National Health Reform

Primary Health Care Reform in Australia - Report to Support Australia’s First National Primary Health Care Strategy

Element 5: Safe, high quality care which is continually improving through relevant research and innovation

Objective: All Australians have access to safe, high quality primary health care services that deliver evidence-based care and accountability for outcomes, support continuous quality improvement, and reward research and innovation.

Top of page

Where are we now?

Safety and quality

There is currently very little information available about the quality of care provided in primary health care and limited monitoring of patient experiences in primary health care in Australia. Aspects of quality of care that are reportedly important to patients include continuity, coordination and integration of care, respect for their values and preferences, information and education, physical comfort, emotional support and involvement of family and friends in their care.²²⁵

One of the few available sources regarding patient experiences in Australia is the 2007 Commonwealth Fund survey, which outlines the following findings in respect to its Australian respondents:

• 20% reported experiencing a medical, medication or lab error;
• 10% reported that their doctor had ordered tests that had already been done;
• 14% reported often receiving conflicting information from different health professionals;
• 36% reported that they received quality and safe care; and
• 51% reported that their regular doctor coordinates care received from other health care providers.²²⁶

A similar survey conducted by the Commonwealth Fund in 2005 indicated that of Australians who reported experiencing medical mistakes or medication errors, 37% of respondents indicated these occurred in the hospital setting.²²⁷

Within primary health care, health care professional associations have developed a range of quality assurance mechanisms for the professions they represent but these vary in comprehensiveness and uptake by clinicians. One example is the Royal Australian College of General Practitioners (RACGP) A Quality Framework for Australian General Practice²²⁸ which aims to provide a dynamic and flexible quality management tool for use in a range of primary health care settings.

The Australian Commission on Quality and Safety in Health Care is charged with leading and coordinating improvements in safety and quality in health care in Australia by identifying issues and policy directions, recommending priorities for action, disseminating knowledge and advocating for safety and quality. The Commission is currently developing a National Strategic Framework for Safety and Quality in all health care settings with a consultation process underway. The Commission’s primary health care committee is focussed on issues of quality and safety for primary health care.

Top of page

Accreditation

Accreditation is often used as the key indicator of safety and quality in health care. Accreditation for most primary health care services is voluntary and coverage varies across professional groups. Since general practices must be accredited or registered for accreditation to participate in the PIP, data from this program are broadly representative of the number of accredited general practices. In 2007-08 PIP practices provided over 81% of GP care in Australia. In part, this reflects the PIP incentives compensating (or partially compensating) practices for the costs associated with accreditation. There is thought to be limited coverage of dental practices (less than 1%), physiotherapy private practices (1.9%) and optometry practices (approximately 2.2%).²²⁹ Around 98% of community pharmacies are registered to participate in the Quality Care Pharmacy Program; of these 67% have been accredited against the Quality Care Pharmacy Program Standards. By contrast, 100% of hospitals, surgical day procedure centres and pathology laboratories are accredited due to mandatory requirements.

The range of external organisations that provide accreditation for primary health care organisations and services use different standards. This is a particular issue for primary health care reform where care is increasingly focussed on delivery through multi-disciplinary teams involving individual health professionals working effectively together.

Accreditation reports are often limited to whether an organisation is accredited or not and when the accreditation expires. There is no detail provided of the health service organisation’s weaknesses or areas of concern identified by the accreditation process. Current accreditation standards are also focussed on processes, with little emphasis on clinical aspects and patient outcomes. In this regard, Australia lags behind other countries such as the UK where comprehensive data on individual facilities is provided on the relevant Healthcare Commission website.

In addition, the evidence base to support accreditation and standards as quality assurance mechanisms for primary health care is limited.²³⁰ The results of research studies are mixed in regard to the financial impact of accreditation, the relationship of quality measures to accreditation and whether accreditation delivers better health outcomes.²³¹

Top of page

Performance indicators and data for primary health care

Although significant progress has been made over the past decade in developing and refining healthcare performance measures both internationally and in Australia, considerable further work needs to be done to develop valid and reliable measures of the performance of the primary health care system.

Currently, a range of different processes are considering performance measurement for the health care system including primary health care. These include:

• National Healthcare Agreement (NHA) and National Partnership Agreements;
• Divisions’ National Quality Performance Service (NQPS);
• Australian Commission on Safety and Quality in Health Care (ACSQHC) Quality Framework;
• Australian Primary Care Collaboratives Program;
• National Prescribing Service (NPS);
• Report on Government Services (RoGS); and
• The Indigenous Healthy for Life program.
  Related to the development of effective systems of performance measurement is the scarcity of current data collections in primary health care including how primary health care systems record quality of care:
• the poor quality of recorded data which may be related to the lack of feedback provided to those collecting it and perceptions around usefulness;
• a lack of automated data extracted from primary health care services; and
• considerations of privacy, time and coding.

In general practice, higher levels of computerisation can support greater use of data, though other primary health care services may be less advanced in this regard. Importantly, improvements in data collection and monitoring, at the clinician and practice level, especially when associated with peer review, has been shown to drive performance improvement.

In addition, compatibility of software and data linkage from different sources is limited. Overall, this restricts the capacity and effectiveness of information systems to support analysis, reporting and quality improvement changes, at all levels. Further discussion about information management in primary health care is provided under Element 6.

Top of page

Pay-for-performance

Many countries are experimenting with pay-for-performance schemes that tie a portion of provider payments to performance measures of quality, patient experience and outcomes.²³² In Australia, the PIP provides a range of targeted incentives (which complement fee-for-service payments) for accredited practices that encourage general practices to improve the quality of care provided to patients – including outcome-based payments.

The incentive payments that specifically focus on health outcomes relate to cervical screening and diabetes management. These two incentives follow a similar pattern of payments, in that they both provide:

• a sign-on payment: where practices are rewarded for either engaging with their local Cervical Screening Register, or implementing a Diabetes register and recall/reminder system;
• an outcomes payment: where payment is made to practitioners (working within a PIP practice) who provide specific services to a certain proportion of a subset of their patients; and
• a service incentive payment: where a payment is made to providers (working within a PIP practice) for either providing cervical screening to high-risk individuals, or for the completion of an annual cycle of diabetes care.

The provision of these incentives directly encourage and reward general practices in undertaking best-practice care for their patients, while also targeting major health issues at a practice population level.

Alongside the PIP, a number of initiatives have supported quality improvement in general practice. For example, the Australian Primary Care Collaboratives Program was established to provide a generic quality improvement model for use in the primary health care setting. General practices are given practical support to help them close the gap between current and best practice and make practice-level changes to improve clinical outcomes, help maintain good health for individuals with or at risk of chronic and complex conditions, and improve access to care.

Evaluation of the first phase has shown that general practices made measurable improvements in patient care and health outcomes. For example, in participating practices, there was a 105% increase in patients with diabetes who have appropriate cholesterol levels and a 45% increase in patients receiving recommended medications after a heart attack.²³³

Top of page

Research and knowledge transfer

Evidence-based policy and practice are fundamental to a high quality, fully functioning primary health care system. The literature states that there are several reasons why research is needed in the primary health care sector, it:

• improves patient care;
• is important for teachers of general practice, providing an evidence base for best practice; and
• stimulates critical thinking.²³⁴

McAvoy (2005) also states that ‘primary care research is the missing link in the development of high quality, evidence-based health care for populations’. In Australia, as in other countries, primary health care research accounts for a relatively small proportion of health research expenditure (around 4% in 2002-03). ²³⁵

Although there is increasing recognition of the complexity of primary health care, there still remains limited participation by primary health care researchers in the governance of national research bodies and a low level of rigorously designed studies in primary health care research compared to other medical disciplines. In addition to clinical research, there is a need for health services research to underpin planning for primary health care service delivery.

Health services research needs to be relevant to primary health care in Australia to recognise the specifics of delivery in the Australian context. Also important for the primary health care context is that most presentations are 'undifferentiated illness' with significant co-morbidities or associated factors. Currently the complexity of primary health care patients is a barrier to either effective clinical research and/or uptake of proven research interventions.

A number of schemes have been established over the last decades to specifically support primary health care research, including the General Practice Clinical Research Program, the Health Services Research Program and the Primary Health Care Research, Evaluation and Development (PHCRED) program. As part of PHCRED, initiatives such as the Australian Primary Health Care Research Institute (APHCRI) have encouraged quick response research activity against targeted priorities. In Indigenous research, the Cooperative Research Centre (CRC) for Aboriginal Health has developed an approach which includes a ‘facilitated research development approach’ where the CRC for Aboriginal Health mediates relationships between researchers, the Aboriginal health sector and government agencies to set research priorities and develop research projects.

While the last decade has seen improvements in developing a research culture in general practice, some other primary health care disciplines lag behind. For example, developing a research base to underpin the discipline of practice nursing is at an early stage and few practice nurses have training in conducting or evaluating research. Engagement of consumers, health economists and other health professionals is also needed to expand the scope of research in primary health care.

Top of page

Translating research into practice

Evidence-based practice is ‘the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients’.²³⁶ However, for primary health care practitioners struggling with time constraints and large caseloads, keeping up-to-date with the current best evidence is a perpetual challenge, especially as it needs to cover a very broad field.

The latest research findings relevant to primary health care are scattered across hundreds of different international scientific journals and other publications. The use of systematic reviews of the scientific literature, clinical practice guidelines and decision support systems can assist all practitioners to ensure that their clinical practice remains consistent with internationally recognised good practice. For example, the Primary Health Care Field Group of the Cochrane Collaboration is concerned with the quality, quantity, dissemination, accessibility and applicability of Cochrane systematic reviews relevant to people who work in primary health care.

There has been a proliferation of guidelines and their authorship, currency, status and quality may not be clear to health care practitioners. Guidelines do not necessarily adhere to accepted best practice guideline development standards, such as those set by the National Health and Medical Research Council (NHMRC), and have tended to be disease-specific and, as such, are often not relevant or useful for managing the complex needs of patients with multi-morbidity.

To be effective, guidelines must:

• be based on the best evidence available (eg supported by the National Institute of Clinical Studies);
• have transparent methodology;
• have clearly identified priority areas and recommendations;
• have current, active implementation plans;
• be adequately disseminated to end users; and
• recognise cultural and traditional values.

Professional associations have a role to play in assisting health care professions to access high quality guidelines relevant to their practice.

The use of integrated Information Technology (IT) systems, incorporating knowledge support systems and their potential to improve compliance with clinical guidelines, reduce errors and provide an audit trail in primary health care is covered in more detail under Element 6.

Improved dissemination of the latest research findings to primary health care practitioners and policy makers is necessary for research to be embedded into practice. The evidence shows that research transfer is likely to be favoured in situations where research is valued, there is critical debate of research methods and results, and there is managerial support for change processes.

An example of a national primary health care practice-based network that is translating research into practice is the Cancer Australia national cooperative clinical group. Australia has 12 national cancer cooperative groups involved in clinical trials. The research emphasis is about improving the survival of cancer patients, contributing to a reduction in premature death and disability, and improving the evidence behind cancer care.

A range of interventions has been developed aimed at translating research findings into practice. These include educational outreach visits, decision-support systems, interactive educational meetings, audit and feedback, local consensus processes, mass media interventions based on social marketing theory, the use of local opinion leaders, patient-mediated interventions, educational sessions, financial incentives and penalties, and administrative interventions.²³⁷

Divisions of General Practice are increasingly providing opportunities to promote best practice particularly to practice nurses and GPs. However, this activity is variable and does not address the needs of the wider range of health care practitioners working in primary health care.

Top of page

What the submissions said?

Safety and quality

In general, submissions recognised the need for greater accountability of primary health care and the need for consumers to have confidence that primary health care operates within a safe, outcome-focussed quality improvement framework. Performance monitoring was generally seen as crucial as an agent for change, for service improvement and as a catalyst. Those submissions that did comment in regard to quality improvement emphasised the importance of embedding quality improvement approaches into ongoing organisational service delivery, planning and development.

It is crucial to build a continuous improvement process into all initiatives related to safety and quality so health services always strive to be better, with better outcomes for consumers.²³⁸ It was generally recognised that for this to happen there would need to be a culture change at every level of primary health care. Organisational development was suggested as the way to enable this culture change to occur.

Our experience suggests that few organisations focus on the use of organisational development (OD) as an effective strategy to achieve improvement in Practice. Performance in healthcare organisations is inextricably linked to leadership, culture, climate and collaboration which can be improved by OD.²³⁹ Several submissions also highlighted the need for a systematic and universal approach to managing quality and safety in primary health care.

Top of page

Barriers to quality improvement

Submissions also highlighted a number of barriers to the implementation of quality improvement across the primary health care system that would need to be overcome. The lack of skills and competence in quality management is one such barrier.

The workforce responsible for service quality and CQI [Continuous Quality Improvement] is often seconded from embedded clinical work and has little or no exposure to quality theory in undergraduate training. There is a need to dedicate resources to develop the competencies of the quality workforce in primary healthcare.²⁴⁰ For this reason, practitioners require considerable support and assistance to build their competence in this field. It was suggested that regional primary health care support organisations could play an important role.

Other submissions pointed to time constraints and financing models that hinder participation of practitioners in quality improvement activities.

The current fee for service system does not support systematic team building and quality improvement activities, and funding and financing models that support the engagement of general practice in QI [Quality Improvement] activities is strongly encouraged. Fee for service does not allow for time out to reflect and improve.²⁴¹

Accreditation

Few submissions commented on issues relating to the accreditation of primary health care services but those that did emphasised the importance of accreditation for maintaining and improving quality of care as long as organisations were not required to undertake several different accreditation processes.

We strongly support the need for all health services to be accredited, but this should not result in us being required to undertake multiple systems of accreditation.²⁴²Several submissions referred to the need to extend accreditation to cover clinical care as well as administrative processes.

Some submissions also highlighted the need for primary health care services that cater for groups with special needs to have the flexibility to choose accreditation packages that are appropriate to their requirements.

While headspace supports the current primary health care accreditation system, greater flexibility is needed to allow parallel accreditation programs to be developed for specialty primary health care services. Many of these services, like headspace, target disadvantaged groups and employ sessional general practitioners, as well as other health professionals and social/vocational staff, placing them largely outside the guidelines for accreditation under AGPAL [Australian General Practice Accreditation Ltd] and limiting access to MBS income.²⁴³The submission from Australian General Practice Accreditation Limited/Quality in Practice sets out a proposal for a profession-led quality improvement framework.²⁴⁴

Top of page

Performance indicators

The importance of developing performance measures that are meaningful and appropriate to clinicians was highlighted.

Thrusting inappropriate and unworkable performance indicators onto general practice only serves to demoralise and frustrate the GP workforce.²⁴⁵ Various lists of suggested performance indicators were provided in the submissions. These are too numerous to detail here. Some examples are:

[Suggest these areas could be monitored and reported against:] Access; timeliness; out-of-pocket costs; appropriateness; affordability; patient centred; health literacy; opportunities for self-management; preventive care; integration with other services; coordination of care; safety; quality; use of health information technologies; flexibility; sustainability (e.g. staff turnover, patient/consumer satisfaction); effectiveness; cost-effectiveness; evidence of collaboration; extent to which partnerships in care are being developed; equity; universality.²⁴⁶ Aspects of quality that were particularly highlighted in the submissions as important to measure include consumer satisfaction, holistic care, equity of access in relation to need and equity of outcomes and chronic disease risk factor reduction.

Submissions from consumer groups emphasised that consumers have an essential role to play in continuous quality improvement and that obtaining feedback from consumers should be an integral part of the quality improvement process. This is rarely the case for the Australian primary health care system where few mechanisms currently exist for consumer feedback to be effectively utilised to improve health outcomes.

Health Issues Centre believes there is an important role for consumers and carers in continuous quality improvement (CQI) approaches. Consumer and carer participation in quality improvement should be implemented through establishing meaningful and non-threatening feedback mechanisms for individuals and involvement of consumers and carers in organisational complaints’ management systems.²⁴⁷ Several submissions referred to the UK where the establishment of ‘critical friends groups’ between clinicians, practice managers and patients has been shown to improve the overall running of practices. Patient feedback is also utilised to guide clinician training in advanced communication and interpersonal skills development. It was suggested that similar approaches could be useful in the Australian context.

Experience from the UK suggests system supports can enable practices/services to strengthen their effectiveness through the routine application of validated and evidence based instruments and training to assist both clinicians and services in improving their capacity to improve both the quality of patient experience and health outcomes for the communities they serve…Australia needs to follow suit by establishing its own mechanisms to enhance the interactions between clinicians and health consumers.²⁴⁸

Data systems

Many submissions highlighted the inadequacies of current primary health care data collection.
…significant investment is required to improve the capacity and quality of recording activity in primary care. Several barriers exist to achieving this at present, not least the variability of clinical software systems in general practice in their ease to record data in a systematic way. We recommend implementation of a minimum set of standards for clinical software systems that would promote simple, systematic recording of healthcare data in practice.²⁴⁹Many submissions emphasised that it is essential that any additional data collection builds on existing data collection capabilities and does not interfere with practitioners’ capacity to deliver clinical care.

Top of page

Pay-for-performance

The potential for the current PIP to be extended as a funding vehicle, to encourage improvements in quality and safety across the primary health care sector, was highlighted.

…the NPHCP [National Primary Health Care Partnership] supports a blended funding system for primary health care that includes payments that recognise quality improvement activities across members of the multidisciplinary care team. This could extend Practice Incentive Program (PIP) style-payments, currently only available to general practice, to recognise quality improvement in services provided outside general practice by allied health practitioners. This may, for example, acknowledge and incentivise the uptake of eHealth systems.²⁵⁰ At the same time, submissions highlighted the need to proceed with caution. The main concern, mentioned in many submissions, was that perverse incentives could adversely affect patient care and potentially increase health inequalities. It was pointed out that ill-conceived incentive payments may actually deter practitioners from working with consumers who have complex needs or are from disadvantaged backgrounds.

Pay for performance targets…could cause inequality of care for patients and discrimination against practices with the most medically disadvantaged patient populations. Performance targets will actively discriminate against GPs who like to tackle difficult patients and reward those who pick and choose. It may stop GPs working in certain areas or not wanting to see certain patients or not ordering certain tests.²⁵¹ Some submissions highlighted the potential for pay-for-performance incentives to adversely affect the morale of practitioners; the consumer’s right to exercise choice regarding treatment options; and the overall holistic/person-centred approach to primary health care.

Concern was also expressed that the development of performance monitoring systems might take resources away from the provision of direct patient care.

[The Australian Medical Association] would caution against placing benchmarks and performance pay systems and structures above the need for more resources for direct patient care. Performance reporting must be set at the system wide level and be used as an indication of the need for more funding and resources and not used to impose penalties when benchmarks are not achieved. Performance indicators must not encourage perverse incentives that could detrimentally affect patient care.²⁵² Top of page

Research and knowledge transfer

Submissions highlight the importance of primary health care being informed by relevant evidence but raise many issues that need to be addressed before this ideal can be realised.

Many submissions emphasise the differences between primary health care research and traditional bio-medical research.

Furthermore, the relatively limited available funding for primary health care research was seen as focusing on general practice and clinical research, rather than health services research or research relevant to the wider primary health care workforce.

… there is very limited investment in primary health care research that does not involve general practice. As a means to improve the targeting of primary health care research, the option of allocating a greater proportion of the available research funds to proactively commissioned research in primary health care will be vital.²⁵³ The urgent need to develop a research culture among primary health care practitioners was frequently raised in submissions.

A lack of research skills and training in research methods among current primary health care practitioners was a constant theme in the submissions. This was seen as one of the major barriers to the development of a research culture across primary health care. Other barriers cited were funding constraints and the time available to practitioners.

We need to identify strategies that support healthcare professionals at the coalface to be research literate and also become involved in research. The current funding models of primary care are mainly based on the small business model with financial disincentives to participating in research. GPs often give a great deal of time to research studies and are penalised by loss of income as a result...²⁵⁴ Top of page

Translating knowledge into practice

It was pointed out that knowledge transfer or translation research is a growing field and that more evidence is becoming available about what is needed to ensure the successful uptake of evidence into practice.

The Australian evidence points to four key elements in the successful uptake of evidence into practice: consultation and engagement of practitioners at all stages of the evidence development, needs assessment in their practice, ability to trial the change in their practice and evaluation and feedback.²⁵⁵ The need to overcome information overload is a key issue for many and clinical practice guidelines were seen as one method for addressing the problem of information overload. However, opinions varied regarding the value of clinical practice guidelines. Submissions also highlighted the need for national guidelines to be customised for local circumstances.

…care needs to be taken to ensure that guidelines are of high quality and that they are implemented effectively. This requires adaptation for a local setting and tailoring evidence based implementation strategies to local factors. However, guidelines will not address all the uncertainties of current clinical practice and should be seen as only one strategy that can help improve the quality of care that clients receive.²⁵⁶ There was widespread support in the submissions for the development of partnerships, networks, linkages and collaborations between academic researchers and practitioners, policy makers and consumers, to assist in translating research findings into practice and nurture research skills.

Some submissions suggested that all primary health care practices should be affiliated with an academic institution and many submissions referred to the Canadian model of academic practices with funded research and teaching time as one that could be considered for adaptation in the Australian context.

Many submissions highlighted the approach taken by the APHCRI as a successful partnership model that could be emulated.

Research models such as that employed by APHCRI support ongoing communication between policy makers and research to help ensure that research is meaningful to policy development and that research outcomes are fed back to policy makers. The expansion of models with a similar aim and outcome to other research institutions should be facilitated by linking their uptake to funding contracts for research institutes.²⁵⁷ Other submissions put forward the NPS model of localised academic detailing, quality education and resource services as successful in assisting to translate research into practice. Some submissions also saw a key role for Divisions of General Practice in encouraging GPs to become involved in research and supporting research projects.

Top of page

What is the way forward?

There are several key issues which come through the various components of this Element. These are:
• the need for policy clarity around what is being measured;
• the need for good quality data to inform quality improvement; and
• that any change in this area needs to deliver real improvements to patients, help health practitioners to do the best job they can, and improve the overall quality of the primary health care sector in Australia.

For this to happen, change needs to be clear and involve minimal compliance costs for all participants.

Safety and quality

There is a need for a stronger framework for safety, quality and performance improvement in primary health care to be developed in consultation with consumers and the primary health care professions based on the building blocks identified.

Accreditation and quality improvement

Accreditation for primary health care services needs to be streamlined and relevant to the practice in order to simplify the plethora of processes currently in place for different components of service delivery.

In light of the support for comprehensive primary health care services there is also a need for expanded accreditation standards to cater for this expanded service system, including a greater focus on patient outcomes and the requirements for effective integrated
multi-disciplinary care.

Performance indicators

There is a need to streamline the existing processes for development of primary health care performance indicators and develop a more strategic approach to quality measurement in primary health care that incorporates national, regional, practice and individual practitioner requirements.

Consumer access to safety, quality and performance information will drive improvements in primary health care services and improved health for individuals, their families and carers.

Reports on primary health care services focussing on issues of particular concern to consumers which are widely available, in formats which are accessible and meaningful to consumers, will be core to meeting the need for this information.

To assist primary health care services, there could be value in developing national guidelines for the development of health reports for the public.

Aspects of patient-centred care are considered in more detail under Element 2.

Top of page

Data systems

There is a need to develop an agreed minimum data set and data collection methodology for an appropriate national data collection in primary health care that could better inform the development of a systems approach at a later date.

Issues relating to electronic data systems in primary health care are covered in more detail under Element 6.

Pay-for-performance

In developing pay-for-performance incentives, consideration will need to be given to the performance indicators which are within the scope of practitioners to achieve. Incentives can be based on achievement as well as exclusions for non-performance as long as they are based on an agreed set of performance indicator benchmarks.

There may be scope to introduce pay-for-performance through the PIP. However, in recognition of the concerns raised in some submissions, pay-for-performance initiatives would need to be developed in consultation with the professions.

Issues relating to pay-for-performance incentives and the potential for extending the PIP are covered further under Element 10.

Research and knowledge transfer

In the future, it will be important that primary health care research is well placed to inform, and respond to the information needs of, decision makers in primary health care policy and practice. Key directions will need to:

• support a broader, more comprehensive conceptualisation of primary health care;
• develop a systematic approach to setting research priorities that are adaptable and responsive to the changing health environment and emerging issues;
• improve integration and coordination of research efforts; and
• increase engagement and knowledge transfer between researchers, practitioners and policy makers.

In moving forward there is also scope for the NHMRC’s existing structure, support mechanisms, broad networks and funding schemes to include a stronger focus on primary health care. This is recognised by their proposal to make primary health care a central part of their strategic plan which is to commence in January 2010. This would allow for an immediate expansion of Australia’s primary health care research effort through facilitating discussion between a range of health professionals involved in primary health care and effective connection to other forms of clinical and health services research.

Top of page

Top of page

---

225 Australian Institute of Health and Welfare, 2008. A set of performance indicators across the health and aged care system, available from: http://www.aihw.gov.au/indicators/performance_indicators_200806_draft.pdf (accessed June 2009).

226 The Commonwealth Fund, 2007. International Health Policy Survey in Seven Countries, available from: http://www.commonwealthfund.org/Content/Surveys/2007/2007-International-Health-Policy-Survey-in-Seven-Countries.aspx (accessed June 2009).

227 The Commonwealth Fund, 2005. International Health Policy Survey of Sicker Adults, available from: http://www.commonwealthfund.org (accessed June 2009).

228 Royal Australian College of General Practitioners, 2006. A Quality Framework for General Practice, available from: http://www.racgp.org.au/qualityframework/ (accessed June 2009).

229 Australian Commission on Safety and Quality in Healthcare, 2008. Windows into Safety and Quality in Health Care, available from: http://www.safetyandquality.gov.au (accessed June 2009).

230 Sunol R, Nicklin W, Bruneau C & Whittaker S, 2009. Promoting research into healthcare accreditation/external evaluation: advancing an ISQua initiative, International Journal for Quality in Health Care, vol. 21, no. 1, pp. 27-28.

231 Greenfield D & Braithwaite J, 2008. Health sector accreditation research: a systematic review, International Journal for Quality in Health Care, vol. 20, no. 3, pp. 172-183, available from: http://intqhc.oxfordjournals.org/cgi/content/full/20/3/172 (accessed June 2009).

Top of page

232 Scott A, 2007. Pay for performance in health care: strategic issues for Australian experiments, Medical Journal of Australia, vol. 187, no. 1, pp. 31-35.

233 Australian Government Department of Health and Ageing, 2008. Australian Primary Care Collaboratives Program, available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pcd-programs-apccp-index.htm (accessed June 2009).

234 McAvoy B, 2005. Primary care research – what in the world is going on? Medical Journal of Australia, vol. 183, no. 2, pp. 110-112, available from: http://www.mja.com.au/public/issues/183_02_180705/mca10267_fm.html (accessed June 2009).

235 ibid.

236 Sackett D, Rosenberg W, Gray J, Haynes R & Richardson W, 1996. Evidence based medicine: what it is and what it isn’t, British Medical Journal, vol. 312, no. 7023, pp. 71-72

237 National Health and Medical Research Council, 2005. How to put the evidence into practice: implementation and dissemination strategies, available from: http://www.nhmrc.gov.au/publications/synopses/_files/cp71.pdf (accessed June 2009).

238 Submission from Consumers Health Forum (Sub #169)

239 Submission from the Greater Green Triangle University, Department of Rural Health (Sub #225)

240 Submission from The Victorian Healthcare Association (Sub #172)

241 Submission from General Practice Network South (Sub #62)

242 Submission from Darebin Community Health (Sub #60)

243 Submission from headspace – Australia’s National Youth Mental Health Foundation (Sub #250)

244 Submission from Australian General Practice Accreditation Limited/Quality in Practice (Sub #114)

245 Submission from Central Coast Division of General Practice (Sub #55)

246 Submission from Australian Health Care Reform Alliance (Sub #212)

247 Submission from Health Issues Centre (Sub #144)

Top of page

248 Submission from Brisbane South Division of General Practice (Sub #182)

249 Submission from Australian Association of Academic General Practice (Sub #38)

250 Submission from National Primary Health Care Partnership (Sub #149)

251 Submission from Board of Hastings Macleay General Practice Network (Sub #34)

252 Submission from Australian Medical Association (Sub #51)

253 Submission from NSW Government (Sub #187)

254 Submission from Australian Association for Academic General Practice (Sub #38)

255 Personal submission (Sub #143)

256 Submission from Australian Physiotherapy Association (Sub #123)

257 Submission from National Primary Health Care Partnership (Sub #149)

Top of page