Table 3 Study findings analysed within the Framework for Complex System Improvement proposed by Kraft, Carayon [27]

Patients and caregivers

Support GPs in improved CVD prevention and care

Engage GPs in Quality Improvement data collection and scrutiny

Highly variable, a key determinant of success

Enrolled GPs personally motivated to improve their practice

GPs have ongoing structured CPD with emphasis on evidence-based care, support from the college

GPs supported by PHN staff during implementation

Increased workload for GP practices would have appreciated more support, e.g. from PHN

Healthtracker, Topbar often needed troubleshooting (PHN generally prompt with this)

Practice members sometimes experienced problems due to knowledge deficits

More incentive required to encourage the sustained use of the tools by GP or PN

Patients voice was not captured in this study: no ability to record their role in adopting preventive care strategy

Patients values and beliefs were not measured in this study – they were seen as recipients of their GP’s advice to be educated in preventive health by their GP

GPs stated Healthtracker to be educational and engaging for patients, but this was reported from the perspective of the GP and PN

Patient-centred workflow processes lacking and should be included in the next stage of the design

Healthtracker was noted to be engaging and valuable for patient use during consultations

Microsystems (small units where care is delivered)

i.e. Practice level

(The General Practices)

GP practices vary widely in nature (size, internal supports, team culture/lack thereof, business models etc.): opportunities for change are affected by this on an individual level. Solo and large practices are seen to struggle more with the adoption of systematised QI practices

GP practice culture and leadership key to implementation

The culture was noted to be very variable

Level of engaged leadership variable

Practice culture/ circumstances dictate or limit possibilities for change in systems. Individual GP priorities appeared to override the ability to introduce changes in practice and systems

Practices required hands-on support – and would have appreciated more proactive help from PHN staff (e.g. regularly scheduled visits, facilitated networking, more in-practice teaching about QI and clinical topics requiring improvement, structured learning using practice data)

Some practices were agile concerning role optimisation and adoption of new processes

Successful implementation required effectively engaging PNs and PMs as well as the GP. Change leadership by a GP ± PN or PM was key to success

Software used varied between practices, sometimes incompatible

They were seen as time-consuming

It quickly became a barrier due to the time required

PHN was generally competent in resolving practice-level IT problems but was often left out of the loop

Individualised approach required

Meso-level Organisations (supporting microsystems)

i.e. PHN, RACGP

Clear guidelines, readily accessible, need for improvement universally agreed

The identity and nature of PHN were in flux at the time of the study. The need for established and trusted relationships between practice and PHN was identified as key to ongoing success

Seen as the role of the PHN by practices

PHN did not visualise its role consistently throughout this project due to a lack of prioritisation and resourcing by senior management for this work

Strategic leadership by executives aligned to QI was fundamental

Personnel selection and support at PHN may have been non-optimal

IT support by PHN key to implementation – PHN offered excellent IT support in most cases, but GP’s did not always utilise this service

Environment

(policy, payment, regulation)

Clear guidance from the Department of health to prioritise this work and part of the new PHN contract. Minimal reimbursement available to assist practices or PHN to fund the work adequately

“Quality Improvement” is part of Australian Primary health care policy documents but not incentivised for individual GP’s nor adequately funded within the entire primary care health system

Adversely affected through changes in ML to PHN

They are not funded. GPs have to do mandatory CPD to maintain Australian Medical registration. RACGP has mandated 1 QI activity every three years for each GP to maintain specialty status and registration

QI Practice Incentive Payment is available for accredited General Practices but not yet linked to any tangible programs related to improvements in services

No current funding is available for practices to support the adoption of any specific technology

PHN contracted to provide generic “QI support” to general practice by the Federal Health department but no actual funding stream to implement