline studies as studies on impacts over time. Of the 14 studies included for further analysis, 6 reported on impacts on service systems; all 14 reported on impacts on care and 6 on client outcomes. Changes to services systems are variable and studies of impacts on care and client outcomes show promising though uneven improvements. There are no economic studies or studies addressing community engagement in CQI activities.Research limitations/implicationsTo supplement existing limited knowledge about which service system change strategies are effective and sustainable for which problems in which settings, there needs to be investment in research and development. Research needs to be grounded in the realities of service delivery and contribute to the development of CQI capacity at the service level. Knowledge translation needs to be built into implementation to ensure maximum benefit to those endeavouring on a daily basis to constantly reflect on and improve the quality of the care they deliver to clients, and to the stewardship structures supporting services at regional, state/territory and national levels.Practical implicationsImproved approaches, methods, data capture and reporting arrangements are needed to enhance existing activity and to ensure maximum benefit to services endeavouring to reflect on and improve quality of care and to the stewardship structure supporting services at regional, state/territory and national levels.Originality/valueAlthough there is a growing body of research evidence about CQI both nationally and internationally, and considerable investment by the federal government in Australia to support CQI as part of routine practice, there has not been a systematic assessment of the achievements of CQI in Indigenous primary health care services. Many unanswered questions remain about the extent of uptake, implementation and impacts. This is a barrier to future investment and regional and local programme design, monitoring and evaluation. The authors conducted a scoping review to address these questions. From this, the authors draw conclusions about the state of knowledge in Australia with a view to informing how future CQI research and evaluation might be intensified.

The potential role of cost-utility analysis in the decision to implement major system change in acute stroke services in metropolitan areas in England

BackgroundThe economic implications of major system change are an important component of the decision to implement health service reconfigurations. Little is known about how best to report the results of economic evaluations of major system change to inform decision-makers. Reconfiguration of acute stroke care in two metropolitan areas in England, namely London and Greater Manchester (GM), was used to analyse the economic implications of two different implementation strategies for major system change.MethodsA decision analytic model was used to calculate difference-in-differences in costs and outcomes before and after the implementation of two major system change strategies in stroke care in London and GM. Values in the model were based on patient level data from Hospital Episode Statistics, linked mortality data from the Office of National Statistics and data from two national stroke audits. Results were presented as net monetary benefit (NMB) and using Programme Budgeting and Marginal Analysis (PBMA) to assess the costs and benefits of a hypothetical typical region in England with approximately 4000 strokes a year.ResultsIn London, after 90 days, there were nine fewer deaths per 1000 patients compared to the rest of England (95% CI –24 to 6) at an additional cost of £770,027 per 1000 stroke patients admitted. There were two additional deaths (95% CI –19 to 23) in GM, with a total costs saving of £156,118 per 1000 patients compared to the rest of England. At a £30,000 willingness to pay the NMB was higher in London and GM than the rest of England over the same time period. The results of the PBMA suggest that a GM style reconfiguration could result in a total greater health benefit to a region. Implementation costs were £136 per patient in London and £75 in GM.ConclusionsThe implementation of major system change in acute stroke care may result in a net health benefit to a region, even one functioning within a fixed budget. The choice of what model of stroke reconfiguration to implement may depend on the relative importance of clinical versus cost outcomes.