Introduction: Primary health care needs to undergo system wide change in order to deliver universal access to high quality and integrated health care whilst reducing inequities and rising healthcare costs. There is no clear or proven blueprint for achieving this change. Additionally the promise of a patient and professional partnership which is at the heart of modern healthcare improvement must be considered.
The rate of change needed in New Zealand primary health care healthcare requires an understanding of how to implement quality improvement in the local context.
Theory/Methods: This research viewed quality improvement programmes in two new Integrated Family Health Centres, to develop new models of care, integrated ways of working and improve efficiency. Interview data was collected, themed and analysed through the lens of Deming’s System of Profound Knowledge (SOPK) exploring the applicability of Deming’s model to primary care improvement.
Results: Both of the centres showed good appreciation of systems thinking and high staff and consumer engagement. There was some variation between the centres in the understanding of human behaviour. Barriers to improvement were created by the lack of formal improvement processes and access to data and improvement expertise.
Deming’s System of Profound Knowledge was applicable to primary care improvement.
Discussion: Complexity and systems thinking were embraced and there was good consumer engagement and staff participation in both sites. Patient feedback and participation were part of developing a culture change toward a more patient centred approach whilst contributing to the motivation for change. However, the balance of extrinsic and intrinsic motivational factors for change varied between the two sites and this impacted on staff engagement.
The use of data for improvement was challenging for both sites which was attributed to resource and expertise constraints. This impacted on the ability to earn from the changes made. Changes were made as ‘plan-do’ rather than complete Plan-Do-Study-Act cycles.
Conclusions: Improvement programmes in primary health care can benefit from a structured improvement programme and framework that facilitates:
• A systems thinking approach
• patient engagement, and
• full staff participation
The application of systems thinking in both centres provided benefits in the development of:
• Patient-centred approach
• One team
• Integrated systems
• Improved culture
• Efficiency gains
Providing training, expertise and the infrastructure to support improvement expertise and data management would have aided the improvement work in both centres.
Lessons learned: Deming’s SOPK provided a holistic lens to view the health centres improvement work. The interconnection between the four domains reflects the complex reality of the health care environment.
Limitations: The main limitation in this research was the lack of previous research into the practical applications of the SOPK. This lack may be due to the open and evolving nature of Deming’s SOPK and its purpose as a way of encouraging deep thinking rather than a checklist.
Suggestions for future research: Enablers and barriers to improvement in primary care were highlighted and future research could investigate these in greater detail.