Submission to Australian Commission on Quality and Safety in Healthcare

Transcription

1 Submission to Australian Commission on Quality and Safety in Healthcare on Practice- level indicators of safety and quality for primary health care Learnings from quality improvement research and practice in the Aboriginal and Torres Strait Islander health context Centre for Primary Health Care Systems Menzies School of Health Research

2 2 Table of Contents Purpose of submission...3 Background...3 The One21seventy CQI process and tools... 4 Data collection: Clinical audits and systems assessment (Step 3)...4 Data analysis and reporting (Step 4)...5 Participatory interpretation, goal setting and action planning (Step 5)...5 One21seventy tools...6 The One21seventy Systems Assessment Tool... 7 Implementation of continuous quality improvement processes...8 Commentary on candidate indicators...8 Summary of key messages...9 References...10 Appendix A: Description of clinical audit tools...12 Appendix B: Description of the Systems Assessment Tool...18

3 3 Purpose of submission The purpose of this submission is to draw attention to a significant body of work carried out on quality improvement in primary health care in Aboriginal and Torres Strait Islander health contexts, including a continuous quality improvement process and tools in use by 179 primary health care centres across Australia. The CQI process and tools are the products of many years of research, building on international best practice and adapted to the Australian context. The strength of this CQI process and tools is that they combine both clinical and broader organisational systems improvement in an integrated and comprehensive package, and include mechanisms that facilitate their uptake across a number of levels. We believe the development and implementation of these processes and tools can inform the work of the Australian Commission on Safety and Quality in Healthcare in the development of practice level indicators of safety and quality for primary health care. In particular, we emphasise the importance of effective frameworks and systems to support the use of indicators. Background More than 170 primary health care centres that provide care to Aboriginal or Torres Strait Islander populations are currently using a suite of quality improvement tools developed by the Menzies School of Health Research and the Lowitja Institute (formerly the Cooperative Research Centre for Aboriginal Health). The tools were developed, trialled and embraced by the Aboriginal and Torres Strait Islander primary health care sector in the course of a long- running action research project, the Audit and Best Practice for Chronic Disease (ABCD) project. (A full listing of publications from this research is contained in the list of References.) The tools are now accessible for widespread use through One21seventy, a not- for- profit business operating under the auspices of the Menzies School of Health Research ( The ABCD project began in 2002 with initial funding from the Safety and Quality Council. It demonstrated that a CQI model could be effective in supporting Aboriginal and Torres Strait Islander primary health care centres to use evidence- based good practice in chronic illness care (Si et al, 2007). The project included the development and refinement of two clinical audit tools and a systems assessment tool, based on the ACIC scale developed by the MacColl Institute for Healthcare Innovation (Bonomi et al. 2002) and adapted for the Australian primary care context. A subsequent ABCD Extension project was conducted from to look at factors effecting the widespread uptake of such a CQI model (Bailie et al., 2008). Further clinical audit tools were developed and refined during this project, along with an online system of data entry and report generation for primary care centres. By the end of the ABCD Extension project, around 120 primary health care centres were using the tools with the support of the research team. Most of those primary care centres have continued to use the tools now they are supplied and supported at cost by One21seventy, and new subscribers continue to take up the service. Data collected over the seven years of the ABCD- ABCD Extension projects (Schierhout et al., 2010) showed that for health centres using this CQI model: delivery of services to help prevention and early detection of chronic disease such as diabetes and renal and heart disease improved by 13%

4 4 delivery of services to help patients manage diabetic conditions improved by 6% 64% of health centres that completed three rounds of data collection achieved improvements of 10% or more in delivery of services to prevent chronic diseases. The strength of the suite of CQI tools provided and supported by One21seventy is that they combine both clinical and broader organisational systems improvement in an integrated and comprehensive package that is designed to achieve change at multiple levels of the health system. The One21seventy CQI process and tools The One21seventy CQI process is an annual Plan- Do- Study- Act cycle that uses a number of tools to gather data by which health centres may inform planning, set goals and plan improvements. Shorter cycles such as those used by collaboratives can also fit within this model. For the purposes of this submission, the critical parts of the One21seventy CQI process are: Step 3: Data collection Step 4: Data analysis and reporting Step 5: Participatory interpretation, goal setting and action planning. Figure 1: The One21seventy annual CQI cycle Data collection: Clinical audits and systems assessment (Step 3) In this step, a variety of data about the primary care centre is collected through the clinical audit tools and the Systems Assessment Tool (SAT). These data are then entered into the One21seventy web- based information system.

5 5 In some health centres or services, data input is done by health centre staff with guidance and support from a regional CQI coordinator or local CQI facilitator. In other places all data input is done by one person such as the local CQI facilitator. Once data entry is completed, data are cleaned making sure there are no inconsistent entries by a One21seventy staff member. Data analysis and reporting (Step 4) After the data are entered and cleaned, the One21seventy web- based information system analyses the data and generates reports. A range of reports can be generated, including: A report for each clinical audit tool, with relevant systems assessment data, and information on goals set in previous cycles (where available). The current cycle s goal setting. Reports can be downloaded as a Microsoft Word document so they are easy for health centres to include in, for example, management or board reports. If health centres agree to share their data with others, reports will show comparative data at the cluster, state/territory and national levels. A cluster of health centres is defined through agreement with the participating health centres and the agency that is funding their participation. These clusters may reflect administrative arrangements (such as districts or regions) or other arrangements related to CQI support. Participatory interpretation, goal setting and action planning (Step 5) This step occurs at the primary care centre and requires the most intensive facilitation in the One21seventy CQI cycle. Ideally, the stage will involve as many members of the local health centre management and staff as possible. Many health centres use an external facilitator for this stage, perhaps a regional CQI coordinator or external consultant. Participatory interpretation involves feedback to the local health centre team on the findings in the audit and system assessment reports, and facilitated discussion of the key messages from those reports. The involvement of a senior clinician is critical at this stage to help with the interpretation of the reports to make sure the meaning is interpreted correctly for the local clinical context. The purpose of these sessions is to: increase the level of shared understanding of the systems and clinical practices that operate in the health centre discuss how well the health centre is performing across a range of services promote understanding of current clinical best practice and systems to support client care review the links between the clinical audits and the systems assessment results to inform improvements in care and/or services in the health centre. Goal setting is when the local health centre team assisted by a facilitator - identifies priority areas for improvement, sets goals and develops strategies to attain those goals. Action planning involves the development of a clear plan of action to address the priorities, goals and strategies identified in the participatory interpretation process. Health centres may choose to use the networks established through their engagement with One21seventy

6 6 to incorporate ideas and advice from other health centres about what has worked well for them. One21seventy tools The One21seventy tools include a range of clinical audit tools and a Systems Assessment Tool (SAT). The clinical audit tools collect data about how the health centre delivers recommended services to prevent or manage chronic conditions and provide maternal and child health care. They reflect best practice and allow health centres to collect the data they need for reporting against key performance indicators. Each audit tool has an accompanying protocol, which provides both a detailed step- by- step guide to using the tool and a guide to the evidence base that underpins the tool s content. The audit tools and protocols are reviewed and updated regularly by specialist working groups to ensure that they reflect current best practice and work well. The clinical audit tools include: 1. Vascular and metabolic syndrome management for: type 2 diabetes hypertension renal disease coronary heart disease. 2. Maternal health. 3. Child health. 4. Preventive health. A description of the types of information collected with each audit tool can be found in Appendix A. The Systems Assessment Tool (SAT) is used to collect information about the state of the health centre s systems required to support good clinical care. The types of systems assessed include delivery systems design, Information systems and decision support, and self- management support. There is further description of the Systems Assessment Tool below. Another critical part of the One21seventy CQI system is its web- based information system that provides: access to audit tools, protocols and training materials input of data from audits, systems assessment, the HCCS and health centre goals data analysis and reporting functions reports that show cluster/jurisdiction comparisons for those health centres consenting to participate in pooled and de- identified data analyses and trends over time access to a range of other resources, including documents and links to the evidence base underlying the audit tools.

7 7 The One21seventy Systems Assessment Tool The importance of health centre systems to support optimal primary health care service delivery is well established. The Systems Assessment Tool (SAT) developed during the ABCD project was based on the Chronic Care Model (Wagner et al, 2001) and the associated Assessment of Chronic Illness Care (ACIC) tool (Bonomi et al., 2002). The SAT articulates the key components of health centre systems that have been identified in these frameworks as important to supporting best practice chronic illness care, and is used for assessing the state and level of development of health centre systems. However, unlike the ACIC scale, the systems assessment tool was designed to be delivered in a group setting with members of a health centre team by an experienced and trained facilitator, providing an important mechanism for change by engaging staff in a conversation about the quality of care and the systems which support it. The SAT is used in conjunction with data and reports from clinical audits to consider how well the health centre s systems support specific areas of care. The clinical audits thus serve as a hard centre to the model in combination with the softer facilitated discussion process of the systems assessment (Gardner et al, 2010). The SAT is used within Step 3 of the One21seventy CQI cycle (Figure 1). The tool consists of data items in five components of primary health care systems: delivery system design, self- management support, decision support and clinical information systems, external linkages, and organisational influence and integration. During a facilitated systems assessment discussion that ideally includes all health centre staff (management, clinical, administrative and support staff), consensus is reached on scoring the development for each item in the five components using a score ranging from 0 11: the higher the score, the better the systems. The scores are subdivided into four categories defined as limited or no support (0 2), basic support (3 5), good support (6 8) and fully developed support (9 11). Brief descriptors help staff decide the level of support and score within that level that they think best represents the systems in their centre. The results of this discussion and the attached scores are documented and brought together with the clinical audit results for interpretation during Step 4. The information arising from this process is then used in an action planning workshop, which sets goals and identifies actions during Step 5. These actions are subsequently implemented as part of the final step in the CQI cycle. While the SAT was initially developed in relation to assessing systems to support primary health care for chronic conditions, during the course of the project additional items were added to the tool in order to incorporate other aspects of care (including preventative care and maternal and child health). Stakeholders interviewed in the ABCD Extension project (Schierhout et al., 2010) identified the value of the SAT in assisting to catalyse a no blame dialogue that helped the primary health care team to identify concrete ways to strengthen its systems. the systems assessment tool, helps [teams] get a grasp of what best practice is for chronic disease primary healthcare and so it sets a frame of reference for them to be able to know what they re working towards. It really provides an objective measure which is particularly helpful because people, in the absence of a framework like that, tend to want to blame

8 8 Where it was used well, the systems assessment process was associated with positive changes in quality of care the services that were identified as doing the systems assessment well showed consistently larger improvements in results for clinical audits than for all services together. Of particular relevance to this submission is the value of the facilitated systems assessment process with health centre staff as a mechanism for organisational development. In many cases, the systems assessment was the first time that health centre staff met as a group or considered the systems that underpinned the delivery of care. Stakeholders also commented on the usefulness of the systems assessment in bringing together different perspectives about a health centre s operations. At a micro level, this could for instance greatly assist in considering the standard to which the health centre is meeting difficult to measure indicators such as appropriateness of communication with Aboriginal and Torres Strait Islander (or other clients of culturally and linguistically diverse backgrounds). Implementation of continuous quality improvement processes Indicators provide measures of quality but their impact will be dependent upon the ways in which they are implemented. The ABCD Extension project looked explicitly at the facilitators and enablers to widespread uptake of what are now the One21seventy CQI process and tools. These findings were reported in detail in Gardner et al. (2010). Of particular relevance to this submission was that, along with many of the facilitators and barriers reported in Table 5 of the Practice- level Indicators of Safety and Quality for Primary Health Care Consultation Paper, the research found that a systematic plan for implementation and a systems- based approach increased the likely uptake of the CQI process, and that the training, infrastructure and other support provided through what is now One21seventy were an important facilitator of widespread uptake. While the flexibility to adapt the process to local contexts was also critical, the existence of a hard core within the model (the clinical audits) also helped provide rigour and structure around which the more fluid elements of quality improvement and change could occur. The combination of a systematic framework for implementation, within which health centres could apply their own priorities, was seen as a major strength of the process. Commentary on candidate indicators On the whole, we support the indicators that are proposed, but such indicators need to be implemented as part of an overall quality improvement initiative, not as stand- alone items. The usefulness of the indicators for quality improvement would be enhanced by tools that facilitate health centres to assess the barriers to service delivery of care processes underlying these indicators, and ways to address these barriers. A few specific issues related to data availability, and linkages to decision- making in the Aboriginal and Torres Strait Islander primary care context are highlighted in Table 1.

9 9 Table 1: Comment on selected candidate indicators No Candidate indicators Description The proportion of Aboriginal and Torres Strait Islander patients who have received communications that are culturally appropriate The proportion of patients who have received communications that are culturally and linguistically appropriate The proportion of regular patients who have been given the patient experience survey within the previous 12 months (using a standard patient experience instrument) The proportion of regular patients who have provided feedback about their patient experience within the previous 12 months (using a standard patient experience instrument) The proportion of regular patients who are very satisfied with specified elements of their patient experience within the previous 12 months (using a standard patient experience instrument) Comment We note that identification of Aboriginal and Torres Strait Islander clients cannot be assumed in health service data; taken out of context, this indicator could provide a disincentive to appropriate identification of Aboriginality (through continued under- identification, services would lower the denominator, and improve their performance on this measure) As mentioned for other indicators, the usefulness of these data for quality improvement would be enhanced by including such measures as part of a QI cycle, with linkages to specific aspects of systems strengthening. Consideration needs to be given to the cultural appropriateness and relevance of such tools to Aboriginal and Torres Strait Islander populations. Summary of key messages There is solid evidence that a comprehensive quality improvement process that combines clinical audits with broader organisational systems (such as that supported by One21seventy) can help improve the quality of care in primary health care settings in Australia. The experience and evidence arising from long- running research on CQI processes in Aboriginal and Torres Strait Islander primary health care could help inform the development and implementation of practice- level indicators for safety and quality in primary health care more broadly. A systems- oriented approach and mechanisms that facilitate discussion about quality across primary health care centres (such as the One21seventy Systems Assessment Tool and facilitated discussion process) support engagement with, uptake and impact of quality improvement processes. Indicators are only as good as the frameworks or systems that support their implementation. Supportive infrastructure (such as data systems) and workforce development training are important facilitators of widespread uptake of CQI processes.

10 10 References Bonomi, AE, Wagner, EH, Glasgow, RE, & VonKorff M. Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement. Health Services Research, (3): Wagner, EH, Glasgow, RE, Davis C, Bonomi AE, Provost L, McCulloch D, Carver P, Sixta C. Quality improvement in chronic illness care: a collaborative approach. Jt Comm Journal of Quality Improvement Feb. 27(2): Publications from ABCD and ABCD Extension project Bailie, R, Si, D, Connors, C, Kwedza, R, O'Donoghue, L, Thompson, S, et al., Variation in quality of preventative care for well adults in Indigenous community health centres in Australia. BMC Health Services Research, : p Gardner, K, Bailie, R, Si, D, O Donoghue, L, Kennedy, C, Liddle, H, et al., Reorienting primary health care for addressing chronic conditions in remote Australia and the South Pacific: Review of evidence and lessons from an innovative quality improvement process. The Australian Journal of Rural Health, : p Si, D, Dowden, M, Kennedy, C, Cox, R, O'Donoghue, L., Bailie, R, et al., Indigenous community care: Documented depression in patients with diabetes. Australian Family Physician, (5): p Rumbold, A, Bailie, R, Si, D, Dowden, M, Kennedy, C, Connors, C, et al., Delivery of maternal health care in Indigenous primary care services: baseline data for an ongoing quality improvement initiative. BMC Pregnancy and Childbirth, (1): p16. Schierhout, G, Brands, J & Bailie, R Audit and Best Practice for Chronic Disease, : Final Report. The Lowitja Institute, Melbourne. Si D, Bailie R, Dowden M, Kennedy C, Cox R, O'Donoghue L, et al. Assessing quality of diabetes care and its variation in Aboriginal community health centres in Australia. Diabetes Metab Res Rev Jan 15. Rumbold AR, Bailie RS, Si D, Dowden MC, Kennedy CM, Cox RJ, et al. Assessing the quality of maternal health care in Indigenous primary care services. Med J Aust May 17;192(10): Gardner KL, Dowden M, Togni S, Bailie R. Understanding uptake of continuous quality improvement in Indigenous primary health care: lessons from a multi- site case study of the Audit and Best Practice for Chronic Disease project. Implement Sci. 2010;5:21. Bailie R, Si D, Shannon C, Semmens J, Rowley K, Scrimgeour DJ, et al. Study protocol: national research partnership to improve primary health care performance and outcomes for Indigenous peoples. BMC Health Serv Res. 2010;10:129. Si D, Bailie R, Zhiqiang W, Weeramanthri T. Comparison of diabetes management in five countries for general and indigenous populations: an internet based review. BMC Health Serv Res. 2010;10.

11 11 Baeza J, Bailie R, Lewis J. Care for chronic conditions for indigenous Australians: Key informants perspectives on policy. Health policy. 2009;92(2): Bailie RS, Si D, Dowden MC, Selvey CE, Kennedy C, Cox R, et al. A systems approach to improving timeliness of immunisation. Vaccine Jun 2;27(27): Bailie RS, Si D, Dowden MC, Connors CM, O'Donoghue L, Liddle HE, et al. Delivery of child health services in Indigenous communities: implications for the federal government's emergency intervention in the Northern Territory. Med J Aust May 19;188(10): Si, D, Bailie, R, Cunningham, J, Robinson, G,Dowden, M, Weeramanthri, T, et al., Describing and analysing primary health care system support for chronic illness care in Indigenous communities in Australia s Northern Territory use of the Chronic Care Model. BMC Health Services Research, : p112. Bailie R, Sibthorpe B, Gardner K, Si D. Quality Improvement in Indigenous Primary Health Care: History, Current Initiatives and Future Directions. Aust J Primary Health. 2008;14:53-7. Bailie R, Si D, Connors C, Weeramanthri T, Clark L, Dowden M, et al. Study protocol: Audit and Best Practice for Chronic Disease Extension (ABCDE) Project. BMC Health Serv Res. 2008;8:184. Si D, Bailie R, Weeramanthri T. Effectiveness of chronic care model- oriented interventions to improve quality of diabetes care: a systematic review. Prim Health Care Res Dev. 2008;9: Bailie R, Si D, Dowden M, O'Donoghue L, Connors C, Robinson G, et al. Improving organisational systems for diabetes care in Australian Indigenous communities. BMC Health Serv Res. 2007;7:67. Si D, Bailie RS, Dowden M, O'Donoghue L, Connors C, Robinson GW, et al. Delivery of preventive health services to Indigenous adults: response to a systems- oriented primary care quality improvement intervention. Med J Aust Oct 15;187(8): Bailie, R, Si, D, O Donoghue, L & Dowden, M. Indigenous health: effective and sustainable health services through continuous quality improvement. MJA (10): p Bailie, R, Si, D, Dowden, M & Lonergan, K Audit and Best Practice for Chronic Disease Project Final Report. Menzies School of Health Research & Cooperative Research Centre for Aboriginal Health. Darwin. Si D, Bailie R, Connors C, Dowden M, Stewart A, Robinson G, et al. Assessing health centre systems for guiding improvement in diabetes care. BMC Health Serv Res. 2005;5:56.

12 12 Appendix A: Description of clinical audit tools Tables A.1- A.4 describe the types of information included within each audit tool. Table A.1: Content of the vascular and metabolic syndrome management clinical audit tool This audit tool can be used to assess for any one or more of the following: diabetes type 2 coronary heart disease renal disease hypertension. Related systems assessment report: Chronic illness management systems assessment. Type of information General Diagnosis Attendance at health centre Risk factors, brief intervention and referral Co- morbidities, complication and procedures Management plan and scheduled services Types of indicators recorded Client characteristics: age, gender, Indigenous status, Medicare number recorded in notes, etc. Diagnosis of diabetes type 2, coronary heart disease, renal disease and/or hypertension and when diagnosis recorded. When client last attended the health centre, reason for attendance, which type of health practitioner saw the client first. Status recorded, risk level, brief intervention or referral provided, in relation to: smoking alcohol use obesity. Diagnosis of related conditions, such as: alcohol- related complications, such as cirrhosis or dementia asthma or chronic obstructive airways disease (COAD) hyperlipidaemia depression and/or other mental illness neuropathy foot ulcers, amputation of foot or leg stroke heart conditions that have required surgery. Record of current Chronic Disease Management Plan, including clinical and/or self- management goals. Record of discussion with client within past 12 months about: chronic disease management and medications

13 13 nutrition physical activity. Blood pressure, weight, waist circumference, eyesight, feet checked within past 6 or 12 months. Flu, pneumococcal vaccinations up to date. Emotional well- being screening and care Record of screening or concern for emotional well- being within past 12 months. Record of referral (such as brief intervention, counselling, medication, cognitive behavioural therapy) and review. Audit of current treatment Investigations Follow- up of abnormal clinical findings Medications prescribed. Records of testing to check kidney function, lipids, blood sugar and blood glucose levels. Record of follow- up if abnormal readings are recorded for blood pressure, glycated haemoglobin (HbA1c) and cholesterol.

14 14 Table A.2: Content of preventive services clinical audit tool Related systems assessment report: Preventive services systems assessment Type of information General Attendance at health centre Types of indicators recorded Client characteristics: age, sex, Indigenous status, Medicare number recorded in notes, etc. When client last attended the health centre, reason for attendance, which type of health practitioner first saw the client. Diagnosis of any chronic or recurrent medical condition requiring regular attendance at medical centre. Medical summary and Adult Health Check forms present. Recording of co- morbidities and risk factors Scheduled preventive services Follow- up of abnormal findings Records of risk factors related to smoking or alcohol. Records of immunisations, care plan or targets. Records of provision of scheduled services including: weight, height, body mass index (BMI), waist measurement tests such as blood pressure, urinalysis, blood glucose, pap smear, sexually transmitted diseases oral health check records of discussion of smoking, nutrition, alcohol, physical activity, mood. Whether abnormal findings were recorded for: blood pressure blood glucose urinalysis. Follow- up of abnormal findings recorded.

15 15 Table A.3: Content of the maternal health clinical audit tool Related systems assessment report: Maternal health services systems assessment Type of information General Attendance for antenatal care and routine supplements Pregnancy risk factors and brief interventions Routine antenatal checks and abnormal findings Lab investigations Postnatal visit Response to abnormal findings Types of indicators recorded Client characteristics: age, Indigenous status, Medicare number recorded in notes, date of baby s birth, baby s birthweight, gestational age and Indigenous status, type of delivery. Information about first and subsequent antenatal visits. Prescriptions of folate and/or iron. Antenatal care plan or record present. Recording of status, follow- up and/or brief intervention around: smoking, alcohol, illicit drugs social risk factors, such as domestic violence, social supports, financial situation medical risk factors, such as medical conditions, gynaecological and obstetric history. Record of routine checks related to weight, height, BMI, blood pressure and urine at points throughout the pregnancy (<13 weeks, weeks, > 26 weeks). Record of pregnancy- related tests carried out, including blood and urine tests, foetal anomaly tests and ultrasounds. Record of postnatal visit. Brief intervention/counselling provided around breastfeeding. Nutrition. Record of follow- up, treatment, etc. in relation to abnormal findings from tests carried out.

16 16 Table A.4: Content of the child health clinical audit tool Related systems assessment report: Child health services systems assessment Type of information General Attendance at health centre Key summary health information Audit of scheduled immunisations Audit of scheduled services Types of indicators recorded Child characteristics: age, sex, Indigenous status, Medicare number recorded in notes. When child last attended the health centre, reason for attendance, which type of health practitioner first saw the client. Does the patient record include: growth chart immunisation chart child health check within past 12 months? Record of whether the child is up- to- date with scheduled immunisations. Record of whether the child is up- to- date with scheduled services for the age brackets of: 0 < 12 months 1 < 3 years 3 < 6 years. Scheduled services include: weight, length, head circumference ear, eye, vision and hearing examination overall development anaemia and/or parasitic infections tests testes check. Brief intervention/advice to carer about: Follow- up of abnormal clinical findings breast feeding nutrition and eating passive smoking risk oral health preventing infection/hygiene physical and mental stimulation social and housing environments. Follow- up, referral or brief intervention provided, if there is evidence of: growth faltering or failure to thrive

17 17 recurrent/chronic ear infections anaemia recurrent/chronic respiratory disease developmental delay concerns about domestic or housing environments, social and financial situation or food security.

18 18 Appendix B: Description of the Systems Assessment Tool Table B.1 sets out the components of systems used in the Systems Assessment Tool (SAT) and the items included within each component. Table B.1: Components and items within the Systems Assessment Tool (SAT) Components of systems 1. Delivery system design This component refers to the extent to which the design of the health centre s infrastructure, staffing profile and allocation of roles and responsibilities, client flow and care processes maximise the potential effectiveness of the centre. 2. Information systems and decision support This component refers to clinical and other information structures (including structures to support clinical decision making) and processes to support the planning, delivery and coordination of care. 3. Self management support This component refers to structures and processes that support clients and families to play a major role in maintaining their health, managing their health problems, and achieving safe and healthy environments. 4. Links with the community, additional health services and other services and resources This component refers to the extent to which the health centre uses external linkages to inform service planning, links clients to outside resources, works out in the community, and contributes to cluster planning and resource development. Items for each component team structure and function clinical leadership appointments and scheduling care planning systematic approach to follow- up continuity of care client access/cultural competence physical infrastructure, supplies and equipment. maintenance and use of electronic client list evidence- based guidelines specialist generalist collaborations. assessment and documentation self- management education and support, behavioural risk reduction and peer support. communication and cooperation on governance and operation of the health centre and other community- based organisations and programs linking health centre clients to outside resources working out in the community communication and cooperation on cluster health planning and development of health resources

19 19 5. Organisational influence and integration This component refers to the use of organisational influence to create a culture and support organisational structures and processes that promote safe, high- quality care; and how well all the system components are integrated across the centre. organisational commitment quality improvement strategies integration of health system components.