Florence Trout MPhil (Massey) FCNA (NZ) Advisor Quality & Risk Management in the Royal New Zealand Plunket Society (Plunket) Email: florence.trout@plunket.org.nz

Introduction
The Te Puawai Journal of December 2003 published The Superiority of Action in Quality Improvement, an article I wrote to signal the Royal New Plunket Society Inc (Plunket) decision to start the journey with the Te Wana Quality Program, and its merits.  This article updates readers with the progress made since then  - a six year journey that for me has been a highlight in my career.  It is encouraging to acknowledge all fourteen Plunket business units (National Office, PlunketLine, and thirteen Plunket Areas throughout New Zealand) for achieving accreditation, a milestone for Plunket and those who are engaged in the program today.

Quality improvement in Plunket is implemented as a cycle of review and planned action in all its managed divisions. The program of choice has similarities to participatory action research methodology. Plunket provides family health promotion programs delivered by paid staff and volunteers, now in its 102nd year. The  universal, quality reviewed, no fee, health promotion program accessible to families at home or near where they live, remains a priority to population health gain.

A thumbnail sketch of Plunket in 2009;

• The universal Well Child Health/Tamariki Ora program is a cornerstone service
• Plunket aims to reduce disparity in child health outcomes
• Focus is to identify the highest need families so that their needs are met in an appropriate and timely way
• Visits are made to about 50,000 families with new babies each year
• Plunket still believes communities should be enabled to help themselves
• Services delivered are worth $100m, funded from various agencies and including volunteer labor (estimated as $15 hour)
• Volunteers are organized in incorporated area society entities and are governors
• Plunket employs over 1000 specially trained staff (95% of whom are women)
• Plunket is a registered Private Training Establishment with New Zealand Qualifications Authority for education programs
• Every Plunket team shares in the accreditation status that recognizes the attainment of sector service standards.

Action in the Te Wana Quality Program is a systematic approach to continual quality improvement. The program is designed to increase the capacity of a community agency’s ability to attain true primary health care standards. Ultimately, better health outcomes can be expected for defined populations through better links with other community groups. The emphasis is on coordinated engagement and continuing improvement at national and area levels.

Why did Plunket choose Te Wana?
Plunket sought a systematic and future oriented quality improvement program to fit its future values.  The Te Wana Quality Program was the program of choice in 2002 and remains the program of choice in 2009. The standards and review processes promote action to ‘challenge ourselves to achieve things and to challenge our organizations to achieve the standards of highest quality’ (Health Care Aotearoa Kaumatua Kaunihera, 1999).  Te Wana values are compatible with Plunket values and include: Te Tiriti o Waitangi, social justice, health promotion, community participation and team work.  There are three good reasons why Te Wana works well for Plunket.  First, the program is recognized by external stakeholders like the Ministry of Health and Primary Health Care Organizations.  Furthermore, it suits the Plunket context as a community-owned, national organization, fitting well with Plunket business plans and core values, and social policy.

Benefits for Plunket
There are several ways that Plunket benefits from involvement in the Te Wana Quality Improvement Program. First of all, it results in increased confidence and capability to deliver a universal service in today’s world.  The bottom-up approach encourages professional growth and development for nurses and others as a holistic team.  It provides opportunities for the development of self assessment of standards and reviewer skills.  It establishes a three year cycle for planned and systematic improvement and is an effective connector with other organizations also using the Te Wana Quality Program.  Finally, and most significantly, the Australian Quality Improvement Council through La Trobe University can award accreditation on the recommendation of Te Wana, the sole NZ license holder affiliated with Health Care Aoetaroa Inc.

Action in health care quality improvement

The four principles suggested by the National Health Committee (2002) for action in health care quality in New Zealand are; greater responsiveness to Maori, stronger leadership, greater consumer involvement, and better coordination. The Te Wana Quality Program has potential to enhance all four principles because of the values and focus on four separate types of activities; an exploratory process to gain understanding of the current situation, a plan made for intervention, action after people involved agree to the intervention process, and reflection or revision to evaluate the intervention (Health Care Aotearoa, 2001).  

Earl-Slater (2002) identifies four actions in his description of action research;  iterative where knowing is added to and built on in order to do better with tightly fitting resources, pragmatic in relying on logical information, participative by owners of change, and reflective with careful thought given to what is happening in reality. These four characteristics can also be identified and compared with systematic quality improvement programs (MoH, 2002, p4). Literature tends to support greater feelings of ownership from action through people involvement, greater insight into processes and constraints, and possibilities for formulating actions based on evidence and analysis (Bennett, 2008; Gunter & Alligood 2002; Rowe, 2002)). This implies that action in quality improvement programs is strongly aligned to action in research. 

Anne Rowe, research and development facilitator at the University of Sheffield (UK), describes a ‘whole systems’ approach to change service delivery (2002). Rowe describes five program principles in achieving real change to systems over a period of two years (p92). The similarities between Rowe’s suggestions and the Te Wana Quality Program are remarkable. The Te Wana program states that sustainable quality improvement occurs through systematic reflection, interaction, learning and collective ownership (HCA & QIC, 2007, p9). Table one compares Rowe’s principles and features with the Te Wana Quality Program principles.

Table one: Comparison of Program Principles, Features and Te Wana.

The compatible principles and features described by Rowe and the characteristics of  implementing Te Wana in Plunket suggest that  this quality program has potential for whole system improvement with active staff engagement. This seems to me to match well with action research. Kelly (2005) offers practical suggestions for community interventions using participatory action research, referring to bridging the theory-implementation gaps in community based research activities.  Community members and professionals can work together to take action, and evaluate outcomes. . 

The Primary Health Care Strategy (MoH, 2001, p 24) states that quality processes are most effective when they are integral to and an ongoing part of the way systems operate. Further, high quality organizations as health providers will be those that have a culture of continual development. While this may be stated clearly, it may not be clear to everyone.

Several authors, including Rains and Ray (2007), and Sang (1999), comment that a shift is called for to move from tokenism to meaningful partnerships with citizens. Four emerging strands suggested by Sang are; recognition of overt identification of rights and responsibilities in relation to health and well-being, need to value learning at every level in the healthcare process, learning to manage one’s own lifestyle and health journey, and working in partnership through mutual discovery and informed consent. These thoughts seem to strengthen the notion of involving staff in quality improvement in a particular way. Process and systems have become extremely important, and as Bennett (2008) states, achieving excellence in community services now and into the future requires clinical engagement and leadership.

Discussion
In New Zealand more emphasis is being placed on primary health care, a priority for local and central governments, and health authorities. However, there are questions yet to be answered as primary health care nurses struggle to allocate time to develop an essential nursing competency - quality improvement in a population health context.

Most community organizations realize that rationed resources means that there is never enough to meet all needs, and, there are many interpretations of what justifies “need” for health care intervention. The Te Wana Quality Program represents a process that is true to its name, supporting accountability and tracking improvements, for families who need care the most. It is a hands-on program which involves Plunket nurses and other staff in new ways, fostering increased enthusiasm for quality improvement. It also involves volunteers and stakeholders in ways previously under utilized.

Millar and Beardall (2001) suggest five common purposes in achieving better health care: 

• providing better access to cost effective primary health care services
• providing better coordination, integration, continuity and comprehensiveness of care
• providing more focus on the patient and improving the experience of care
• providing better working conditions for health care providers, and
• improving health and reducing inequities in heath status.

All of these themes are inherent in the Te Wana Quality Program. Plunket now has a repeating cycle for reflection using a set of appropriate standards, giving nurses more opportunity to enhance effective responses to child health promotion in populations. Practical ways to meet obligations in the Treaty of Waitangi are also helpful.
Most primary health care nurses struggle to deliver a meaningful service to diverse families based on assessing health determinants, a population concept. Many different measures are needed, and the word quality is used in a variety of ways by various groups of nurses.  Griffiths (1995) suggests that measures of structure and process should be validated by their relationship to outcomes, and will remain the best quality indicators as outcome data are often more difficult to find. The first priority may be to develop a deeper understanding of structure and process in order to improve the strength of subsequent investigation of population outcomes (Griffiths, 1995, p1098). It is interesting to acknowledge the Ministry of Health project in 2006, jointly funded with the Pediatric Society to develop a monitoring framework for child and youth health. Craig, Jackson, and Han (2007) report recommendations for additional measures or indicators to achieve maximal child health gains for New Zealand, useful elements in outcome evaluations.

The decision made by the Royal New Zealand Plunket Society Inc to implement the Te Wana Quality Program has developed the understanding for a cycle of continual quality improvement in the organization as a whole. While the standards give structure and explicit values to assessment activities, the potential to strengthen better primary health care outcomes for better child health remains future clinical and funding challenges.

Conclusion
Nurses and others have opportunities to fully participate in improving quality over time in a range of ways. Experience has shown that Te Wana is true to its name – “to challenge ourselves to achieve things, and to challenge our organizations to achieve the standards of the highest quality” (Kaumatua Kaunihera, Te Wana Quality Program 2007, p2), and implementing the program is a journey without end. Improvement means that scarce resources for health care must include allocating resources to sustain quality improvement. All staff need to know they do a good job and can improve on relevant standards. Leaders need to support continuous quality improvement in ongoing cycles.  Quality improvement in PHC is recognized for complexity arising from many community agencies involved with the same families. And finally, continuous improvement of services must lead to better population health outcomes, specifically for Maori families.

These sentiments are compatible with those expressed by a number of authors, suggesting that staff engagement needs to be a holistic process rather than a particular isolated event. Each geographical Plunket area is responsible for their own journey in improving quality of child populations, to the same sector standards. Establishing defined and relevant quality improvement goals will eventually lead to better primary health care measured by population specific methods, and, more satisfaction for staff. This journey provides nurses with challenges, opportunities and connections with other community focused agencies, the beginning to learning how to impact on child health gains for populations..

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For information about Te Wana  -   www. hca.org.nz
For information about the Plunket Society – www.plunket.org.nz

References

Bennett, V. (2008). Taking a lead in change in The Journal of the Community Practitioners’ and Health Visitors’ Association, 81(7), 36.

Craig, E. Jackson, C. Han DY, NZCYES Steering Committee (2007). Monitoring the health of New Zealand children and young people: Literature review and framework development. Paediatric Society of New Zealand, New Zealand Child and Youth Epidemiology Service, Auckland. nzcyes@auckland.ac.nz

Earl-Slater, A. (2002). The superiority of action research? British Journal of Clinical Governance, 7 (2), 32-135.

Griffiths, P. (1995). Progress in measuring nursing outcomes. Journal of Advanced Nursing, 21, 1092-1100.

Gunther, M. & Alligood, R. (2002). A discipline-specific determination of high quality nursing care. Journal of Advanced Nursing, 38 (4), 353-359.

Health Care Aotearoa & Quality Improvement Council Ltd. (2007).  Te Wana Quality Program Second edition. Te Wana Quality Program, New Zealand.

Health Care Aotearoa (2001). Te Wana Handbook 2nd edition. Author. Wellington.
            http://www.hca.org.nz 

Kelly, P. (2005). Practical suggestions for community interventions using participatory action research. Public Health Nursing, 22 (1), 65-73.

Millar, J. & Beardall, S. (2001). Will primary healthcare reform improve health? Hospital Quarterly, Fall, 41.

Ministry of Health. (2001). The Primary Health Care Strategy. Author, Wellington.
            http://www.moh.govt.nz  ISBN 0-478-24307-3.

Ministry of Health (2002). Towards Clinical Excellence. Author, Wellington. http://www.moh.govt.nz   ISBN 0-478-27040-2.

National Health Committee (2002). Safe systems supporting safe care.  Report on health care quality improvement in New Zealand. Wellington.
 http://www.nhc.govt.nz

Rains, J.W. & Ray, D.W. (2007). Participatory action research for community health promotion. Public Health Nursing, 12 (4), 256-261.

Rowe, A. (2002). Using a ‘whole systems’ approach to change service delivery. Community Practitioner, 75 (3), 91-93.

Sang, B. (1999). The customer is sometimes right. Journal of Health Services, 109, 22-3.