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Wagstaff D, Arfin S, Korver A, Chappel P, Rashan A, Haniffa R, Beane A. Interventions for improving critical care in low- and middle-income countries: a systematic review. Intensive Care Med 2024; 50:832-848. [PMID: 38748264 DOI: 10.1007/s00134-024-07377-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/27/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE To systematically review the typology, impact, quality of evidence, barriers, and facilitators to implementation of Quality Improvement (QI) interventions for adult critical care in low- and middle-income countries (LMICs). METHODS MEDLINE, EMBASE, Cochrane Library and ClinicalTrials.gov were searched on 1st September 2022. The studies were included if they described the implementation of QI interventions for adult critical care in LMICs, available as full text, in English and published after 2000. The risks of bias were assessed using the ROB 2.0/ROBINS-I tools. Intervention strategies were categorised according to a Knowledge Translation framework. Interventions' effectiveness were synthesised by vote counting and assessed with a binomial test. Barriers and facilitators to implementation were narratively synthesised using the Consolidated Framework for Implementation Research. RESULTS 78 studies were included. Risk of bias was high. The most common intervention strategies were Education, Audit & Feedback (A&F) and Protocols/Guidelines/Bundles/Checklists (PGBC). Two multifaceted strategies improved both process and outcome measures: Education and A&F (p = 0.008); and PGBC with Education and A&F (p = 0.001, p < 0.001). Facilitators to implementation were stakeholder engagement, organisational readiness for implementation, and adaptability of interventions. Barriers were lack of resources and incompatibility with clinical workflows. CONCLUSIONS The evidence for QI in critical care in LMICs is sparse and at high risk of bias but suggests that multifaceted interventions are most effective. Co-designing interventions with and engaging stakeholders, communicating relative advantages, employing local champions and adapting to feedback can improve implementation. Hybrid study designs, process evaluations and adherence to reporting guidelines would improve the evidence base.
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Affiliation(s)
| | - Sumaiya Arfin
- The George Institute for Global Health, New Delhi, India.
| | - Alba Korver
- Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | | | - Rashan Haniffa
- Pandemic Sciences Hub and Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- NICS-MORU, Colombo, Sri Lanka
| | - Abi Beane
- Pandemic Sciences Hub and Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- NICS-MORU, Colombo, Sri Lanka
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Wagstaff D, Moonesinghe SR. Publishing quality improvement studies: learning to share and sharing to learn. BJA OPEN 2023; 5:100123. [PMID: 37587994 PMCID: PMC10430837 DOI: 10.1016/j.bjao.2023.100123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/03/2023] [Indexed: 08/18/2023]
Abstract
This editorial welcomes the decision of BJA Open to publish quality improvement (QI) studies. It summarises the current problems with conducting, evaluating, and publishing QI studies. It highlights existing guidance for prospective authors to follow regarding the reporting of QI interventions, their context(s), underlying theories, and evaluation. In so doing, we hope to encourage the publication of more QI studies of sufficient quality to facilitate learning or replication elsewhere.
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Affiliation(s)
- Duncan Wagstaff
- Centre for Perioperative Medicine and Division of Surgery and Interventional Science, University College London, London, UK
| | - Suneetha Ramani Moonesinghe
- Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
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Quaife M, Estafinos AS, Keraga DW, Lohmann J, Hill Z, Kiflie A, Marchant T, Borghi J, Schellenberg J. Changes in health worker knowledge and motivation in the context of a quality improvement programme in Ethiopia. Health Policy Plan 2021; 36:1508-1520. [PMID: 34374420 PMCID: PMC8597962 DOI: 10.1093/heapol/czab094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/14/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
A knowledgeable and motivated workforce is critical for health systems to provide high-quality services. Many low- and middle-income countries face shortages in human resources and low health worker motivation but are also home to a burgeoning number of quality improvement (QI) programmes. This study evaluates whether and how motivation and clinical knowledge in three cadres of health workers changed in the context of a QI programme for maternal and newborn health in Ethiopia. This mixed-methods study used a pre–post comparison group design with matched comparison areas. We interviewed 395 health workers at baseline in April 2018 and 404 at endline in June 2019 from seven districts (woredas) with QI and seven comparison woredas. Three cadres were interviewed: health extension workers, facility-based skilled midlevel maternal and newborn care providers, and non-patient-facing staff. A qualitative component sought to triangulate and further elucidate quantitative findings using in-depth interviews with 22 health workers. Motivation was assessed quantitatively, exploratory factor analysis was used to categorize motivation dimensions, and regression-based difference-in-difference analyses were conducted. Knowledge was assessed through a clinical vignette. Qualitative data were analysed in a deductive process based on a framework derived from quantitative results. Although knowledge of the QI programme was high (79%) among participants from QI woreda at endline, participation in QI teams was lower (56%). There was strong evidence that health worker knowledge increased more in areas with QI than comparison areas. Three motivation dimensions emerged from the data: (1) ‘helping others’, (2) ‘pride and satisfaction’ and (3) ‘external recognition and support’. We found strong evidence that motivation across these factors improved in both QI and comparison areas, with weak evidence of greater increases in comparison areas. Qualitative data suggested the QI programme may have improved motivation by allowing staff to provide better care. This study suggests that although QI programmes can increase health worker knowledge, there may be little effect on motivation. Programme evaluations should measure a wide range of outcomes to fully understand their impact.
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Affiliation(s)
- Matthew Quaife
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | | | | | - Julia Lohmann
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Zelee Hill
- Institute for Global Health, University College London, Gower Street, London WC1E 6BT, UK
| | - Abiyou Kiflie
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia
| | - Tanya Marchant
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Josephine Borghi
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Joanna Schellenberg
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Affiliation(s)
- Thomas Bartman
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Richard J Brilli
- John F. Wolfe Endowed Chair in Medical Leadership and Pediatric Quality and Safety; Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
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Hu ZJ, Fusch G, Hu C, Wang JY, El Helou Z, Hassan MT, Mbuagbaw L, El Helou S, Thabane L. Completeness of reporting of quality improvement studies in neonatology is inadequate: a systematic literature survey. BMJ Open Qual 2021; 10:bmjoq-2020-001273. [PMID: 34127453 PMCID: PMC8204179 DOI: 10.1136/bmjoq-2020-001273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/02/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Quality improvement (QI) is a growing field of inquiry in healthcare, but the reporting quality of QI studies in neonatology remains unclear. We conducted a systematic survey of the literature to assess the reporting quality of QI studies and factors associated with reporting quality. METHODS We searched Medline for publications of QI studies from 2016 to 16 April 2020. Pairs of reviewers independently screened citations and assessed reporting quality using a 31-item modified Standards for Quality Improvement Reporting Excellence, 2nd edition (SQUIRE 2.0) checklist. We reported the number (percentage) of studies that reported each item and their corresponding 95% CIs. We used Poisson regression to explore factors associated with reporting quality, namely, journal endorsement of SQUIRE 2.0, declaration of funding sources, year of publication and number of authors. The results were reported as incidence rate ratio (IRR) and 95% CI. RESULTS Of 1921 citations, 336 were eligible; among them, we randomly selected 100 articles to assess reporting quality. The mean (standard deviation) number of SQUIRE 2.0 items adhered to was 22.0 (4.5). Percentage of articles reporting each item varied from 26% to 100%. Journal endorsement of SQUIRE 2.0 (IRR=1.11, 95% CI 1.02 to 1.21, p=0.015), declaration of funding sources and increasing number of authors were significantly associated with better reporting. CONCLUSIONS Reporting quality of QI studies in neonatology is inadequate. Endorsing the SQUIRE 2.0 guideline is a step that journals can implement to enhance the completeness of reporting.
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Affiliation(s)
- Zheng Jing Hu
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gerhard Fusch
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Catherine Hu
- Bachelor of Arts and Science, McMaster University, Hamilton, Ontario, Canada
| | - Jie Yi Wang
- Bachelor of Medical Sciences, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Zoe El Helou
- Bachelor of Health Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Muhammad Taaha Hassan
- Bachelor of Health Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Salhab El Helou
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Inata Y, Nakagami-Yamaguchi E, Ogawa Y, Hatachi T, Takeuchi M. Quality Assessment of the Literature on Quality Improvement in PICUs: A Systematic Review. Pediatr Crit Care Med 2021; 22:553-560. [PMID: 33729730 DOI: 10.1097/pcc.0000000000002683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To synthesize the literature describing quality improvement in PICUs and to appraise the quality of extant research. DATA SOURCES We searched the PubMed, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials databases between May and June 2020. STUDY SELECTION Peer-reviewed articles in English that report quality improvement interventions in PICUs were included. Titles and abstracts were screened, and articles were reviewed to determine whether they met quality improvement criteria. DATA EXTRACTION Data were abstracted using a structured template. The quality of the included articles was assessed using the Quality Improvement Minimum Quality Criteria Set and scored on a scale of 0-16. DATA SYNTHESIS Of the 2,449 articles identified, 158 were included in the analysis. The most common targets of quality improvement interventions were healthcare-associated infections (n = 17, 10.8%), handoffs (n = 15, 9.5%), rounds (n = 13, 8.2%), sedation/pain/delirium (n = 13, 8.2%), medication safety (n = 11, 7.0%), and unplanned extubation (n = 9, 5.7%). Of the six domains of healthcare quality described by the Institute of Medicine, patient-centeredness and timeliness were infrequently addressed, and none of the studies addressed equity. The median quality score based on the Quality Improvement Minimum Quality Criteria Set was 11.0 (25-75th interquartile range, 9.0-13.0). Although the quantity and quality of articles have been increasing, only 17% of the studies were deemed "high quality," having a score between 14 and 16. Only eight articles (5%) cited Standards for QUality Improvement Reporting Excellence guidelines for reporting quality improvement works. CONCLUSIONS The number of publications, including high-quality publications, on quality improvement interventions in PICUs has been increasing. However, low-quality articles continue to be published, even in recent years. Therefore, there is room for improvement in the quality of reporting.
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Affiliation(s)
- Yu Inata
- Department of Medical Quality and Safety Science, Osaka City University Graduate School of Medicine, Osaka, Japan
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Etsuko Nakagami-Yamaguchi
- Department of Medical Quality and Safety Science, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yuko Ogawa
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Takeshi Hatachi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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Abstract
Purpose Organisations within healthcare increasingly operate in rapidly changing environments and present wide variation in performance. It can be argued that this variation is influenced by the capability of an organisation to improve: its improvement capability. However, there is little theoretical research on improvement capability. The purpose of this paper is to set out the current diverse body of research on improvement capability and develop a theoretically informed conceptual framework. Design/methodology/approach This paper conceptualises improvement capability as a dynamic capability. This suggests that improvement capability is comprised of organisational routines that are bundled together, and adapt and react to organisational circumstances. Existing research conceptualises these bundles as three elements (microfoundations): sensing, seizing and reconfiguring. This conceptualisation is used to explore how improvement capability can be understood, by inductively categorising eight dimensions of improvement capability to develop a theoretically informed conceptual framework. Findings This paper shows that the three microfoundations which make up a dynamic capability are present in the identified improvement capability dimensions. This theoretically based conceptual framework provides a rich explanation of how improvement capability can be configured. Originality/value Identifying the component parts of improvement capability helps to explain why some organisations are less successful in improvement than others. This theoretically informed framework can support managers and policy makers to identify improvement capability dimensions in need of development. Further empirical research, particularly in non-market settings, such as publicly funded healthcare is required to enhance understanding of improvement capability and its configuration.
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