title: Quality improvement in practice: improving diabetes care and patient outcomes in Aboriginal Community Controlled Health Services.
abstract: BACKGROUND
  Management of chronic disease, including diabetes, is a central focus of most Aboriginal Community Controlled Health Services (ACCHSs) in Australia. We have previously demonstrated that diabetes monitoring and outcomes can be improved and maintained over a 10-year period at Derby Aboriginal Health Service (DAHS). While continuous quality improvement (CQI) has been shown to improve service delivery rates and clinical outcome measures, the process of interpreting audit results and developing strategies for improvement is less well described. This paper describes the evaluation of care of patients with type 2 diabetes mellitus (T2DM) and features of effective CQI in ACCHSs in the remote Kimberley region of north Western Australia.
  
  
  METHODS
  Retrospective audit of records for Aboriginal and Torres Strait Islander primary care patients aged ≥15 years with a confirmed diagnosis of T2DM at four Kimberley ACCHSs from 1 July 2011 to 30 June 2012. Interviews with health service staff and focus group discussions with patients post audit.
  
  
  METHODS
  diabetes care related activities, clinical outcome measures and factors influencing good diabetes related care and effective CQI.
  
  
  RESULTS
  A total of 348 patients from the four ACCHSs were included in the study. Clinical care activities were generally high across three of the four health services (at least 71% of patients had cholesterol recorded, 89% blood pressure, 84% HbA1c). Patients from DAHS had lower median cholesterol levels (4.4 mmol/L) and the highest proportion of patients meeting clinical targets for HbA1c (31% v 16% ACCHS-3; P = 0.02). Features that facilitated good care included clearly defined staff roles for diabetes management, support and involvement of Aboriginal Health Workers, efficient recall systems, and well-coordinated allied health services. Effective CQI features included seamless and timely data collection, local ownership of the process, openness to admitting deficiencies and willingness to embrace change.
  
  
  CONCLUSIONS
  Well-designed health care delivery and CQI systems, with a strong sense of ownership over diabetes management led to increased service delivery rates and improved clinical outcome measures in ACCHSs. Locally run CQI processes may be more responsive to individual health services and more sustainable than externally driven systems.
authors.affiliation: Launceston Clinical School, University of Tasmania, Locked Bag 1377, Launceston, TAS 7250, Australia. alice.stoneman90@gmail.com.
authors.forename: Alice
authors.initials: A
authors.lastname: Stoneman
authors.forename: David
authors.initials: D
authors.lastname: Atkinson
authors.forename: Maureen
authors.initials: M
authors.lastname: Davey
authors.forename: Julia V
authors.initials: JV
authors.lastname: Marley
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D003695:Delivery of Health Care / Q000592:standards*; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy / Q000208:ethnology*; D005260:Female; D017144:Focus Groups; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D036301:Qualitative Research; D058996:Quality Improvement; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult; D000095283:Australian Aboriginal and Torres Strait Islander Peoples