Are quality improvement collaboratives effective? A systematic review

Improvement in antibacterial use in intensive care units from Argentina: A quality improvement collaborative process evaluation using Normalization Process Theory

BACKGROUND

Healthcare-associated infections and antibiotic resistance worsen globally. Antibiotic stewardship programs (ASP) aim to optimise infection treatment and curb resistance, yet implementation hurdles persist. This study examined ASP challenges in ICUs.

METHODS

This study employed a qualitative methodological design to evaluate the implementation process of an antibiotic stewardship program (ASP) in eight intensive care units (ICUs) across Argentina. Thirty-four semi-structured interviews with healthcare workers (HCWs) were conducted. Interviews were analysed guided by Normalisation Process Theory, examining coherence, cognitive participation, collective action, and reflexive monitoring constructs.

RESULTS

Key challenges included insufficient human resources, lack of institutional support, and resistance to change, particularly among staff not initially involved in the study. Despite these challenges, the program saw partial success in improving ICU practices, particularly in antibiotic use and communication across departments. The main strategy implemented in this quality improvement collaborative was the use of improvement cycles, which served as the central component for driving change. However, participation in improvement cycles was inconsistent, and sustainability post-intervention remains uncertain due to workload pressures and the need for continuous education. Concerns about workload and communication barriers persisted. Many participants did not perceive training as a separate component, which led to low engagement. Resistance to change became evident during modifications to clinical guidelines. The intervention had a positive impact on various processes, including communication and record keeping.

CONCLUSION

This study underscores the persistent challenges in implementing ASPs in healthcare, emphasising the need for enhanced collaboration, workforce capacity building, and evidence-based practices to overcome barriers and optimize antimicrobial use to improve patient outcomes.

How to Design and Write Your Quality Improvement Study for Publication: Pearls and Pitfalls

Objective

To describe a pragmatic process for translating quality improvement (QI) projects into published manuscripts.

Scope

Types of QI work that are generalizable and have broad relevance (to journals and readers), design principles that are important for publishable QI work, how QI manuscript organization might differ from biomedical manuscripts, how to use and not to use Standards for Quality Improvement Reporting Excellence and other guidelines, pitfalls, and how to avoid/repair them.

Identifying high-impact-opportunity hospitals for improving healthcare quality based on a national population analysis of inter-hospital variation in mortality, readmissions and prolonged length of stay

OBJECTIVES

To study between-hospital variation in mortality, readmissions and prolonged length of stay across Belgian hospitals.

DESIGN

A retrospective nationwide observational study.

SETTING

Secondary and tertiary acute-care hospitals in Belgium.

PARTICIPANTS

We studied 4 560 993 hospital stays in 99 (98%) Belgian acute-care hospitals between 2016 and 2018.

PRIMARY OUTCOME MEASURES

Using generalised linear mixed models, we calculated hospital-specific and Major Diagnostic Category (MDC)-specific risk-adjusted in-hospital mortality, readmissions within 30 days and length of stay above the MDC-specific 90th percentile and assessed between-hospital variation through estimated variance components.

RESULTS

There was strong evidence of between-hospital variation in mortality, readmissions and prolonged length of stay across the vast majority of patient service lines. Overall, should hospitals with upper-quartile risk-standardised rates succeed in improving to the median level, a yearly 4076 hospital deaths, 3671 readmissions and 15 787 long patient stays could potentially be avoided in those hospitals. Our analysis revealed a select set of 'high-impact-opportunity hospitals' characterised by poor performance across outcomes and across a large number of MDCs.

CONCLUSIONS

Analysis of between-hospital variation highlights important differences in patient outcomes that are not explained by known patient or hospital characteristics. Identifying 'high-impact-opportunity hospitals' can help government inspection bodies and hospital managers to establish targeted audits and inspections to generate effective quality improvement initiatives.

Improving Antibiotic Use in Argentine Pediatric Hospitals: A Process Evaluation Using Normalization Process Theory

Introduction

In the pediatric setting, overprescribing of antibiotics contributes to the rise of multidrug-resistant organisms. Antimicrobial stewardship programs (ASPs) are recommended to optimize antibiotic use and combat resistance. However, the implementation of ASPs in low- and middle-income countries faces several challenges. This study aimed to evaluate the implementation process of a multifaceted ASP in 2 pediatric hospitals in Argentina.

Methods

A qualitative study was conducted in two large public children's hospitals in Argentina, using semistructured interviews with 32 healthcare providers at the beginning and end of the ASP implementation. The study was guided by the normalization process theory.

Results

The intervention faced challenges, including limited understanding of its objectives, confusion with existing practices, and insufficient commitment from senior staff. Although junior staff were more receptive, communication barriers with external staff and workload concerns hindered broader adoption. Infectious disease specialists primarily led implementation, with limited involvement of other staff, particularly in training activities. Despite these challenges, participants reported improvements, such as the development of standardized antibiotic guidelines, better interdisciplinary collaboration, and improved communication. However, organizational support and resistance to new practices remained barriers.

Conclusions

This study highlights the importance of organizational context and staff commitment in ASP implementation. Tailored strategies that address the specific challenges of low- and middle-income countries are needed to effectively implement ASPs.

Breast Cancer Patient Flap Management After Mastectomy: A Best Practice Implementation Project

BACKGROUND

Breast cancer is a prevalent malignancy in women, with mastectomy as the main surgery. Common postmastectomy complications are seroma (15%-81%), infections (2.9%-3.8%), and flap necrosis (10%-18%), severely impacting quality of life and costs. However, there's a lack of standardized flap care protocols and limited staff knowledge.

OBJECTIVES

This study aims to apply best evidence for flap management post-mastectomy to standardize practices, reduce complications, and enhance patient's quality of life.

METHODS

This project followed JBI PACES and GRiP principles, implementing evidence-based practices in a Chinese tertiary hospital between January and May 2023. It entailed evidence identification, integration into clinical context, protocol development, baseline audits, barrier/enabler analysis. The study compared pre- and post-evidence implementation rates of flap complications, healthcare staff's knowledge/skill scores on mastectomy flap management, and audit indicator adherence by both staff and patients.

RESULTS

After evidence application, flap ischemia/necrosis rates dropped from 8.57% to 5.56% (P < .001), wound infection rates after surgery reduced from 5.71% to 2.78% (P < .001), and seroma rates decreased from 17.14% to 2.78% (P < .001). Healthcare staff's knowledge and skill scores for flap management following mastectomy increased from 50.67 ±18.32 preimplementation to 98.33 ± 4.01 (t = -13.90, P < .001). Audit criterion compliance rates increased from 8.57% to 94.29% to between 91.67% and 100%, with statistically significant differences in all 15 criteria (P < .001).

CONCLUSIONS

Evidence-based management of flaps after mastectomy improves healthcare staff's knowledge and skills, enhances nursing quality, effectively reduces flap complications in patients, and boosts their quality of life.

Good practices to optimise the performance of maternal and neonatal quality improvement teams: Results from a longitudinal qualitative evaluation in South Africa, before, and during COVID-19

Many maternal and neonatal deaths can be avoided if quality healthcare is provided. To this end, the South African National Department of Health implemented a quality improvement (QI) programme (2018-2022) to improve maternal and neonatal health services in 21 public health facilities. This study sought to identify good practices aimed at improving QI teams' performance by identifying optimal facility-level contextual factors and implementation processes. We purposively selected 14 facilities of the 21 facilities for a longitudinal qualitative process evaluation. We interviewed 17 team leaders, 47 members, and five QI advisors who provided technical support to the teams. The data were analysed using framework analysis. We choose the Consolidated Framework for Implementation Research as framework given that it explicates contexts and processes that shape programme implementation. Six quality improvement teams were assessed as well-performing, and eight as less well-performing. This research conceptualises a 'life course lens' for setting up and managing a QI team. We identified eight good practices, six related to implementation processes, and two contextual variables that will optimise team performance. The two most impactful practices to improve the performance of a QI team were (i) selecting healthcare workers with quality improvement-specific characteristics, and (ii) appointing advisors whose interpersonal skills match their technical quality improvement competencies.

Quality priorities related to the management of type 2 diabetes in primary care: results from the COMPAS + quality improvement collaborative

BACKGROUND

This study aims to describe the main type 2 diabetes mellitus (T2DM) quality improvement (QI) challenges identified by primary care teams in the province of Quebec who participated in the COMPAS + QI collaborative.

METHODS

A qualitative descriptive design was used to analyse the results of 8 COMPAS + workshops conducted in 4 regions of the province between 2016 and 2020. Deductive content analysis was performed to classify the reported QI priorities under the Consolidated Framework for Implementation Research domains; and proposed change strategies under the Behavior Change Wheel (BCW) intervention functions.

RESULTS

A total of 177 participants attended the T2DM COMPAS + workshops. Three QI priorities were identified: (1) lack of coordination and integration of T2DM care and services; (2) lack of preventive services for pre-diabetes and T2DM; and (3) lack of integration of the patients-as-partners approach to support T2DM self-management. The proposed QI strategies to address those priorities were classified under the education, training, persuasion, habilitation and restructuring BCW intervention functions.

CONCLUSION

This study provides insights on how QI collaboratives can support the identification of QI priorities and strategies to improve T2DM management in primary care.

The role of QI collaboratives in neonatology

Quality improvement collaboratives (QICs) use their collective experiences from participating centers to accelerate the translation of evidence into practice, resulting in reduced variation and improved clinical outcomes. There are several regional, national, and international QICs in neonatology. In this review, we discuss the framework and evaluate national QICs primarily based in US and share the contributions of selected studies. We found that the QICs in neonatology play a significant role in identification of target topics, developing best practices, improving provider knowledge, building QI capacity, and improving outcomes. The key strengths of QICs are that they produce more generalizable learnings, involve a larger patient population which enhances statistical analysis, and offer resources to smaller institutions. Limitations include institutions contributing unequally to the overall results, difficulty in interpreting results when multiple improvement strategies are applied simultaneously, and the possible lack of academic recognition for individual center leadership.

Reducing the Risk of Delayed Colorectal Cancer Diagnoses Through an Ambulatory Safety Net Collaborative

BACKGROUND

An estimated 12 million adults in the United States experience delayed diagnoses and other diagnostic errors annually. Ambulatory safety nets (ASNs) are an intervention to reduce delayed diagnoses by identifying patients with abnormal results overdue for follow-up using registries, workflow redesign, and patient navigation. The authors sought to co-design a collaborative and implement colorectal cancer (CRC) ASNs across various health care settings.

METHODS

A working group was convened to co-design implementation guidance, measures, and the collaborative model. Collaborative sites were recruited through a medical professional liability insurance program and chose to begin with developing an ASN for positive at-home CRC screening or overdue surveillance colonoscopy. The 18-month Breakthrough Series Collaborative ran from January 2022 to July 2023, with sites continuing to collect data while sustaining their ASNs. Data were collected from sites monthly on patients in the ASN, including the proportion that was successfully contacted, scheduled, and completed a follow-up colonoscopy.

RESULTS

Six sites participated; four had an operational ASN at the end of the Breakthrough Series, with the remaining sites launching three months later. From October 2022 through February 2024, the Collaborative ASNs collectively identified 5,165 patients from the registry as needing outreach. Among patients needing outreach, 3,555 (68.8%) were successfully contacted, 2,060 (39.9%) were scheduled for a colonoscopy, and 1,504 (29.1%) completed their colonoscopy.

CONCLUSION

The Collaborative successfully identified patients with previously abnormal CRC screening and facilitated completion of follow-up testing. The CRC ASN Implementation Guide offers a comprehensive road map for health care leaders interested in implementing CRC ASNs.

Consequences of how third sector organisations are commissioned in the NHS and local authorities in England: a mixed-methods study

Background

As a matter of policy, voluntary, community and social enterprises contribute substantially to the English health and care system. Few studies explain how the National Health Service and local authorities commission them, what outputs result, what contexts influence these outcomes and what differentiates this kind of commissioning.

Objectives

To explain how voluntary, community and social enterprises are commissioned, the consequences, what barriers both parties face and what absorptive capacities they need.

Design

Observational mixed-methods realist analysis: exploratory scoping, cross-sectional analysis of National Health Service Clinical Commissioning Group spending on voluntary, community and social enterprises, systematic comparison of case studies, action learning. Social prescribing, learning disability support and end-of-life care were tracers.

Setting

Maximum-variety sample of six English local health and care economies, 2019-23.

Participants

Commissioning staff; voluntary, community and social enterprise members.

Interventions

None; observational study.

Main outcome measures

How the consequences of commissioning compared with the original aims of the commissioners and the voluntary, community and social enterprises: predominantly qualitative (non-measurable) outcomes.

Data sources

Data sources were: 189 interviews, 58 policy and position papers, 37 items of rapportage, 692,659 Clinical Commissioning Group invoices, 102 Freedom of Information enquiries, 131 survey responses, 18 local project group meetings, 4 national action learning set meetings. Data collected in England during 2019-23.

Results

Two modes of commissioning operated in parallel. Commodified commissioning relied on creating a principal-agent relationship between commissioner and the voluntary, community and social enterprises, on formal competitive selection ('procurement') of providers. Collaborative commissioning relied on 'embedded' interorganisational relationships, mutual recognition of resource dependencies, a negotiated division of labour between organisations, and control through persuasion. Commissioners and voluntary, community and social enterprises often worked around the procurement regulations. Both modes were present everywhere but the balance depended inter alia on the number and size of voluntary, community and social enterprises in each locality, their past commissioning experience, the character of the tracer activity, and the level of deprivation and the geographic dispersal of the populations served. The COVID-19 pandemic produced a shift towards collaborative commissioning. Voluntary, community and social enterprises were not always funded at the full cost of their activity. Integrated Care System formation temporarily disrupted local co-commissioning networks but offered a longer-term prospect of greater voluntary, community and social enterprise influence on co-commissioning. To develop absorptive capacity, commissioners needed stronger managerial and communication capabilities, and voluntary, community and social enterprises needed greater capability to evidence what outcomes their proposals would deliver.

Limitations

Published data quality limited the spending profile accuracy, which did not include local authority commissioning. Case studies did not cover London, and focused on three tracer activities. Absorptive capacity survey was not a random sample.

Conclusions

The two modes of commissioning sometimes conflicted. Workarounds arose from organisations' embeddedness and collaboration, which the procurement regulations often disrupted. Commissioning activity at below its full cost appears unsustainable.

Future work

Spending profiles of local authority commissioning; analysis of commissioning in London and of activities besides the present tracers. Analysis of absorptive capacity and its consequences, adjusting the concept for application to voluntary, community and social enterprises. Comparison with other health systems' commissioning of voluntary, community and social enterprises.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128107) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 39. See the NIHR Funding and Awards website for further award information.

A Virtual Breakthrough Series Collaborative for Missed Test Results: A Stepped-Wedge Cluster-Randomized Clinical Trial

Importance

Missed test results, defined as test results not followed up within an appropriate time frame, are common and lead to delays in diagnosis and treatment.

Objective

To evaluate the effect of a quality improvement collaborative, the Virtual Breakthrough Series (VBTS), on the follow-up rate of 2 types of test results prone to being missed: chest imaging suspicious for lung cancer and laboratory findings suggestive of colorectal cancer.

Design, Setting, and Participants

This stepped-wedge cluster-randomized clinical trial was conducted between February 2020 and March 2022 at 12 Department of Veterans Affairs (VA) medical centers, with a predefined 3-cohort roll-out. Each cohort was exposed to 3 phases: preintervention, action, and continuous improvement. Follow-up ranged from 0 to 12 months, depending on cohort. Teams at each site were led by a project leader and included diverse interdisciplinary representation, with a mix of clinical and technical experts, senior leaders, nursing champions, and other interdisciplinary team members. Analysis was conducted per protocol, and data were analyzed from April 2022 to March 2024.

Intervention

All teams participated in a VBTS, which included instruction on reducing rates of missed test results at their site.

Main Outcomes and Measures

The primary outcome was changes in the percentage of abnormal test result follow-up, comparing the preintervention phase with the action phase. Secondary outcomes were effects across cohorts and the intervention's effect on sites with the highest and lowest preintervention follow-up rates. Previously validated electronic algorithms measured abnormal imaging and laboratory test result follow-up rates.

Results

A total of 11 teams completed the VBTS and implemented 47 (mean, 4 per team; range, 3-8 per team; mode, 3 per team) unique interventions to improve missed test results. A total of 40 027 colorectal cancer-related tests were performed, with 5130 abnormal results, of which 1286 results were flagged by the electronic trigger (e-trigger) algorithm as being missed. For lung cancer-related studies, 376 765 tests were performed, with 7314 abnormal results and 2436 flagged by the e-trigger as being missed. There was no significant difference in the percentage of abnormal test results followed up by study phase, consistent across all 3 cohorts. The estimated mean difference between the preintervention and action phases was -0.78 (95% CI, -6.88 to 5.31) percentage points for the colorectal e-trigger and 0.36 (95% CI, -5.19 to 5.9) percentage points for the lung e-trigger. However, there was a significant effect of the intervention by site, with the site with the lowest follow-up rate at baseline increasing its follow-up rate from 27.8% in the preintervention phase to 55.6% in the action phase.

Conclusions and Relevance

In this cluster-randomized clinical trial of the VBTS intervention, there was no improvement in the percentage of test results receiving follow-up. However, the VBTS may offer benefits for sites with low baseline performance.

Trial Registration

ClinicalTrials.gov Identifier: NCT04166240.

Qualitative Evaluation of a Quality Improvement Collaborative Implementation to Improve Acute Ischemic Stroke Treatment in Nova Scotia, Canada

The Atlantic Canada Together Enhancing Acute Stroke Treatment (ACTEAST) project is a modified quality improvement collaborative (mQIC) designed to improve ischemic stroke treatment rates and efficiency in Atlantic Canada. This study evaluated the implementation of the mQIC in Nova Scotia using qualitative methods. The mQIC spanned 6 months, including two learning sessions, webinars, and a per-site virtual visit. The learning sessions featured presentations about the project and the improvement efforts at some sites. Each session included an action planning period where the participants planned for the implementation efforts over the following 2 to 4 months, called "action periods". Eleven hospitals and Emergency Health Services (EHS) of Nova Scotia participated. The Consolidated Framework for Implementation Research (CFIR) was utilized to develop a semi-structured interview guide to uncover barriers and facilitators to mQIC's implementation. Interviews were conducted with 14 healthcare professionals from 10 entities, generating 458 references coded into 28 CFIR constructs. The interviews started on 17 June 2021, 2 months after the intervention period, and ended on 7 October 2021. Notably, 84% of these references were positively framed as facilitators., highlighting the various aspects of the mQIC and its context that supported successful implementation. These facilitators encompassed factors such as networks and communications, strong leadership engagement, and a collaborative culture. Significant barriers included resource availability, relative priorities, communication challenges, and engaging key stakeholders. Some barriers were prominent during specific phases. The study provides insights into quality improvement initiatives in stroke care, reflecting the generally positive opinions of the interviewees regarding the mQIC. While the quantitative analysis is still ongoing, this study highlights the importance of addressing context-specific barriers and leveraging the identified facilitators for successful implementation.

Rates Of Patient Safety Indicators In Belgian Hospitals Were Low But Generally Higher Than In US Hospitals, 2016-18

More than two decades ago, the Agency for Healthcare Research and Quality developed its Patient Safety Indicators (PSIs) to monitor potentially preventable and severe adverse events within hospitals. Application of PSIs outside the US was explored more than a decade ago, but it is uncertain whether they remain relevant within Europe, as no up-to-date assessments of overall PSI-associated adverse event rates or interhospital variability can be found in the literature. This article assesses the nationwide occurrence and variability of thirteen adverse events for a case study of Belgium. We studied 4,765,850 patient stays across all 101 hospitals for 2016-18. We established that although adverse event rates were generally low, with an adverse event observed in 0.1 percent of medical hospital stays and in 1.2 percent of surgical hospital stays, they were higher than equivalent US rates and were prone to considerable between-hospital variability. Failure-to-rescue rates, for example, equaled 23 percent, whereas some hospitals exceeded nationwide central line-associated bloodstream infection rates by a factor of 8. Policy makers and hospital managers can prioritize PSIs that have high adverse event rates or large variability, such as failure to rescue or central line-associated bloodstream infections, to improve the quality of care in Belgian hospitals.

Optimising antibacterial utilisation in Argentine intensive care units: a quality improvement collaborative

BACKGROUND

There is limited evidence from antimicrobial stewardship programmes in less-resourced settings. This study aimed to improve the quality of antibacterial prescriptions by mitigating overuse and promoting the use of narrow-spectrum agents in intensive care units (ICUs) in a middle-income country.

METHODS

We established a quality improvement collaborative (QIC) model involving nine Argentine ICUs over 11 months with a 16-week baseline period (BP) and a 32-week implementation period (IP). Our intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions and education. The intervention was delivered in two learning sessions with three action periods along with coaching support and basic quality improvement training.

RESULTS

We included 912 patients, 357 in BP and 555 in IP. The latter had higher APACHE II (17 (95% CI: 12 to 21) vs 15 (95% CI: 11 to 20), p=0.036), SOFA scores (6 (95% CI: 4 to 9) vs 5 (95% CI: 3 to 8), p=0.006), renal failure (41.6% vs 33.1%, p=0.009), sepsis (36.1% vs 31.6%, p<0.001) and septic shock (40.0% vs 33.8%, p<0.001). The days of antibacterial therapy (DOT) were similar between the groups (change in the slope from BP to IP 28.1 (95% CI: -17.4 to 73.5), p=0.2405). There were no differences in the antibacterial defined daily dose (DDD) between the groups (change in the slope from BP to IP 43.9, (95% CI: -12.3 to 100.0), p=0.1413).The rate of antibacterial de-escalation based on microbiological culture was higher during the IP (62.0% vs 45.3%, p<0.001).The infection prevention control (IPC) assessment framework was increased in eight ICUs.

CONCLUSION

Implementing an antimicrobial stewardship program in ICUs in a middle-income country via a QIC demonstrated success in improving antibacterial de-escalation based on microbiological culture results, but not on DOT or DDD. In addition, eight out of nine ICUs improved their IPC Assessment Framework Score.

The utility of website-based quality improvement tools for health professionals: a systematic review

As technology continues to advance, it is important to understand how website-based tools can support quality improvement. Website-based tools refer to resources such as toolkits that users can access and use autonomously through a dedicated website. This review examined how website-based tools can support healthcare professionals with quality improvement, including the optimal processes used to develop tools and the elements of an effective tool. A systematic search of seven databases was conducted to include articles published between January 2012 and January 2024. Articles were included if they were peer reviewed, written in English, based in health settings, and reported the development or evaluation of a quality improvement website-based tool for professionals. A narrative synthesis was conducted using NVivo. Risk of bias was assessed using the Mixed Methods Appraisal Tool. All papers were independently screened and coded by two authors using a six-phase conceptual framework by Braun and Clarke. Eighteen studies met the inclusion criteria. Themes identified were tool development processes, quality improvement mechanisms and barriers and facilitators to tool usage. Digitalizing existing quality improvement processes (n = 7), identifying gaps in practice (n = 6), and contributing to professional development (n = 3) were common quality improvement aims. Tools were associated with the reported enhancement of accuracy and efficiency in clinical tasks, improvement in adherence to guidelines, facilitation of reflective practice, and provision of tailored feedback for continuous quality improvement. Common features were educational resources (n = 7) and assisting the user to assess current practices against standards/recommendations (n = 6), which supported professionals in achieving better clinical outcomes, increased professional satisfaction and streamlined workflow in various settings. Studies reported facilitators to tool usage including relevance to practice, accessibility, and facilitating multidisciplinary action, making these tools practical and time-efficient for healthcare. However, barriers such as being time consuming, irrelevant to practice, difficult to use, and lack of organizational engagement were reported. Almost all tools were co-developed with stakeholders. The co-design approaches varied, reflecting different levels of stakeholder engagement and adoption of co-design methodologies. It is noted that the quality of included studies was low. These findings offer valuable insights for future development of quality improvement website-based tools in healthcare. Recommendations include ensuring tools are co-developed with healthcare professionals, focusing on practical usability and addressing common barriers to enhance engagement and effectiveness in improving healthcare quality. Randomized controlled trials are warranted to provide objective evidence of tool efficacy.

Acceptability and feasibility of using a blended quality improvement strategy among health workers to monitor women engagement in Option B+ program in Lilongwe Malawi

Option B + provides lifelong ART to pregnant and breastfeeding women with HIV to reduce mother-to-child transmission of HIV (eMTCT) and improve maternal health. The effectiveness of Option B + relies on continuous engagement, but suboptimal monitoring of HIV care hinders our measurements of engagement. Process mapping and quality improvement (PROMAQI) is a quality improvement strategy for healthcare workers (HCWs) to optimize complex processes such as monitoring HIV care. We assessed the acceptability and feasibility of the PROMAQI among HCWs and identified barriers and facilitators for PROMAQI implementation. A cross-sectional study using a mixed method approach was conducted from August 2021 to March 2022 across five urban health facilities participating in PROMAQI implementation n the Lilongwe district, Malawi. We assessed PROMAQI acceptability and feasibility at the end of the study. A 5-point Likert (1 = worst to 5 = best) scale tool was administered to 110 HCWs (n = 15-33 per facility) involved in PROMAQI implementationThese data were analysed using descriptive statistics Among the 110 HCWs, twenty-two (QI team (n = 11) and QI implementers (n = 11)) were purposively selected for in-depth interviews. Thematic analysis was conducted using deducted and inductive approaches. The theoretical framework for acceptability (TFA) was used to identify reasons for acceptability. The Consolidated Framework for Implementation Research (CFIR) was used to characterize the barriers and facilitators of PROMAQI implementation. HCWs recruited had a median age of 37 (32-43) years, 82.0% of whom were female. Most (42%) had completed secondary education, and 84% were nurses and community health workers. The median (IQR) acceptability and feasibility scores for the PROMAQI were 5 (IQR 4-5) and 4 (IQR 4-5), respectively. Reasons for high PROMAQI acceptability included addressing a relevant gap and improving performance. Perceived implementation barriers included poor work attitudes, time constraints, resource limitations, knowledge gaps, and workbook difficulties. The facilitators included communication, mentorship, training, and financial incentives. PROMAQI is a highly acceptable and feasible tool for monitoring engagement of women in Option B + . Addressing these barriers may optimize the implementation of PROMAQI. Scaling up PROMAQI may enhance retention in the Option B + program and facilitate eMTCT.

Call for Action to Target Interhospital Variation in Cardiovascular Mortality, Readmissions, and Length-of-Stay: Results of a National Population Analysis

BACKGROUND

Excessive interhospital variation threatens healthcare quality. Data on variation in patient outcomes across the whole cardiovascular spectrum are lacking. We aimed to examine interhospital variability for 28 cardiovascular All Patient Refined-Diagnosis-related Groups (APR-DRGs).

METHODS

We studied 103,299 cardiovascular admissions in 99 (98%) Belgian acute-care hospitals between 2012 and 2018. Using generalized linear mixed models, we estimated hospital-specific and APR-DRG-specific risk-standardized rates for in-hospital mortality, 30-day readmissions, and length-of-stay above the APR-DRG-specific 90th percentile. Interhospital variation was assessed based on estimated variance components and time trends between the 2012-2014 and 2016-2018 periods were examined.

RESULTS

There was strong evidence of interhospital variation, with statistically significant variation across the 3 outcomes for 5 APR-DRGs after accounting for patient and hospital factors: percutaneous cardiovascular procedures with acute myocardial infarction, heart failure, hypertension, angina pectoris, and arrhythmia. Medical diagnoses, with in particular hypertension, heart failure, angina pectoris, and cardiac arrest, showed strongest variability, with hypertension displaying the largest median odds ratio for mortality (2.51). Overall, hospitals performing at the upper-quartile level should achieve improvements to the median level, and an annual 633 deaths, 322 readmissions, and 1578 extended hospital stays could potentially be avoided.

CONCLUSIONS

Analysis of interhospital variation highlights important outcome differences that are not explained by known patient or hospital characteristics. Targeting variation is therefore a promising strategy to improve cardiovascular care. Considering their treatment in multidisciplinary teams, policy makers, and managers should prioritize heart failure, hypertension, cardiac arrest, and angina pectoris improvements by targeting guideline implementation outside the cardiology department.

A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022

BACKGROUND

Studies of implementation strategies range in rigor, design, and evaluated outcomes, presenting interpretation challenges for practitioners and researchers. This systematic review aimed to describe the body of research evidence testing implementation strategies across diverse settings and domains, using the Expert Recommendations for Implementing Change (ERIC) taxonomy to classify strategies and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework to classify outcomes.

METHODS

We conducted a systematic review of studies examining implementation strategies from 2010-2022 and registered with PROSPERO (CRD42021235592). We searched databases using terms "implementation strategy", "intervention", "bundle", "support", and their variants. We also solicited study recommendations from implementation science experts and mined existing systematic reviews. We included studies that quantitatively assessed the impact of at least one implementation strategy to improve health or health care using an outcome that could be mapped to the five evaluation dimensions of RE-AIM. Only studies meeting prespecified methodologic standards were included. We described the characteristics of studies and frequency of implementation strategy use across study arms. We also examined common strategy pairings and cooccurrence with significant outcomes.

FINDINGS

Our search resulted in 16,605 studies; 129 met inclusion criteria. Studies tested an average of 6.73 strategies (0-20 range). The most assessed outcomes were Effectiveness (n=82; 64%) and Implementation (n=73; 56%). The implementation strategies most frequently occurring in the experimental arm were Distribute Educational Materials (n=99), Conduct Educational Meetings (n=96), Audit and Provide Feedback (n=76), and External Facilitation (n=59). These strategies were often used in combination. Nineteen implementation strategies were frequently tested and associated with significantly improved outcomes. However, many strategies were not tested sufficiently to draw conclusions.

CONCLUSION

This review of 129 methodologically rigorous studies built upon prior implementation science data syntheses to identify implementation strategies that had been experimentally tested and summarized their impact on outcomes across diverse outcomes and clinical settings. We present recommendations for improving future similar efforts.

Heideveld-Chevalking A, Kristensen K, Huibertina Davida van Tuyl L, Põlluste K, Weynants C, Garel P, Sousa P, Talving P, Marx D, Žaludek A, Romero E, Rodríguez A, Orrego C. Improving quality and patient safety in surgical care through standardisation and harmonisation of perioperative care (SAFEST project): A research protocol for a mixed methods study

INTRODUCTION

Adverse events in health care affect 8% to 12% of patients admitted to hospitals in the European Union (EU), with surgical adverse events being the most common types reported.

AIM

SAFEST project aims to enhance perioperative care quality and patient safety by establishing and implementing widely supported evidence-based perioperative patient safety practices to reduce surgical adverse events.

METHODS

We will conduct a mixed-methods hybrid type III implementation study supporting the development and adoption of evidence-based practices through a Quality Improvement Learning Collaborative (QILC) in co-creation with stakeholders. The project will be conducted in 10 hospitals and related healthcare facilities of 5 European countries. We will assess the level of adherence to the standardised practices, as well as surgical complications incidence, patient-reported outcomes, contextual factors influencing the implementation of the patient safety practices, and sustainability. The project will consist of six components: 1) Development of patient safety standardised practices in perioperative care; 2) Guided self-evaluation of the standardised practices; 3) Identification of priorities and actions plans; 4) Implementation of a QILC strategy; 5) Evaluation of the strategy effectiveness; 6) Patient empowerment for patient safety. Sustainability of the project will be ensured by systematic assessment of sustainability factors and business plans. Towards the end of the project, a call for participation will be launched to allow other hospitals to conduct the self-evaluation of the standardized practices.

DISCUSSION

The SAFEST project will promote patient safety standardized practices in the continuum of care for adult patients undergoing surgery. This project will result in a broad implementation of evidence-based practices for perioperative care, spanning from the care provided before hospital admission to post-operative recovery at home or outpatient facilities. Different implementation challenges will be faced in the application of the evidence-based practices, which will be mitigated by developing context-specific implementation strategies. Results will be disseminated in peer-reviewed publications and will be available in an online platform.

Process evaluation of a data-driven quality improvement program within a cluster randomised controlled trial to improve coronary heart disease management in Australian primary care

BACKGROUND

This study evaluates primary care practices' engagement with various features of a quality improvement (QI) intervention for patients with coronary heart disease (CHD) in four Australian states.

METHODS

Twenty-seven practices participated in the QI intervention from November 2019 -November 2020. A combination of surveys, semi-structured interviews and other materials within the QUality improvement in primary care to prevent hospitalisations and improve Effectiveness and efficiency of care for people Living with heart disease (QUEL) study were used in the process evaluation. Data were summarised using descriptive statistical and thematic analyses for 26 practices.

RESULTS

Sixty-four practice team members and Primary Health Networks staff provided feedback, and nine of the 63 participants participated in the interviews. Seventy-eight percent (40/54) were either general practitioners or practice managers. Although 69% of the practices self-reported improvement in their management of heart disease, engagement with the intervention varied. Forty-two percent (11/26) of the practices attended five or more learning workshops, 69% (18/26) used Plan-Do-Study-Act cycles, and the median (Interquartile intervals) visits per practice to the online SharePoint site were 170 (146-252) visits. Qualitative data identified learning workshops and monthly feedback reports as the key features of the intervention.

CONCLUSION

Practice engagement in a multi-featured data-driven QI intervention was common, with learning workshops and monthly feedback reports identified as the most useful features. A better understanding of these features will help influence future implementation of similar interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12619001790134.

Quality improvement collaborative for improving patient care delivery in Argentine public health sector intensive care units

BACKGROUND

The demand for healthcare services during the COVID-19 pandemic was excessive for less-resourced settings, with intensive care units (ICUs) taking the heaviest toll.

OBJECTIVE

The aim was to achieve adequate personal protective equipment (PPE) use in 90% of patient encounters, to reach 90% compliance with objectives of patient flow (OPF) and to provide emotional support tools to 90% of healthcare workers (HCWs).

METHODS

We conducted a quasi-experimental study with an interrupted time-series design in 14 ICUs in Argentina. We randomly selected adult critically ill patients admitted from July 2020 to July 2021 and active HCWs in the same period. We implemented a quality improvement collaborative (QIC) with a baseline phase (BP) and an intervention phase (IP). The QIC included learning sessions, periods of action and improvement cycles (plan-do-study-act) virtually coached by experts via platform web-based activities. The main study outcomes encompassed the following elements: proper utilisation of PPE, compliance with nine specific OPF using daily goal sheets through direct observations and utilisation of a web-based tool for tracking emotional well-being among HCWs.

RESULTS

We collected 7341 observations of PPE use (977 in BP and 6364 in IP) with an improvement in adequate use from 58.4% to 71.9% (RR 1.2, 95% CI 1.17 to 1.29, p<0.001). We observed 7428 patient encounters to evaluate compliance with 9 OPF (879 in BP and 6549 in IP) with an improvement in compliance from 53.9% to 67% (RR 1.24, 95% CI 1.17 to 1.32, p<0.001). The results showed that HCWs did not use the support tool for self-mental health evaluation as much as expected.

CONCLUSION

A QIC was effective in improving healthcare processes and adequate PPE use, even in the context of a pandemic, indicating the possibility of expanding QIC networks nationwide to improve overall healthcare delivery. The limited reception of emotional support tools requires further analyses.

A National Quality Improvement Collaborative to Improve Antibiotic Use in Pediatric Infections

BACKGROUND

Nearly 25% of antibiotics prescribed to children are inappropriate or unnecessary, subjecting patients to avoidable adverse medication effects and cost.

METHODS

We conducted a quality improvement initiative across 118 hospitals participating in the American Academy of Pediatrics Value in Inpatient Pediatrics Network 2020 to 2022. We aimed to increase the proportion of children receiving appropriate: (1) empirical, (2) definitive, and (3) duration of antibiotic therapy for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infections to ≥85% by Jan 1, 2022. Sites reviewed encounters of children >60 days old evaluated in the emergency department or hospital. Interventions included monthly audit with feedback, educational webinars, peer coaching, order sets, and a mobile app containing site-specific, antibiogram-based treatment recommendations. Sites submitted 18 months of baseline, 2-months washout, and 10 months intervention data. We performed interrupted time series (analyses for each measure.

RESULTS

Sites reviewed 43 916 encounters (30 799 preintervention, 13 117 post). Overall median [interquartile range] adherence to empirical, definitive, and duration of antibiotic therapy was 67% [65% to 70%]; 74% [72% to 75%] and 61% [58% to 65%], respectively at baseline and was 72% [71% to 72%]; 79% [79% to 80%] and 71% [69% to 73%], respectively, during the intervention period. Interrupted time series revealed a 13% (95% confidence interval: 1% to 26%) intercept change at intervention for empirical therapy and a 1.1% (95% confidence interval: 0.4% to 1.9%) monthly increase in adherence per month for antibiotic duration above baseline rates. Balancing measures of care escalation and revisit or readmission did not increase.

CONCLUSIONS

This multisite collaborative increased appropriate antibiotic use for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infection among diverse hospitals.

Economic analysis of surgical outcome monitoring using control charts: the SHEWHART cluster randomised trial

IMPORTANCE

Surgical complications represent a considerable proportion of hospital expenses. Therefore, interventions that improve surgical outcomes could reduce healthcare costs.

OBJECTIVE

Evaluate the effects of implementing surgical outcome monitoring using control charts to reduce hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.

DESIGN

National, parallel, cluster-randomised SHEWHART trial using a difference-in-difference approach.

SETTING

40 surgical departments from distinct hospitals across France.

PARTICIPANTS

155 362 patients over the age of 18 years, who underwent hernia repair, cholecystectomy, appendectomy, bariatric, colorectal, hepatopancreatic or oesophageal and gastric surgery were included in analyses.

INTERVENTION

After the baseline assessment period (2014-2015), hospitals were randomly allocated to the intervention or control groups. In 2017-2018, the 20 hospitals assigned to the intervention were provided quarterly with control charts for monitoring their surgical outcomes (inpatient death, intensive care stay, reoperation and severe complications). At each site, pairs, consisting of one surgeon and a collaborator (surgeon, anaesthesiologist or nurse), were trained to conduct control chart team meetings, display posters in operating rooms, maintain logbooks and design improvement plans.

MAIN OUTCOMES

Number of hospital bed-days per patient within 30 days following surgery, including the index stay and any acute care readmissions related to the occurrence of major adverse events, and hospital costs reimbursed for this care per patient by the insurer.

RESULTS

Postintervention, hospital bed-days per patient within 30 days following surgery decreased at an adjusted ratio of rate ratio (RRR) of 0.97 (95% CI 0.95 to 0.98; p<0.001), corresponding to a 3.3% reduction (95% CI 2.1% to 4.6%) for intervention hospitals versus control hospitals. Hospital costs reimbursed for this care per patient by the insurer significantly decreased at an adjusted ratio of cost ratio (RCR) of 0.99 (95% CI 0.98 to 1.00; p=0.01), corresponding to a 1.3% decrease (95% CI 0.0% to 2.6%). The consumption of a total of 8910 hospital bed-days (95% CI 5611 to 12 634 bed-days) and €2 615 524 (95% CI €32 366 to €5 405 528) was avoided in the intervention hospitals postintervention.

CONCLUSIONS

Using control charts paired with indicator feedback to surgical teams was associated with significant reductions in hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.

TRIAL REGISTRATION NUMBER

NCT02569450.

What is quality in long covid care? Lessons from a national quality improvement collaborative and multi-site ethnography

BACKGROUND

Long covid (post covid-19 condition) is a complex condition with diverse manifestations, uncertain prognosis and wide variation in current approaches to management. There have been calls for formal quality standards to reduce a so-called "postcode lottery" of care. The original aim of this study-to examine the nature of quality in long covid care and reduce unwarranted variation in services-evolved to focus on examining the reasons why standardizing care was so challenging in this condition.

METHODS

In 2021-2023, we ran a quality improvement collaborative across 10 UK sites. The dataset reported here was mostly but not entirely qualitative. It included data on the origins and current context of each clinic, interviews with staff and patients, and ethnographic observations at 13 clinics (50 consultations) and 45 multidisciplinary team (MDT) meetings (244 patient cases). Data collection and analysis were informed by relevant lenses from clinical care (e.g. evidence-based guidelines), improvement science (e.g. quality improvement cycles) and philosophy of knowledge.

RESULTS

Participating clinics made progress towards standardizing assessment and management in some topics; some variation remained but this could usually be explained. Clinics had different histories and path dependencies, occupied a different place in their healthcare ecosystem and served a varied caseload including a high proportion of patients with comorbidities. A key mechanism for achieving high-quality long covid care was when local MDTs deliberated on unusual, complex or challenging cases for which evidence-based guidelines provided no easy answers. In such cases, collective learning occurred through idiographic (case-based) reasoning, in which practitioners build lessons from the particular to the general. This contrasts with the nomothetic reasoning implicit in evidence-based guidelines, in which reasoning is assumed to go from the general (e.g. findings of clinical trials) to the particular (management of individual patients).

CONCLUSION

Not all variation in long covid services is unwarranted. Largely because long covid's manifestations are so varied and comorbidities common, generic "evidence-based" standards require much individual adaptation. In this complex condition, quality improvement resources may be productively spent supporting MDTs to optimise their case-based learning through interdisciplinary discussion. Quality assessment of a long covid service should include review of a sample of individual cases to assess how guidelines have been interpreted and personalized to meet patients' unique needs.

STUDY REGISTRATION

NCT05057260, ISRCTN15022307.

Does WASH FIT improve water, sanitation, and hygiene and related health impacts in healthcare facilities? A systematic review

Introduction

Environmental health services (e.g., water, sanitation, hygiene, cleaning, waste management) in healthcare facilities are important to improve health outcomes and strengthen health systems, but coverage gaps remain. The World Health Organization and United Nations Children's Fund developed WASH FIT, a quality improvement tool, to help assess and improve environmental health services. Fifty-three countries have adopted it. However, there is little evidence of its effectiveness. This systematic review evaluates whether WASH FIT improves environmental health services or associated health outcomes and impacts.

Methods

We conducted database searches to identify relevant studies and extracted data on study design, healthcare facility characteristics, and inputs, activities, outputs, outcomes, and impacts associated with WASH FIT. We summarized the findings using a logic model framework and narrative synthesis.

Results

We included 31 studies in the review. Most inputs and activities were described qualitatively. Twenty-three studies reported quantitative outputs, primary WASH FIT indicator scores, and personnel trained on WASH FIT. Nine studies reported longitudinal data demonstrating changes in these outputs throughout WASH FIT implementation. Six studies reported quantitative outcomes measurements; the remainder described outcomes qualitatively or not at all. Common outcomes included allocated funding for environmental health services, community engagement, and government collaboration, changes in knowledge, attitudes, or practices among healthcare staff, patients, or community members, and policy changes. No studies directly measured impacts or evaluated WASH FIT against a rigorous control group.

Conclusions

Available evidence is insufficient to evaluate WASH FIT's effects on outputs, outcomes, and impacts. Further effort is needed to comprehensively identify the inputs and activities required to implement WASH FIT and to draw specific links between changes in outputs, outcomes, and impacts. Short-term opportunities exist to improve evidence by more comprehensive reporting of WASH FIT assessments and exploiting data on health impacts within health management information systems. In the long term, we recommend experimental studies. This evidence is important to ensure that funding invested for WASH FIT implementation is used cost-effectively and that opportunities to adapt and refine WASH FIT are fully realized as it continues to grow in use and influence.

Large-Scale Telemedicine Implementation for Outpatient Clinicians: Results From a Pandemic-Adapted Learning Collaborative

Learning collaboratives are seldom used outside of health care quality improvement. We describe a condensed, 10-week learning collaborative ("Telemedicine Hack") that facilitated telemedicine implementation for outpatient clinicians early in the COVID-19 pandemic. Live attendance averaged 1688 participants per session. Of 1005 baseline survey respondents, 57% were clinicians with one-third identifying as from a racial/ethnic minoritized group. Practice characteristics included primary care (71%), rural settings (51%), and community health centers (28%). Of three surveys, a high of 438 (81%) of 540 clinicians had billed ≥1 video-based telemedicine visit. Our learning collaborative "sprint" is a promising model for scaling knowledge during emergencies and addressing health inequities.

Assessing progress in managing and improving quality in nascent integrated care systems in England

OBJECTIVES

In 2022, England embarked on an ambitious reorganisation to produce an integrated health and care system, intended also to maximise population health. The newly created integrated care systems (ICSs) aim to improve quality of care, by achieving the best outcomes for individuals and populations through the provision of evidence-based services. An emerging approach for managing quality in organisations is the Quality Management System (QMS) framework. Using the framework, this study assessed how ICSs are managing and improving quality.

METHODS

Four ICSs were purposively sampled, with the data collected between November 2021 and May 2022. Semi-structured interviews with system leaders (n=60) from health and social care, public health and local representatives were held. We also observed key ICS meetings and reviewed relevant documents. A thematic framework approach based on the QMS framework was used to analyse the data.

RESULTS

The ICSs placed an emphasis on population health, reducing inequity and improving access. This represents a shift in focus from the traditional clinical approach to quality. There were tensions between quality assurance and improvement, with concerns that a narrow focus on assurance would impede ICSs from addressing broader quality issues, such as tackling inequalities and unwarranted variation in care and outcomes. Partnerships, a key enabler for integration, was seen as integral to achieving improvements in quality. Overall, the ICSs expressed concerns that any progress made in quality development and in improving population health would be tempered by unprecedented system pressures.

CONCLUSION

It is unclear whether ICSs can achieve their ambition. As they move away from an assurance-dominated model of quality to one that emphasises openness, learning and improvement, they must simultaneously build the digital infrastructure, staff expertise and culture to support such a shift.

Virtual quality improvement collaborative with primary care practices during COVID-19: a case study within a clinically integrated network

INTRODUCTION

Quality improvement collaboratives (QICs) are a common approach to facilitate practice change and improve care delivery. Attention to QIC implementation processes and outcomes can inform best practices for designing and delivering collaborative content. In partnership with a clinically integrated network, we evaluated implementation outcomes for a virtual QIC with independent primary care practices delivered during COVID-19.

METHODS

We conducted a longitudinal case study evaluation of a virtual QIC in which practices participated in bimonthly online meetings and monthly tailored QI coaching sessions from July 2020 to June 2021. Implementation outcomes included: (1) level of engagement (meeting attendance and poll questions), (2) QI capacity (assessments completed by QI coaches), (3) use of QI tools (plan-do-check-act (PDCA) cycles started and completed) and (4) participant perceptions of acceptability (interviews and surveys).

RESULTS

Seven clinics from five primary care practices participated in the virtual QIC. Of the seven sites, five were community health centres, three were in rural counties and clinic size ranged from 1 to 7 physicians. For engagement, all practices had at least one member attend all online QIC meetings and most (9/11 (82%)) poll respondents reported meeting with their QI coach at least once per month. For QI capacity, practice-level scores showed improvements in foundational, intermediate and advanced QI work. For QI tools used, 26 PDCA cycles were initiated with 9 completed. Most (10/11 (91%)) survey respondents were satisfied with their virtual QIC experience. Twelve interviews revealed additional themes such as challenges in obtaining real-time data and working with multiple electronic medical record systems.

DISCUSSION

A virtual QIC conducted with independent primary care practices during COVID-19 resulted in high participation and satisfaction. QI capacity and use of QI tools increased over 1 year. These implementation outcomes suggest that virtual QICs may be an attractive alternative to engage independent practices in QI work.

Motivational drivers for health professionals in a large quality improvement collaborative project in Brazil: a qualitative study

BACKGROUND

The success of collaborative quality improvement (QI) projects in healthcare depends on the context and engagement of health teams; however, the factors that modulate teams' motivation to participate in these projects are still unclear. The objective of the current study was to explore the barriers to and facilitators of motivation; the perspective was health professionals in a large project aiming to implement evidence-based infection prevention practices in intensive care units of Brazilian hospitals.

METHODS

This qualitative study was based on content analysis of semistructured in-depth interviews held with health professionals who participated in a collaborative QI project named "Improving patient safety on a large scale in Brazil". In accordance with the principle of saturation, we selected a final sample of 12 hospitals located throughout the five regions of Brazil that have implemented QI; then, we conducted videoconference interviews with 28 health professionals from those hospitals. We encoded the interview data with NVivo software, and the interrelations among the data were assessed with the COM-B model.

RESULTS

The key barriers identified were belief that improvement increases workload, lack of knowledge about quality improvement, resistance to change, minimal involvement of physicians, lack of supplies, lack support from senior managers and work overload. The primary driver of motivation was tangible outcomes, as evidenced by a decrease in infections. Additionally, factors such as the active participation of senior managers, teamwork, learning in practice and understanding the reason for changes played significant roles in fostering motivation.

CONCLUSION

The motivation of health professionals to participate in collaborative QI projects is driven by a variety of barriers and facilitators. The interactions between the senior manager, quality improvement teams, and healthcare professionals generate attitudes that modulate motivation. Thus, these aspects should be considered during the implementation of such projects. Future research could explore the cost-effectiveness of motivational approaches.

Quality Improvement Efforts in VA Community Living Centers Following Public Reporting of Performance

For two decades, the U.S. government has publicly reported performance measures for most nursing homes, spurring some improvements in quality. Public reporting is new, however, to Department of Veterans Affairs nursing homes (Community Living Centers [CLCs]). As part of a large, public integrated healthcare system, CLCs operate with unique financial and market incentives. Thus, their responses to public reporting may differ from private sector nursing homes. In three CLCs with varied public ratings, we used an exploratory, qualitative case study approach involving semi-structured interviews to compare how CLC leaders (n = 12) perceived public reporting and its influence on quality improvement. Across CLCs, respondents said public reporting was helpful for transparency and to provide an "outside perspective" on CLC performance. Respondents described employing similar strategies to improve their public ratings: using data, engaging staff, and clearly defining staff roles vis-à-vis quality improvement, although more effort was required to implement change in lower performing CLCs. Our findings augment those from prior studies and offer new insights into the potential for public reporting to spur quality improvement in public nursing homes and those that are part of integrated healthcare systems.

Estimating the savings of a national project to prevent healthcare-associated infections in intensive care units

BACKGROUND

Healthcare-associated infections (HAIs) have a significant impact on patients' morbidity and mortality, and have a detrimental financial impact on the healthcare system. Various strategies exist to prevent HAIs, but economic evaluations are needed to determine which are most appropriate.

AIM

To present the financial impact of a nationwide project on HAI prevention in intensive care units (ICUs) using a quality improvement (QI) approach.

METHODS

A health economic evaluation assessed the financial results of the QI initiative 'Saúde em Nossas Mãos' (SNM), implemented in Brazil between January 2018 and December 2020. Among 116 participating institutions, 13 (11.2%) fully reported the aggregate cost and stratified patients (with vs without HAIs) in the pre-intervention and post-intervention periods. Average cost (AC) was calculated for each analysed HAI: central-line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTIs). The absorption model and time-driven activity-based costing were used for cost estimations. The numbers of infections that the project could have prevented during its implementation were estimated to demonstrate the financial impact of the SNM initiative.

RESULTS

The aggregated ACs calculated for each HAI from these 13 ICUs - US$8480 for CLABSIs, US$10,039 for VAP, and US$7464 for CAUTIs - were extrapolated to the total number of HAIs prevented by the project (1727 CLABSIs, 3797 VAP and 2150 CAUTIs). The overall savings of the SNM as of December 2020 were estimated at US$68.8 million, with an estimated return on investment (ROI) of 765%.

CONCLUSION

Reporting accurate financial data on HAI prevention strategies is still challenging in Brazil. These results suggest that a national QI initiative to prevent HAIs in critical care settings is a feasible and value-based approach, reducing financial waste and yielding a significant ROI for the healthcare system.

What are the features of high-performing quality improvement collaboratives? A qualitative case study of a state-wide collaboratives programme

OBJECTIVES

Despite their widespread use, the evidence base for the effectiveness of quality improvement collaboratives remains mixed. Lack of clarity about 'what good looks like' in collaboratives remains a persistent problem. We aimed to identify the distinctive features of a state-wide collaboratives programme that has demonstrated sustained improvements in quality of care in a range of clinical specialties over a long period.

DESIGN

Qualitative case study involving interviews with purposively sampled participants, observations and analysis of documents.

SETTING

The Michigan Collaborative Quality Initiatives programme.

PARTICIPANTS

38 participants, including clinicians and managers from 10 collaboratives, and staff from the University of Michigan and Blue Cross Blue Shield of Michigan.

RESULTS

We identified five features that characterised success in the collaboratives programme: learning from positive deviance; high-quality coordination; high-quality measurement and comparative performance feedback; careful use of motivational levers; and mobilising professional leadership and building community. Rigorous measurement, securing professional leadership and engagement, cultivating a collaborative culture, creating accountability for quality, and relieving participating sites of unnecessary burdens associated with programme participation were all important to high performance.

CONCLUSIONS

Our findings offer valuable learning for optimising collaboration-based approaches to improvement in healthcare, with implications for the design, structure and resourcing of quality improvement collaboratives. These findings are likely to be useful to clinicians, managers, policy-makers and health system leaders engaged in multiorganisational approaches to improving quality and safety.

"Diving in the deep-end and swimming": a mixed methods study using normalization process theory to evaluate a learning collaborative approach for the implementation of palliative care practices in hemodialysis centers

BACKGROUND

Normalization Process Theory (NPT) is an implementation theory that can be used to explain how and why implementation strategies work or not in particular circumstances. We used it to understand the mechanisms that lead to the adoption and routinization of palliative care within hemodialysis centers.

METHODS

We employed a longitudinal, mixed methods approach to comprehensively evaluate the implementation of palliative care practices among ten hemodialysis centers participating in an Institute for Healthcare Improvement Breakthrough- Series learning collaborative. Qualitative methods included longitudinal observations of collaborative activities, and interviews with implementers at the end of the study. We used an inductive and deductive approach to thematic analysis informed by NPT constructs (coherence, cognitive participation, collective action, reflexive monitoring) and implementation outcomes. The NoMAD survey, which measures NPT constructs, was completed by implementers at each hemodialysis center during early and late implementation.

RESULTS

The four mechanisms posited in NPT had a dynamic and layered relationship during the implementation process. Collaborative participants participated because they believed in the value and legitimacy of palliative care for patients receiving hemodialysis and thus had high levels of cognitive participation at the start. Didactic Learning Sessions were important for building practice coherence, and sense-making was solidified through testing new skills in practice and first-hand observation during coaching visits by an expert. Collective action was hampered by limited time among team members and practical issues such as arranging meetings with patients. Reflexive monitoring of the positive benefit to patient and family experiences was key in shifting mindsets from disease-centric towards a patient-centered model of care. NoMAD survey scores showed modest improvement over time, with collective action having the lowest scores.

CONCLUSIONS

NPT was a useful framework for understanding the implementation of palliative care practices within hemodialysis centers. We found a nonlinear relationship among the mechanisms which is reflected in our model of implementation of palliative care practices through a learning collaborative. These findings suggest that the implementation of complex practices such as palliative care may be more successful through iterative learning and practice opportunities as the mechanisms for change are layered and mutually reinforcing.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04125537 . Registered 14 October 2019 - Retrospectively registered.

Pathways Project Pragmatic Lessons Learned: Integrating Supportive Care Best Practices into Real-World Kidney Care

Key Points

A multisite quality improvement project using the Institute for Healthcare Improvement learning collaborative structure helped kidney care teams identify seriously ill patients and implement supportive care best practices. Helpful approaches included needs assessment, Quality Assurance and Performance Improvement tools, peer exchange, clinician role modeling, data feedback, and technical assistance. Dialysis center teams tailored implementation of best practices into routine dialysis workflows with nephrologist prerogative to delegate goals of care conversations to nurse practitioners and social workers.

Background

Despite two decades of national and international guidelines urging greater availability of kidney supportive care (KSC), uptake in the United States has been slow. We conducted a multisite quality improvement project with ten US dialysis centers to foster implementation of three KSC best practices. This article shares pragmatic lessons learned by the project organizers.

Methods

The project team engaged in reflection to distill key lessons about what did or did not work in implementing KSC.

Results

The seven key lessons are (1 ) systematically assess KSC needs; (2 ) prioritize both the initial practices to be implemented and the patients who have the most urgent needs; (3 ) use a multifaceted approach to bolster communication skills, including in-person role modeling and mentoring; (4 ) empower nurse practitioners and social workers to conduct advance care planning through teamwork and warm handoffs; (5 ) provide tailored technical assistance to help sites improve documentation and electronic health record processes for storing advance care planning information; (6 ) coach dialysis centers in how to use required Quality Assurance and Performance Improvement processes to improve KSC; and (7 ) implement systematic approaches to support patients who choose active medical management without dialysis.

Conclusions

Treatment of patients with kidney disease is provided in a complex system, especially when considered across the continuum, from CKD to kidney failure on dialysis, and at the end of life. Even among enthusiastic early adopters of KSC, 18 months was insufficient time to implement the three prioritized KSC best practices. Concentrating on a few key practices helped teams focus and see progress in targeted areas. However, effect for patients was attenuated because federal policy and financial incentives are not aligned with KSC best practices and goals.

Clinical Trial registry name and registration number

Pathways Project: KSC, NCT04125537 .

Did the Acute Frailty Network improve outcomes for older people living with frailty? A staggered difference-in-difference panel event study

OBJECTIVES

To evaluate whether the Acute Frailty Network (AFN) was more effective than usual practice in supporting older people living with frailty to return home from hospital sooner and healthier.

DESIGN

Staggered difference-in-difference panel event study allowing for differential effects across intervention cohorts.

SETTING

All English National Health Service (NHS) acute hospital sites.

PARTICIPANTS

All 1 410 427 NHS patients aged 75+ with high frailty risk who had an emergency hospital admission to acute, general or geriatric medicine departments between 1 January 2012 and 31 March 2019.

INTERVENTION

Membership of the AFN, a quality improvement collaborative designed to support acute hospitals in England deliver evidence-based care for older people with frailty. 66 hospital sites joined the AFN in six sequential cohorts, the first starting in January 2015, the sixth in May 2018. Usual care was delivered in the remaining 248 control sites.

MAIN OUTCOME MEASURES

Length of hospital stay, in-hospital mortality, institutionalisation, hospital readmission.

RESULTS

No significant effects of AFN membership were found for any of the four outcomes nor were there significant effects for any individual cohort.

CONCLUSIONS

To realise its aims, the AFN might need to develop better resourced intervention and implementation strategies.

Service delivery interventions to improve maternal and newborn health in low- and middle-income countries: scoping review of quality improvement, implementation research and health system strengthening approaches

INTRODUCTION

This review explores the characteristics of service delivery-related interventions to improve maternal and newborn health (MNH) in low-and middle-income countries (LMICs) over the last two decades, comparing three common framings of these interventions, namely, quality improvement (QI), implementation science/research (IS/IR), and health system strengthening (HSS).

METHODS

The review followed the staged scoping review methodology proposed by Levac et al. (2010). We developed and piloted a systematic search strategy, limited to English language peer-reviewed articles published on LMICs between 2000 and March 2022. Analysis was conducted in two-quantitative and qualitative-phases. In the quantitative phase, we counted the year of publication, country(-ies) of origin, and the presence of the terms 'quality improvement', 'health system strengthening' or 'implementation science'/ 'implementation research' in titles, abstracts and key words. From this analysis, a subset of papers referred to as 'archetypes' (terms appearing in two or more of titles, abstract and key words) was analysed qualitatively, to draw out key concepts/theories and underlying mechanisms of change associated with each approach.

RESULTS

The searches from different databases resulted in a total of 3,323 hits. After removal of duplicates and screening, a total of 231 relevant articles remained for data extraction. These were distributed across the globe; more than half (n = 134) were published since 2017. Fifty-five (55) articles representing archetypes of the approach (30 QI, 16 IS/IR, 9 HSS) were analysed qualitatively. As anticipated, we identified distinct patterns in each approach. QI archetypes tended towards defined process interventions (most typically, plan-do-study-act cycles); IS/IR archetypes reported a wide variety of interventions, but had in common evaluation methodologies and explanatory theories; and HSS archetypes adopted systemic perspectives. Despite their distinctiveness, there was also overlap and fluidity between approaches, with papers often referencing more than one approach. Recognising the complexity of improving MNH services, there was an increased orientation towards participatory, context-specific designs in all three approaches.

CONCLUSIONS

Programmes to improve MNH outcomes will benefit from a better appreciation of the distinctiveness and relatedness of different approaches to service delivery strengthening, how these have evolved and how they can be combined.

What factors influence a Quality Improvement Collaborative in improving contraceptive services for foreign-born women? A qualitative study in Sweden

BACKGROUND

Improved contraceptive services could reduce the unmet need for contraception and unintended pregnancies globally. This is especially true among foreign-born women in high-income countries, as the health outcomes related to unmet need of contraception disproportionally affect this group. A widely used quality improvement approach to improve health care services is Quality Improvement Collaborative (QIC). However, evidence on to what extent, how and why it is effective and what factors influence a QIC in different healthcare contexts is limited. The purpose of this study was to analyse what factors have influenced a successful QIC intervention that is aimed to improve contraceptive service in postpartum care, mainly targeting foreign-born women in Sweden.

METHODS

A qualitative, deductive design was used, guided by the Consolidated Framework for Implementation Research (CFIR). The study triangulated secondary data from four learning seminars as part of the QIC, with primary interview data with four QIC-facilitators. The QIC involved midwives at three maternal health clinics in Stockholm County, Sweden, 2018-2019.

RESULTS

Factors from all five CFIR domains were identified, however, the majority of factors that influenced the QIC were found inside the QIC-setting, in three domains: intervention characteristics, inner setting and process. Outside factors and those related to individuals were less influential. A favourable learning climate, emphasizing co-creation and mutual learning, facilitated reflections among the participating midwives. The application of the QIC was facilitated by adaptability, trialability, and a motivated and skilled project team. Our study further suggests that the QIC was complex because it required a high level of engagement from the midwives and facilitators. Additionally, it was challenging due to unclear roles and objectives in the initial phases.

CONCLUSIONS

The application of the CFIR framework identified crucial factors influencing the success of a QIC in contraceptive services in a high-income setting. These factors highlight the importance of establishing a learning climate characterised by co-creation and mutual learning among the participating midwives as well as the facilitators. Furthermore, to invest in planning and formation of the project group during the QIC initiation; and to ensure adaptability and trialability of the improvement activities.

Quality improvement interventions to prevent the use of hospital services among nursing home residents: protocol for a systematic review and meta-analysis

INTRODUCTION

Quality improvement interventions are a promising strategy for reducing hospital services use among nursing home residents. However, evidence for their effectiveness is limited. It is unclear which characteristics of the quality improvement intervention and activities planned to facilitate implementation may promote fidelity to organisational and system changes. This systematic review and meta-analysis will assess the effectiveness of quality improvement interventions and implementation strategies aimed at reducing hospital services use among nursing home residents.

METHODS AND ANALYSIS

The MEDLINE, CINAHL, Cochrane Library, Embase and Web of Science databases will be comprehensively searched in September 2023. The eligible studies should focus on the implementation of a quality improvement intervention defined as the systematic, continuous approach that designs, tests and implements changes using real-time measurement to reduce hospitalisations or emergency department visits among long-stay nursing home residents. Quality improvement details and implementation strategies will be deductively categorised into effective practice and organisation of care taxonomy domains for delivery arrangements and implementation strategies. Quality and bias assessments will be completed using the Quality Improvement Minimum Quality Criteria Set and the Joanna Briggs Institute Critical Appraisal Tools.The results will be pooled in a meta-analysis, by combining the natural logarithms of the rate ratios across the studies or by calculating the rate ratio using the generic inverse-variance method. Heterogeneity will be assessed using the I2 or H2 statistics if the number of included studies will be less than 10. Raw data will be requested from the authors, as required.

ETHICS AND DISSEMINATION

Ethical approval is not required. The results will be published in a peer-review journal and presented at (inter)national conferences.

PROSPERO REGISTRATION NUMBER

CRD42022364195.

Quality improvement collaborative to optimize heart failure care in patients from a network of clinics in Argentina during the COVID-19 pandemic

Heart failure (HF) is a major clinical and public health problem associated with significant mortality, morbidity, and health-care costs. Despite the existence of evidence-based guidelines for the optimal treatment of HF, the quality of care remains suboptimal. Our aim was to increase the use a care bundle in 50% of enrolled subjects during their hospitalization and discharge and to reduce their readmission for HF causes by 10%. We conducted an uncontrolled before-after study in eight hospitals in Argentina to evaluate the effect of a quality improvement intervention on the use of an HF care bundle in patients with HF New York Heart Association (NYHA) Class II-III. The HF bundle of care included medication, continuum of care, lifestyle habits, and predischarge examinations. Training and follow-up of multidisciplinary teams in each center were performed through learning sessions and plan-do-study-act improvement cycles. Data collectors reviewed bundle compliance in the health records of recruited patients after their hospital discharge and verified readmissions through phone calls to patients within 30-40 days after discharge. We recruited 200 patients (83 before and 127 during the intervention phase), and bundle compliance increased from 9.6% to 28.3% [odds ratio 3.71, 95% confidence interval (8.46; 1.63); P = .002]. Despite a slow improvement during the first months, bundle compliance gained momentum near the end of the intervention surpassing 80%. We observed a non-significant decreased readmission rate within 30 days of discharge due to HF in the postintervention period [8.4% vs. 5.5%, odds ratio 0.63, 95% CI (1.88; 0.21); P = .410]. Qualitative analysis showed that members of the intervention teams acknowledged the improvement of work organization and standardization of care, teamwork, shared mental model, and health record completeness as well as the utility of training fellows. Despite the challenges related to the pandemic, better care of patients with HF NYHA Class II-III was possible through simple interventions and collaborative work. Graphical abstract.

From purists to pragmatists: a qualitative evaluation of how implementation processes and contexts shaped the uptake and methodological adaptations of a maternal and neonatal quality improvement programme in South Africa prior to, and during COVID-19

BACKGROUND

Despite progress, maternal and neonatal mortality and still births remain high in South Africa. The South African National Department of Health implemented a quality improvement (QI) programme, called Mphatlalatsane, to reduce maternal and neonatal mortality and still births. It was implemented in 21 public health facilities, seven per participating province, between 2018 and 2022.

METHODS

We conducted a qualitative process evaluation of the contextual and implementation process factors' influence on implementation uptake amongst the QI teams in 15 purposively selected facilities. Data collection included three interview rounds with the leaders and members of the QI teams in each facility; intermittent interviews with the QI advisors; programme documentation review; observation of programme management meetings; and keeping a fieldwork journal. All data were thematically analysed in Atlas.ti. Implementation uptake varied across the three provinces and between facilities within provinces.

RESULTS

Between March and August 2020, the COVID-19 pandemic disrupted uptake in all provinces but affected QI teams in one province more severely than others, because they received limited pre-pandemic training. Better uptake among other sites was attributed to receiving more QI training pre-COVID-19, having an experienced QI advisor, and good teamwork. Uptake was more challenging amongst hospital teams which had more staff and more complicated MNH services, versus the primary healthcare facilities. We also attributed better uptake to greater district management support. A key factor shaping uptake was leaders' intrinsic motivation to apply QI methodology. We found that, across sites, organic adaptations to the QI methodology were made by teams, started during COVID-19. Teams did away with rapid testing of change ideas and keeping a paper trail of the steps followed. Though still using data to identify service problems, they used self-developed audit tools to record intervention effectiveness, and not the prescribed tools.

CONCLUSIONS

Our study underscores the critical role of intrinsic motivation of team leaders, support from experienced technical QI advisors, and context-sensitive adaptations to maximise QI uptake when traditionally recognised QI steps cannot be followed.

Implementing shared decision making for early-stage breast cancer treatment using a coproduction learning collaborative: the SHAIR Collaborative protocol

BACKGROUND

Shared decision making (SDM) in breast cancer care improves outcomes, but it is not routinely implemented. Results from the What Matters Most trial demonstrated that early-stage breast cancer surgery conversation aids, when used by surgeons after brief training, improved SDM and patient-reported outcomes. Trial surgeons and patients both encouraged using the conversation aids in routine care. We will develop and evaluate an online learning collaborative, called the SHared decision making Adoption Implementation Resource (SHAIR) Collaborative, to promote early-stage breast cancer surgery SDM by implementing the conversation aids into routine preoperative care. Learning collaboratives are known to be effective for quality improvement in clinical care, but no breast cancer learning collaborative currently exists. Our specific aims are to (1) provide the SHAIR Collaborative resources to clinical sites to use with eligible patients, (2) examine the relationship between the use of the SHAIR Collaborative resources and patient reach, and (3) promote the emergence of a sustained learning collaborative in this clinical field, building on a partnership with the American Society of Breast Surgeons (ASBrS).

METHODS

We will conduct a two-phased implementation project: phase 1 pilot at five sites and phase 2 scale up at up to an additional 32 clinical sites across North America. The SHAIR Collaborative online platform will offer free access to conversation aids, training videos, electronic health record and patient portal integration guidance, a feedback dashboard, webinars, support center, and forum. We will use RE-AIM for data collection and evaluation. Our primary outcome is patient reach. Secondary data will include (1) patient-reported data from an optional, anonymous online survey, (2) number of active sites and interviews with site champions, (3) Normalization MeAsure Development questionnaire data from phase 1 sites, adaptations data utilizing the Framework for Reporting Adaptations and Modifications-Extended/-Implementation Strategies, and tracking implementation facilitating factors, and (4) progress on sustainability strategy and plans with ASBrS.

DISCUSSION

The SHAIR Collaborative will reach early-stage breast cancer patients across North America, evaluate patient-reported outcomes, engage up to 37 active sites, and potentially inform engagement factors affecting implementation success and may be sustained by ASBrS.

'The objective was about not blaming one another': a qualitative study to explore how collaboration is experienced within quality improvement collaboratives in Ethiopia

BACKGROUND

Quality improvement collaboratives are a common approach to improving quality of care. They rely on collaboration across and within health facilities to enable and accelerate quality improvement. Originating in high-income settings, little is known about how collaboration transfers to low-income settings, despite the widespread use of these collaboratives.

METHOD

We explored collaboration within quality improvement collaboratives in Ethiopia through 42 in-depth interviews with staff of two hospitals and four health centers and three with quality improvement mentors. Data were analysed thematically using a deductive and inductive approach.

RESULTS

There was collaboration at learning sessions though experience sharing, co-learning and peer pressure. Respondents were used to a blaming environment, which they contrasted to the open and non-blaming environment at the learning sessions. Respondents formed new relationships that led to across facility practical support. Within facilities, those in the quality improvement team continued to collaborate through the plan-do-study-act cycles, although this required high engagement and support from mentors. Few staff were able to attend learning sessions and within facility transfer of quality improvement knowledge was rare. This affected broader participation and led to some resentment and resistance. Improved teamwork skills and behaviors occurred at individual rather than facility or systems level, with implications for sustainability. Challenges to collaboration included unequal participation, lack of knowledge transfer, high workloads, staff turnover and a culture of dependency.

CONCLUSION

We conclude that collaboration can occur and is valued within a traditionally hierarchical system, but may require explicit support at learning sessions and by mentors. More emphasis is needed on ensuring quality improvement knowledge transfer, buy-in and system level change. This could include a modified collaborative design to provide facility-level support for spread.

The relationship between publication of high-quality evidence and changes in the volume and trend of subacromial decompression surgery for patients with subacromial pain syndrome in hospitals across Australia, Europe and the United States: a controlled interrupted time series analysis

AIMS

To evaluate the extent to which publication of high-quality randomised controlled trials(RCTs) in 2018 was associated with a change in volume or trend of subacromial decompression(SAD) surgery in patients with subacromial pain syndrome(SAPS) treated in hospitals across various countries.

METHODS

Routinely collected administrative data of the Global Health Data@work collaborative were used to identify SAPS patients who underwent SAD surgery in six hospitals from five countries (Australia, Belgium, Netherlands, United Kingdom, United States) between 01/2016 and 02/2020. Following a controlled interrupted time series design, segmented Poisson regression was used to compare trends in monthly SAD surgeries before(01/2016-01/2018) and after(02/2018-02/2020) publication of the RCTs. The control group consisted of musculoskeletal patients undergoing other procedures.

RESULTS

A total of 3.046 SAD surgeries were performed among SAPS patients treated in five hospitals; one hospital did not perform any SAD surgeries. Overall, publication of trial results was associated with a significant reduction in the trend to use SAD surgery of 2% per month (Incidence rate ratio (IRR) 0.984[0.971-0.998]; P = 0.021), but with large variation between hospitals. No changes in the control group were observed. However, publication of trial results was also associated with a 2% monthly increased trend (IRR 1.019[1.004-1.034]; P = 0.014) towards other procedures performed in SAPS patients.

CONCLUSION

Publication of RCT results was associated with a significantly decreased trend in SAD surgery for SAPS patients, although large variation between participating hospitals existed and a possible shift in coding practices cannot be ruled out. This highlights the complexities of implementing recommendations to change routine clinical practice even if based on high-quality evidence.

Intensified follow-up of patients with type 1 diabetes and poor glycaemic control: a multicentre quality improvement collaborative based on data from the Norwegian Diabetes Register for Adults

BACKGROUND

Patients with type 1 diabetes mellitus (T1DM) and poor glycaemic control are at high risk of developing microvascular and macrovascular complications. The aim of this study was to determine if a quality improvement collaborative (QIC) initiated by the Norwegian Diabetes Register for adults (NDR-A) could reduce the proportion of patients with T1DM with poor glycaemic control (defined as glycated haemoglobin (HbA1c)≥75 mmol/mol) and reduce mean HbA1c at participating clinics compared with 14 control clinics.

METHOD

Multicentre study with controlled before and after design. Representatives of 13 diabetes outpatient clinics (n=5145 patients with T1DM) in the intervention group attended four project meetings during an 18-month QIC. They were required to identify areas requiring improvement at their clinic and make action plans. Continuous feedback on HbA1c outcomes was provided by NDR-A during the project. In total 4084 patients with type 1 diabetes attended the control clinics.

RESULTS

Between 2016 and 2019, the overall proportion of patients with T1DM and HbA1c≥75 mmol/mol in the intervention group were reduced from 19.3% to 14.1% (p<0.001). Corresponding proportions in the control group were reduced from 17.3% (2016) to 14.4% (2019) (p<0.001). Between 2016 and 2019, overall mean HbA1c decreased by 2.8 mmol/mol (p<0.001) at intervention clinics compared with 2.3 mmol/mol (p<0.001) at control clinics. After adjusting for the baseline differences in glycaemic control, there were no significant differences in the overall improvement in glycaemic control between intervention and control clinics.

CONCLUSIONS

The registry linked QIC did not result in a significantly greater improvement in glycaemic control at intervention clinics compared with control clinics. However, there has been a sustained improvement in glycaemic control and importantly a significant reduction in the proportion of patients with poor glycaemic control at both intervention and control clinics during and after the QIC time frame. It is possible that some of this improvement may be due to a spillover effect from the QIC.

Exploring quality improvement for diabetes care in First Nations communities in Canada: a multiple case study

BACKGROUND

Indigenous peoples in Canada experience higher rates of diabetes and worse outcomes than non-Indigenous populations in Canada. Strategies are needed to address underlying health inequities and improve access to quality diabetes care. As part of the national FORGE AHEAD Research Program, this study explores two primary healthcare teams' quality improvement (QI) process of developing and implementing strategies to improve the quality of diabetes care in First Nations communities in Canada.

METHODS

This study utilized a community-based participatory and qualitative case study methodology. Multiple qualitative data sources were analyzed to understand: (1) how knowledge and information was used to inform the teams' QI process; (2) how the process was influenced by the context of primary care services within communities; and (3) the factors that supported or hindered their QI process.

RESULTS

The findings of this study demonstrate how teams drew upon multiple sources of knowledge and information to inform their QI work, the importance of strengthening relationships and building relationships with the community, the influence of organizational support and capacity, and the key factors that facilitated QI efforts.

CONCLUSIONS

This study contributes to the ongoing calls for research in understanding the process and factors affecting the implementation of QI strategies, particularly within Indigenous communities. The knowledge generated may help inform community action and the future development, implementation and scale-up of QI programs in Indigenous communities in Canada and globally.

IMplementing best practice post-partum contraceptive services through a quality imPROVEment initiative for and with immigrant women in Sweden (IMPROVE it): a protocol for a cluster randomised control trial with a process evaluation

BACKGROUND

Immigrant women's challenges in realizing sexual and reproductive health and rights (SRHR) are exacerbated by the lack of knowledge regarding how to tailor post-partum contraceptive services to their needs. Therefore, the overall aim of the IMPROVE-it project is to promote equity in SRHR through improvement of contraceptive services with and for immigrant women, and, thus, to strengthen women's possibility to choose and initiate effective contraceptive methods post-partum.

METHODS

This Quality Improvement Collaborative (QIC) on contraceptive services and use will combine a cluster randomized controlled trial (cRCT) with a process evaluation. The cRCT will be conducted at 28 maternal health clinics (MHCs) in Sweden, that are the clusters and unit of randomization, and include women attending regular post-partum visits within 16 weeks post birth. Utilizing the Breakthrough Series Collaborative model, the study's intervention strategies include learning sessions, action periods, and workshops informed by joint learning, co-design, and evidence-based practices. The primary outcome, women's choice of an effective contraceptive method within 16 weeks after giving birth, will be measured using the Swedish Pregnancy Register (SPR). Secondary outcomes regarding women's experiences of contraceptive counselling, use and satisfaction of chosen contraceptive method will be evaluated using questionnaires completed by participating women at enrolment, 6 and 12 months post enrolment. The outcomes including readiness, motivation, competence and confidence will be measured through project documentation and questionnaires. The project's primary outcome involving women's choice of contraceptive method will be estimated by using a logistic regression analysis. A multivariate analysis will be performed to control for age, sociodemographic characteristics, and reproductive history. The process evaluation will be conducted using recordings from learning sessions, questionnaires aimed at participating midwives, intervention checklists and project documents.

DISCUSSION

The intervention's co-design activities will meaningfully include immigrants in implementation research and allow midwives to have a direct, immediate impact on improving patient care. This study will also provide evidence as to what extent, how and why the QIC was effective in post-partum contraceptive services.

TRIAL REGISTRATION

NCT05521646, August 30, 2022.

Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial: a protocol for a multicentre, stepped-wedge cluster randomized trial

BACKGROUND

Evidence-based Practice for Improving Quality (EPIQ) is a collaborative quality improvement method adopted by the Canadian Neonatal Network that led to decreased mortality and morbidity in very preterm neonates. The Alberta Collaborative Quality Improvement Strategies to Improve Outcomes of Moderate and Late Preterm Infants (ABC-QI) Trial aims to evaluate the impact of EPIQ collaborative quality improvement strategies in moderate and late preterm neonates in Alberta, Canada.

METHODS

In a 4-year, multicentre, stepped-wedge cluster randomized trial involving 12 neonatal intensive care units (NICUs), we will collect baseline data with the current practices in the first year (all NICUs in the control arm). Four NICUs will transition to the intervention arm at the end of each year, with 1 year of follow-up after the last group transitions to the intervention arm. Neonates born at 32 + 0 to 36 + 6 weeks' gestation with primary admission to NICUs or postpartum units will be included. The intervention includes implementation of respiratory and nutritional care bundles using EPIQ strategies, including quality improvement team building, quality improvement education, bundle implementation, quality improvement mentoring and collaborative networking. The primary outcome is length of hospital stay; secondary outcomes include health care costs and short-term clinical outcomes. Neonatal intensive care unit staff will complete a survey in the first year to assess quality improvement culture in each unit, and a sample will be interviewed 1 year after implementation in each unit to evaluate the implementation process.

INTERPRETATION

The ABC-QI Trial will assess whether collaborative quality improvement strategies affect length of stay in moderate and late preterm neonates. It will provide detailed population-based data to support future research, benchmarking and quality improvement.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT05231200.

"Quality teaches you how to use water. It doesn't provide a water pump": a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program

BACKGROUND

Quality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives' varied impacts.

METHODS

To understand mechanisms and contextual influences we conducted 55 in-depth interviews with staff from four health centres and two hospitals involved in quality improvement collaboratives in Ethiopia. We also generated control charts for selected indicators to explore any impacts of the collaboratives.

RESULTS

The cross facility learning sessions increased the prominence and focus on quality, allowed learning from experts and peers and were motivational through public recognition of success or a desire to emulate peers. Within facilities, new structures and processes were created. These were fragile and sometimes alienating to those outside the improvement team. The trusted and respected mentors were important for support, motivation and accountability. Where mentor visits were infrequent or mentors less skilled, team function was impacted. These mechanisms were more prominent, and quality improvement more functional, in facilities with strong leadership and pre-existing good teamwork; as staff had shared goals, an active approach to problems and were more willing and able to be flexible to implement change ideas. Quality improvement structures and processes were more likely to be internally driven and knowledge transferred to other staff in these facilities, which reduced the impact of staff turnover and increased buy-in. In facilities which lacked essential inputs, staff struggled to see how the collaborative could meaningfully improve quality and were less likely to have functioning quality improvement. The unexpected civil unrest in one region strongly disrupted the health system and the collaborative. These contextual issues were fluid, with multiple interactions and linkages.

CONCLUSIONS

The study confirms the need to carefully consider context in the implementation of quality improvement collaboratives. Facilities that implement quality improvement successfully may be those that already have characteristics that foster quality. Quality improvement may be alienating to those outside of the improvement team and implementers should not assume the organic spread or transfer of quality improvement knowledge.