The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review

Association Between Patient Safety Culture and Missed Nursing Care in Healthcare Settings: A Systematic Review and Meta-Analysis

AIM

To appraise and synthesise existing research on the relationship between patient safety culture and missed nursing care.

DESIGN

Systematic review and meta-analysis.

METHODS

Peer-reviewed articles published from 2010 onwards were searched from five databases (CINAHL, ProQuest, PubMed, ScienceDirect and Web of Science). A total of nine studies were identified. Among these, seven studies with a combined sample size of 1661 participants were included in the meta-analysis.

RESULTS

The meta-analysis revealed a significant negative correlation between overall patient safety culture and missed nursing care, with a pooled correlation coefficient of -0.205 (95% CI: -0.251 to -0.158) (p < 0.001). Heterogeneity was low to moderate (I2 = 13.18%, 95% CI: 0.00 to 78.60), and publication bias tests indicated no significant bias (Egger's test p = 0.0603; Begg's test p = 0.3476).

CONCLUSION

The findings underscore a significant inverse relationship between patient safety culture and missed nursing care, highlighting the specific predictive roles of management support, organisational learning and unit-level safety culture. Enhancing patient safety culture within healthcare organisations can be a strategic approach to mitigate missed nursing care.

IMPACT

Nursing leaders and administrators should prioritise fostering a safety-oriented culture through targeted interventions, continuous education and supportive policies to improve patient care outcomes.

REPORTING METHOD

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Illuminating power dynamics that influenced a relational coordination program in a tertiary hospital: An institutional ethnography study

BACKGROUND

Amidst the difficulty and contentiousness of improving hospitals, a relatively new approach is the Relational Model of Organizational Change (RMOC). However, this approach has its own challenges, including reports that its focus on communication and relationships is undervalued despite evidence supporting its use to facilitate practice improvements in hospitals. Research suggests power dynamics in hospitals influences how the RMOC is used, but the precise mechanisms through which this occurs have not been fully examined.

PURPOSE

The purpose of this study was to examine how power dynamics shaped the implementation of a program using the RMOC in a hospital: the QPH RC Program.

METHODOLOGY

Institutional ethnography was applied to explicate textually mediated ruling relations (power dynamics) and examine how they exerted their influence on the QPH RC Program. This involved interviewing people and analyzing texts embedded in work processes that organized the implementation of the program.

RESULTS

The QPH RC Program was embedded in a cluster of ruling relations comprising an economic rationalist and scientific discourse and project management methodology. These ruling relations exerted their power via textually mediated social processes that influenced the focus and management of the program.

CONCLUSION

The ruling relations functioned to align the QPH RC Program with the priorities of the hospital, suggesting that financial objectives were prioritized over objectives to improve communication or culture.

PRACTICE IMPLICATIONS

Future research and practice change should include investigating and addressing the intersection of institutional contexts and the application of the RMOC to facilitate practice improvements in health care organizations, particularly hospitals.

Development of a remote implementation support strategy to enhance integration of depression treatment into primary care settings in rural India

Introduction

Contextually responsive implementation support strategies are needed to enhance the integration of mental health services into primary health care. Technical assistance is widely used as a core "capacity building" strategy, primarily for increasing the motivation and capacity of individuals (e.g., frontline workers) to adopt evidence-based interventions in healthcare settings. This article documents the systematic design of a technical assistance strategy for supporting primary care staff (e.g., nurses) in integrating depression care, from screening to treatment, aligned with a non-communicable disease program across seven health facilities in the Sehore District of Madhya Pradesh, India.

Methods

We conducted a mapping exercise of local health facilities with dedicated staff and a literature review to inform the development of the technical assistance strategy.

Results

Reporting guidelines guided the structure of the strategy protocol. The evidence-supported strategy, called Remote Coaching Support, is tailored to the local setting. It uses quality improvement methods like the Plan-Do-Act-Study cycle and training materials to help coaches deliver support remotely via video/phone-based calls and WhatsApp messaging with the overall goal of increasing uptake and fidelity of depression screening and referral among primary care staff in alignment with an existing non-communicable diseases program.

Conclusion

The development of Remote Coaching Support involved iterative improvements through team meetings and practice-training feedback, though limitations exist due to a lack of systematic implementation standards, especially in this setting. This strategy will be tested in increasing scales to refine its application, with effectiveness and acceptability results to be evaluated in a randomized control trial.

Firm, yet flexible: a fidelity debate paper with two case examples

BACKGROUND

In healthcare research and practice, intervention and implementation fidelity represent the steadfast adherence to core components of research-supported interventions and the strategies employed for their implementation. Evaluating fidelity involves determining whether these core components were delivered as intended. Without fidelity data, the results of complex interventions cannot be meaningfully interpreted. Increasingly, the necessity for firmness and strict adherence by implementers and their organizations has been questioned, with calls for flexibility to accommodate contextual conditions. This shift makes contemporary fidelity a balancing act, requiring researchers to navigate various tensions. This debate paper explores these tensions, drawing on experiences from developing fidelity assessments in two ongoing effectiveness-implementation hybrid trials.

MAIN BODY

First, given often scarce knowledge about the core components of complex interventions and implementation strategies, decisions about fidelity requirements involve a degree of subjective reasoning. Researchers should make these decisions transparent using theory or logic models. Second, because fidelity is context-dependent and applies to both interventions and implementation strategies, researchers must rethink fidelity concepts with every study while balancing firmness and flexibility. This is particularly crucial for hybrid studies, with their differing emphasis on intervention and implementation fidelity. Third, fidelity concepts typically focus on individual behaviors. However, since organizational and system factors also influence fidelity, there is a growing need to define fidelity criteria at these levels. Finally, as contemporary fidelity concepts prioritize flexible over firm adherence, building, evaluating, and maintaining fidelity in healthcare research has become more complex. This complexity calls for intensified efforts to expand the knowledge base for pragmatic and adaptive fidelity measurement in trial and routine healthcare settings.

CONCLUSION

Contemporary conceptualizations of fidelity place greater demands on how fidelity is examined, necessitating the expansion of fidelity frameworks to include organizational and system levels, the service- and study-specific conceptualizations of intervention and implementation fidelity, and the development of pragmatic approaches for assessing fidelity in research and practice. Continuing to build knowledge on how to balance requirements for firmness and flexibility remains a crucial task within the field of implementation science.

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.

Improving the primary care clinical testing process in southwest Scotland: a systems-based approach

INTRODUCTION

Across all healthcare environments, inadequately specified patient test requests are commonly encountered and can lead to wasted clinician time and healthcare resources, in addition to either missed or unnecessary testing taking place.Before this work, in a general practice in Southwest Scotland, a mean value of 42% of test requests were already uploaded to ordercomms (a widely used system in general practice for designating clinical testing instructions) at patient presentation, leaving an opportunity for error and wasted clinician time/resources.

METHODS

Patient appointment records were retrospectively reviewed in a general practice in Southwest Scotland to monitor the proportion of test requests already uploaded to ordercomms at the time of patient presentation.The use of quality improvement tools and plan-do-study-act cycling allowed the testing of four change ideas attributable to different 'pathways' of origin for test requests.Change ideas included increasing clinician and secondary care/docman origin test requests already on ordercomms prior to patient presentation, reducing patient origin test requests and improving the test requesting system.

RESULTS

The percentage of test requests already on ordercomms at patient presentation increased from a mean of 42% to 89% over a 30 week test period. The use of test pre-set templates was a welcome intervention that was agreed to be made accessible to 30+ regional general practices.

CONCLUSION

The use of pre-set templates for clinical testing encouraged a 47% rise in test requests already uploaded to ordercomms prior to patient presentation. This saved up to 90 min of clinician time weekly and ensured patients received the correct tests at the appropriate time.Our findings supported the use of pre-set testing templates, in combination with effective information communication, and were recommended for use in any clinical environment requiring patient testing.

In Pursuit of Optimal Outcomes: A Framework for Quality Standards in Immune Effector Cell Therapy

Immune effector cell (IEC) therapy represents a transformative advancement in oncology, leveraging the immune system to combat various malignancies. This article outlines a comprehensive framework for establishing and maintaining quality standards in IEC therapy amidst rapid scientific and clinical advancements. We emphasize the integration of structured process measures, robust quality assurance, and meticulous outcome evaluation to ensure treatment efficacy and safety. Key components include multidisciplinary expertise, stringent accreditation protocols, and advanced data management systems, which facilitate standardized reporting and continual innovation. The collaborative effort among stakeholders-ranging from patients and healthcare providers to regulatory bodies-is crucial in delivering high-quality IEC therapies. This framework aims to enhance patient outcomes and cement the role of IEC therapy as a cornerstone of modern oncology, promoting continuous improvement and adherence to high standards across the therapeutic spectrum.

Increase in Newborns Ventilated Within the First Minute of Life and Reduced Mortality After Clinical Data-Guided Simulation Training

INTRODUCTION

Birth asphyxia-related deaths is a major global concern. Rapid initiation of ventilation within the "Golden Minute" is important for intact survival but reported to be challenging, especially in low-/middle-income countries. Helping Babies Breathe (HBB) is a simulation-based training program for newborn resuscitation. The aim of this HBB quality improvement (QI) intervention was to decrease time from birth to ventilation and document potential changes in perinatal outcomes.

METHOD

Prospective observational QI study in a rural Tanzanian hospital, October 1, 2017, to August 31, 2021, first-year baseline, second-year QI/simulation intervention, and 2-year postintervention. Trained research assistants observed wide-ranging information from all births (N = 12,938). The intervention included monthly targeted HBB simulation training addressing documented gaps in clinical care, clinical debriefings, and feedback meetings.

RESULTS

During the QI/simulation intervention, 68.5% nonbreathing newborns were ventilated within 60 seconds after birth compared with 15.8% during baseline and 42.2% and 28.9% during the 2 postintervention years ( P < 0.001). Time to first ventilation decreased from median 101 (quartiles 72-150) to 55 (45-67) seconds ( P < 0.001), before increasing to 67 (49-97) and 85 (57-133) seconds after intervention. More nonbreathing newborns were ventilated in the intervention period (12.9%) compared with baseline (8.5%) and the postintervention years (10.6% and 9.4%) ( P < 0.001). Assumed fresh stillborns decreased significantly from baseline to intervention (3.2%-0.7%) ( P = 0.013).

CONCLUSIONS

This QI study demonstrates an increase in nonbreathing newborns being ventilated within the Golden Minute and a significant reduction in fresh stillborns after introduction of an HBB QI/simulation intervention. Improvements are partially reversed after intervention, highlighting the need for continuous simulation-based training and research into QI efforts essential for sustainable changes.

Opportunities for Laboratory Testing to Inform Antimicrobial Use for Bovine Respiratory Disease: Application of Information Quality Value Stream Maps in Commercial Feedlots

BACKGROUND/OBJECTIVES

The implementation of information quality value stream maps (IQ-VSMs) in food animal production systems can increase our understanding of the opportunities and challenges when using laboratory testing for antimicrobial resistance (AMR) to support antimicrobial stewardship (AMS). Our objectives were to (1) explore the implementation of information quality value stream mapping as a continuous improvement tool to inform decisions for bovine respiratory disease (BRD) management and AMS and (2) apply the information quality dimensions to identified Kaizen opportunities for the integration of laboratory data into BRD management systems to assess the appropriateness of BRD treatment plans in western Canadian feedlot production.

METHODS

A 'Current State' IQ-VSM outlined the processes, available information, information processing steps, and control decisions contributing to BRD management and treatment in commercial western Canadian feedlots, recognizing that laboratory BRD pathogens and AMR data are typically not part of BRD management.

RESULTS

The 'Future State' IQ-VSM incorporated Kaizen opportunities for improvement, including (i) the strategic collection of respiratory samples from representative samples of calves for laboratory analysis, regardless of clinical BRD status, (ii) compilation of laboratory data at the pen and feedlot levels, and (iii) analysis of pen- and feedlot-level laboratory data to inform the veterinarian's assessment of the appropriateness of current BRD treatment plans.

CONCLUSIONS

The IQ-VSMs provided a valuable framework to visualize the integration of BRD pathogen and AMR laboratory data to support AMS and address any potential future testing requirements.

Exploring the use of social network analysis methods in process improvement within healthcare organizations: a scoping review

BACKGROUND

Communication breakdowns among healthcare providers have been identified as a significant cause of preventable adverse events, including harm to patients. A large proportion of studies investigating communication in healthcare organizations lack the necessary understanding of social networks to make meaningful improvements. Process Improvement in healthcare (systematic approach of identifying, analyzing, and enhancing workflows) is needed to improve quality and patient safety. This review aimed to characterize the use of SNA methods in Process Improvement within healthcare organizations.

METHODS

Relevant studies were identified through a systematic search of seven databases from inception - October 2022. No limits were placed on study design or language. The reviewers independently charted data from eligible full-text studies using a standardized data abstraction form and resolved discrepancies by consensus. The abstracted information was synthesized quantitatively and narratively.

RESULTS

Upon full-text review, 38 unique articles were included. Most studies were published between 2015 and 2021 (26, 68%). Studies focused primarily on physicians and nursing staff. The majority of identified studies were descriptive and cross-sectional, with 5 studies using longitudinal experimental study designs. SNA studies in healthcare focusing on process improvement spanned three themes: Organizational structure (e.g., hierarchical structures, professional boundaries, geographical dispersion, technology limitations that impact communication and collaboration), team performance (e.g., communication patterns and information flow among providers., and influential actors (e.g., key individuals or roles within healthcare teams who serve as central connectors or influencers in communication and decision-making processes).

CONCLUSIONS

SNA methods can characterize Process Improvement through mapping, quantifying, and visualizing social relations, revealing inefficiencies, which can then be targeted to develop interventions to enhance communication, foster collaboration, and improve patient safety.

Starting continuous improvement; creating a common understanding of stroke care delivery in a general hospital

BACKGROUND

Continuous improvement is based on fostering practitioners' suggestions to modify their own work processes This improvement strategy is widely applied in healthcare but difficult to maintain. The cross-disciplinary nature of many care processes constitutes an extra impediment.

METHODS

The study had an explorative design with a qualitative single-case approach. The case presents a project to improve the treatment of patients with thrombotic stroke. Data was obtained via hands on involvement, documents, observations, and interviews with participants in a cross-functional improvement group. A thematic analysis method was employed.

RESULTS

Through learning how tasks were carried out in other disciplines, the participants developed a common understanding of why it took so long to provide treatment to stroke patients. These insights were used to implement practical changes, leading to immediate improvements in stroke care delivery. The results were fed back so that successes became visible. Participants' understandings of the local context enabled them to convince peers of the rationale of changes, setting in motion a permanent improvement structure. The participants considered that mapping and then assessing the entire workflow across disciplines were relevant methods for improving the quality of patient care.

CONCLUSION

Starting an improvement project in a cross disciplinary environment requires deep engagement on the part of professionals. A quintessential prerequisite is therefore the realization that the quality of care depends on cross-disciplinary cooperation. A facilitated learning arena needs to (1) create insights into each other's colleagues' tasks and process interdependencies, (2) increase understanding of how the distribution of tasks among specialist units affects the quality of care, and (3) frequently report and provide feedback on results to keep the process going.

How consistent are the key recommendations, and what is the quality of guidelines and expert consensus regarding paediatric cow's milk protein allergy?

The objective of this study was to assess the quality and consistency of recommendations in clinical practice guidelines (CPGs) and expert consensus on paediatric cow's milk protein allergy (CMPA) to serve as a foundation for future revisions and enhancements of clinical guidelines and consensus documents. We conducted a comprehensive literature search across several databases, including the Chinese Biomedical Literature Database (CBM), PubMed, Embase, Web of Science, UpToDate, ClinicalKey, DynaMed Plus and BMJ Best Practice. We spanned the search period from the inception of each database through October 1, 2023. We integrated subject headings (MeSH/Emtree) and keywords into the search strategy, used the search methodologies of existing literature and developed it in collaboration with a librarian. Two trained researchers independently conducted the literature screening and data extraction. We evaluated methodological quality and recommendations by using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) and AGREE-Recommendations for Excellence (AGREE-REX) tools. Moreover, we compared and summarized key recommendations from high-quality CPGs. Our study included 27 CPGs and expert consensus documents on CMPA. Only four CPGs (14.8%) achieved a high-quality AGREE II rating. The four high-quality CPGs consistently provided recommendations for CMPA. The highest scoring domains for AGREE II were 'scope and purpose' (77 ± 12%) and 'clarity of presentation' (75 ± 22%). The lowest scoring domains were 'stakeholder involvement' (49 ± 21%), 'rigor of development' (34 ± 20%) and 'applicability' (12 ± 20%). Evaluation with AGREE-REX generally demonstrated low scores across its domains.   Conclusion: Recommendations within high-quality CPGs for the paediatric CMPA showed fundamental consistency. Nevertheless, the methodology and recommendation content of CPGs and the expert consensus exhibited low quality, thus indicating a substantial scope for enhancement. Guideline developers should rigorously follow the AGREE II and AGREE-REX standards in creating CPGs or expert consensuses to guarantee their clinical efficacy in managing paediatric CMPA. What is Known: • The quality of clinical practice guidelines and expert consensus on paediatric cow's milk protein allergy (CMPA) remains uncertain. • There is a lack of clarity regarding the consistency of crucial recommendations for CMPA management. What is New: • Improving the methodological quality of guidelines and consensus on CMPA requires greater emphasis on stakeholder engagement, rigorous development processes, and practical applicability. • The recommendations from four high-quality guidelines align. However, addressing clinical applicability, integrating values and preferences, and ensuring actionable implementation are critical to improving the quality of all guidelines.

Identifying the contributors to nursing caring success stories

AIMS

To (a) seek examples of nursing caring success stories and (b) identify the common contributors to these successes. By focusing on the successes of nursing care rather than critically examining failures, this research seeks to provide examples of proven and feasible approaches and processes for improving care.

DESIGN

This study used a narrative inquiry design.

METHODS

Data were collected through group interviews. Four interviews were conducted with a total of 20 nurse participants working in inpatient settings in South Australian hospitals. A thematic analysis approach was used to analyse the data.

RESULTS

Two dominant themes concerning the contributors to caring success were identified. These contributors were (1) the provision of holistic care and (2) the influence of the caring community, which includes family members and other patients. The findings also indicated that the definition of caring success according to nurses is not aligned with organisational performance indicators but is more closely represented by caring values.

CONCLUSION

Success, according to nurses, is not exclusively defined by patient outcomes but includes the approach to, and process of, care delivery.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses value the caring process while working in an environment that primarily values clinical and systems-level outcomes. Nurses want patients and their families, allied health professionals and hospital executives to be involved and invested in the process of care.

IMPACT

This study addressed a gap in the current literature to identify commonalities in nursing success stories, the contributors informing these successes and how these contributors can facilitate improved patient care. Understanding nursing definitions of caring success provides an opportunity to expand upon current accepted industry definitions and perspectives such as key performance indicators.

REPORTING METHOD

Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

PATIENT OR PUBLIC CONTRIBUTION

No direct patient or public contribution.

Readiness to provide comprehensive emergency obstetric and neonatal care: a cross-sectional study in 30 health facilities in Tanzania

BACKGROUND

Despite the global progress in bringing health services closer to the population, mothers and their newborns still receive substandard care leading to morbidity and mortality. Health facilities' capacity to deliver the service is a prerequisite for quality health care. This study aimed to assess health facilities' readiness to provide comprehensive emergency obstetric and newborn care (CEmONC), comprising of blood transfusion, caesarean section and basic services, and hence to inform improvement in the quality of care interventions in Tanzania.

METHODS

A cross-sectional assessment of 30 CEmONC health facilities implementing the Safer Births Bundle of Care package in five regions of Tanzania was carried out between December 2020 and January 2021. We adapted the World Health Organization's Service Availability and Readiness Assessment tool to assess amenities, equipment, trained staff, guidelines, medicines, and diagnostic facilities. Composite readiness scores were calculated for each category and results were compared at the health facility level. For categorical variables, we tested for differences by Fisher's exact test; for readiness scores, differences were tested by a linear mixed model analysis, taking into account dependencies within the regions. We used p < 0.05 as our level of significance.

RESULTS

The overall readiness to provide CEmONC was 69.0% and significantly higher for regional hospitals followed by district hospitals. Average readiness was 78.9% for basic amenities, 76.7% for medical equipment, 76.0% for diagnosis and treatment commodities, 63.6% for staffing and 50.0% for guidelines. There was a variation in the availability of items at the individual health facility level and across levels of facilities. We found a significant difference in the availability of basic amenities, equipment, staffing, and guidelines between regional, and district hospitals and health centres (p = 0.05). Regional hospitals had significantly higher scores of medical equipment than district hospitals and health centers (p = 0.02). There was no significant difference in the availability of commodities for diagnosis and treatment between different facility levels.

CONCLUSION

Facilities' readiness was inadequate and varied across different levels of the facility. There is room to improve the facilities' readiness to deliver quality maternal and newborn care. The responsible authorities should take immediate actions to address the observed deficiencies while carefully choosing the most effective and feasible interventions and monitoring progress in readiness.

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.

Barriers and Challenges to Implementing a Quality Improvement Program: Political and Administrative Challenges

Quality improvement (QI) programs have rapidly grown in health care over recent years. Despite increasing evidence of successful QI initiatives resulting in improved outcomes, the adoption and implementation of QI programs remain a challenge worldwide. This paper briefly describes political and administrative barriers that impede the implementation of QI programs, including political and ideological factors, socioeconomic and educational barriers, and barriers related to data collection, privacy, and security. Key political and administrative barriers identified include resource limitations due to inadequate public funding, stringent laws, and change resistance. Potential solutions include support and commitment from regional and national authorities, consultation of all involved parties during QI program development, and financial incentives. The barrier of limited resources is starker among low- and middle-income countries (LMICs) compared with high-income countries (HICs) due to the absence of adequate infrastructure, personnel equipped with QI-oriented skills, and analytical technology. Solutions that have facilitated QI programs in some LMICs include outreach and collaboration with other health centers and established QI programs in HICs. The lack of QI-specific training and education in medical curricula challenges QI implementation but can be mitigated through the provision of QI promotion webinars, QI-specific project opportunities, and formalized QI training modules. Finally, barriers related to data collection, privacy, and security include laws hindering the availability of quality data, inefficient data collection and processes, and outdated clinical information systems. Access to high-quality data, organized record-keeping, and alignment of data collection processes will help alleviate these barriers to QI program implementation. The multidimensional nature of these barriers means that proposed solutions will require coordination from multiple stakeholders, government support, and leaders across multiple fields.

Continuous Quality Improvement in the Substance Abuse and Mental Health Services Administration's Technology Transfer Center Network: A Process Evaluation

In healthcare and related fields, there is often a gap between research and practice. Scholars have developed frameworks to support dissemination and implementation of best practices, such as the Interactive Systems Framework for Dissemination and Implementation, which shows how scientific innovations are conveyed to practitioners through tools, training, and technical assistance (TA). Underpinning those aspects of the model are evaluation and continuous quality improvement (CQI). However, a recent meta-analysis suggests that the approaches to and outcomes from CQI in healthcare vary considerably, and that more evaluative work is needed. Therefore, this paper describes an assessment of CQI processes within the Substance Abuse and Mental Health Services Administration's (SAMHSA) Technology Transfer Center (TTC) Network, a large TA/TTC system in the United States comprised of 39 distinct centers. We conducted key informant interviews (n = 71 representing 28 centers in the Network) and three surveys (100% center response rates) focused on CQI, time/effort allocation, and Government Performance and Results Act (GPRA) measures. We used data from each of these study components to provide a robust picture of CQI within a TA/TTC system, identifying Network-specific concepts, concerns about conflation of the GPRA data with CQI, and principles that might be studied more generally.

Moving from prove to improve: A collaborative continuous quality improvement process for advancing Clinical and Translational Science

Structured processes to improve the quality and impact of clinical and translational research are a required element of the Clinical and Translational Sciences Awards (CTSA) program and are central to awardees' strategic management efforts. Quality improvement is often assumed to be an ordinary consequence of evaluation programs, in which standardized metrics are tabulated and reported externally. Yet evaluation programs may not actually be very effective at driving quality improvement: required metrics may lack direct relevance; they lack incentive to improve on areas of relative strength; and the validity of inter-site comparability may be limited. In this article, we describe how we convened leaders at our CTSA hub in an iterative planning process to improve the quality of our CTSA program by intentionally focusing on how data collection activities can primarily advance continuous quality improvement (CQI) rather than strictly serve as evaluative tools. We describe our CQI process, which consists of three key components: (1) Logic models outlining goals and associated mechanisms; (2) relevant metrics to evaluate performance improvement opportunities; and (3) an interconnected and collaborative CQI framework that defines actions and timelines to enhance performance.

Doctors' perspectives on the quality of medical imaging in public hospitals in eThekwini District

Background

There is a paucity of literature on perspectives of referring doctors about the quality of medical imaging services and this study closes this gap in literature.

Aim

This quality assurance (QA) study aimed to explore the perspectives of doctors on the quality of medical imaging services in selected regional hospitals within eThekwini District of KwaZulu-Natal.

Setting

The study was conducted in four public regional hospitals.

Methods

An exploratory descriptive qualitative research design involving 30 min-45 min of in-depth individual interviews was used. A purposive sampling technique was used to select research participants and hospitals to ensure adequate responses to the research questions. The sample involved nine participants and was guided by data saturation. Responses were recorded through notes and voice recordings and thematic analysis was used to analyse data.

Results

Three main themes (timeliness of examinations, communication and radiology reports and image quality) and eight subthemes (waiting times, shortage of radiographers, workload, communication between doctors and radiographers, requisition forms, unavailability of radiology reports, clarity of images and image acquisition protocols) emerged from the data. Challenges experienced were exacerbated by high workload and shortage of radiologists and radiographers. Doctors in the data collection sites were mainly dissatisfied with services provided by the medical imaging departments.

Conclusion

Regular engagements between medical imaging departments and doctors are important in enhancing the provision of quality care to patients. In-service training of radiographers and employment of additional radiographers and finding solutions to mitigate shortage of radiologists are recommended.

Contribution

This quality assurance (QA) study focused on experiences of doctors while many other medical imaging QA studies in South Africa are equipment based. In-service training of radiographers is recommended to improve image quality and communication skills.

Hospital-Based Pediatric Quality Improvement Interventions and Health Disparities: A Scoping Review of the Literature

BACKGROUND AND OBJECTIVES

Quality improvement (QI) has the potential to reduce health disparities through multiple mechanisms, including by standardizing care and addressing social barriers to health. National organizations require that hospital systems integrate equity into quality efforts, but effective approaches remain unclear. We aimed to examine the association of hospital-based pediatric QI interventions and racial and ethnic, language, and socioeconomic disparities in health outcomes.

METHODS

Quantitative studies from January 1, 2000 to December 11, 2023 reporting the effects of pediatric hospital-based QI were selected from PubMed and Embase. Studies were excluded if outcomes were not stratified by race and ethnicity, language, or socioeconomic status. Studies were reviewed in duplicate for inclusion and by 1 author for data extraction.

RESULTS

A total of 22 studies were included. Most studies (n = 19, 86%) revealed preexisting disparities, and 68% of those (n = 13) found disparities reductions post-intervention. Studies with disparity-focused objectives or interventions more commonly found reduced disparities than studies of general QI (85% vs 33%). Hospital-based process standardization was associated with reduced disparities in provider practices. Most interventions associated with reduced disparities in patient-facing outcomes involved community/ambulatory partnership. Limitations included potential exclusion of relevant studies, topic heterogenity, and risk of bias.

CONCLUSIONS

Although the authors of few published hospital-based QI initiatives assessed their equity effect, intentionally designed QI studies were associated with reduced disparities. Interventions focused on care standardization may reduce disparities in care quality, although multilevel interventions are likely needed to affect the health care structures that influence more significant patient outcomes.

A scoping review of continuous quality improvement in healthcare system: conceptualization, models and tools, barriers and facilitators, and impact

BACKGROUND

The growing adoption of continuous quality improvement (CQI) initiatives in healthcare has generated a surge in research interest to gain a deeper understanding of CQI. However, comprehensive evidence regarding the diverse facets of CQI in healthcare has been limited. Our review sought to comprehensively grasp the conceptualization and principles of CQI, explore existing models and tools, analyze barriers and facilitators, and investigate its overall impacts.

METHODS

This qualitative scoping review was conducted using Arksey and O'Malley's methodological framework. We searched articles in PubMed, Web of Science, Scopus, and EMBASE databases. In addition, we accessed articles from Google Scholar. We used mixed-method analysis, including qualitative content analysis and quantitative descriptive for quantitative findings to summarize findings and PRISMA extension for scoping reviews (PRISMA-ScR) framework to report the overall works.

RESULTS

A total of 87 articles, which covered 14 CQI models, were included in the review. While 19 tools were used for CQI models and initiatives, Plan-Do-Study/Check-Act cycle was the commonly employed model to understand the CQI implementation process. The main reported purposes of using CQI, as its positive impact, are to improve the structure of the health system (e.g., leadership, health workforce, health technology use, supplies, and costs), enhance healthcare delivery processes and outputs (e.g., care coordination and linkages, satisfaction, accessibility, continuity of care, safety, and efficiency), and improve treatment outcome (reduce morbidity and mortality). The implementation of CQI is not without challenges. There are cultural (i.e., resistance/reluctance to quality-focused culture and fear of blame or punishment), technical, structural (related to organizational structure, processes, and systems), and strategic (inadequate planning and inappropriate goals) related barriers that were commonly reported during the implementation of CQI.

CONCLUSIONS

Implementing CQI initiatives necessitates thoroughly comprehending key principles such as teamwork and timeline. To effectively address challenges, it's crucial to identify obstacles and implement optimal interventions proactively. Healthcare professionals and leaders need to be mentally equipped and cognizant of the significant role CQI initiatives play in achieving purposes for quality of care.

Collaborative implementation of an evidence-based package of integrated primary mental healthcare using quality improvement within a learning health systems approach: Lessons from the Mental health INTegration programme in South Africa

Introduction

The treatment gap for mental health disorders persists in low- and middle-income countries despite overwhelming evidence of the efficacy of task-sharing mental health interventions. Key barriers in the uptake of these innovations include the absence of policy to support implementation and diverting of staff from usual routines in health systems that are already overstretched. South Africa enjoys a conducive policy environment; however, strategies for operationalizing the policy ideals are lacking. This paper describes the Mental health INTegration Programme (MhINT), which adopted a health system strengthening approach to embed an evidence-based task-sharing care package for depression to integrate mental health care into chronic care at primary health care (PHC).

Methods

The MhINT care package consisting of psycho-education talks, nurse-led mental health assessment, and a structured psychosocial counselling intervention provided by lay counsellors was implemented in Amajuba district in KwaZulu-Natal over a 2-year period. A learning health systems approach was adopted, using continuous quality improvement (CQI) strategies to facilitate embedding of the intervention.MhINT was implemented along five phases: the project phase wherein teams to drive implementation were formed; the diagnostic phase where routinely collected data were used to identify system barriers to integrated mental health care; the intervention phase consisting of capacity building and using Plan-Do-Study-Act cycles to address implementation barriers and the impact and sustaining improvement phases entailed assessing the impact of the program and initiation of system-level interventions to sustain and institutionalize successful change ideas.

Results

Integrated planning and monitoring were enabled by including key mental health service indicators in weekly meetings designed to track the performance of noncommunicable diseases and human immunovirus clinical programmes. Lack of standardization in mental health screening prompted the validation of a mental health screening tool and testing feasibility of its use in centralized screening stations. A culture of collaborative problem-solving was promoted through CQI data-driven learning sessions. The province-level screening rate increased by 10%, whilst the district screening rate increased by 7% and new patients initiated to mental health treatment increased by 16%.

Conclusions

The CQI approach holds promise in facilitating the attainment of integrated mental health care in resource-scarce contexts. A collaborative relationship between researchers and health system stakeholders is an important strategy for facilitating the uptake of evidence-based innovations. However, the lack of interventions to address healthcare workers' own mental health poses a threat to integrated mental health care at PHC.

How social networks influence the local implementation of initiatives developed in quality improvement collaboratives in health care: A qualitative process study

BACKGROUND

Quality improvement collaboratives (QICs) have facilitated cross-organizational knowledge exchange in health care. However, the local implementation of many quality improvement (QI) initiatives continues to fail, signaling a need to better understand the contributing factors. Organizational context, particularly the role of social networks in facilitating or hindering implementation within organizations, remains a potentially critical yet underexplored area to addressing this gap.

PURPOSE

We took a dynamic process perspective to understand how QI project managers' social networks influence the local implementation of QI initiatives developed through QICs.

METHODOLOGY

We explored the case of a QIC by triangulating data from an online survey, semistructured interviews, and archival documents from 10 organizations. We divided implementation into four stages and employed qualitative text analysis to examine the relationship between three characteristics of network structure (degree centrality, network density, and betweenness centrality) and the progress of each QI initiative.

RESULTS

The progress of QI initiatives varied considerably among organizations. The transition between stages was influenced by all three network characteristics to varying degrees, depending on the stage. Project managers whose QI initiatives progressed to advanced stages of implementation had formed ad hoc clusters of colleagues passionate about the initiatives.

CONCLUSION

Implementing QI initiatives appears to be facilitated by the formation of clusters of supportive individuals within organizations; this formation requires high betweenness centrality and high network density.

PRACTICE IMPLICATIONS

Flexibly modifying specific network characteristics depending on the stage of implementation may help project managers advance their QI initiatives, achieving more uniform results from QICs.

Decoding the persistence of delayed hospital discharge: An in-depth scoping review and insights from two decades

OBJECTIVE

This article addresses the persistent challenge of Delayed Hospital Discharge (DHD) and aims to provide a comprehensive overview, synthesis, and actionable, sustainable plan based on the synthesis of the systematic review articles spanning the past 24 years. Our research aims to comprehensively examine DHD, identifying its primary causes and emphasizing the significance of effective communication and management in healthcare settings.

METHODS

We conducted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) method for synthesizing findings from 23 review papers published over the last two decades, encompassing over 700 studies. In addition, we employed a practical and comprehensive framework to tackle DHD. Rooted in Linderman's model, our approach focused on continuous process improvement (CPI), which highlights senior management commitment, technical/administrative support, and social/transitional care. Our proposed CPI method comprised several stages: planning, implementation, data analysis, and adaptation, all contributing to continuous improvement in healthcare delivery. This method provided valuable insights and recommendations for addressing DHD challenges.

FINDINGS

Our DHD analysis revealed crucial insights across multiple dimensions. Firstly, examining causes and interventions uncovered issues such as limited discharge destinations, signaling unsustainable solutions, and inefficient care coordination. The second aspect explored the patient and caregiver experience, emphasizing challenges linked to staff uncertainty and negative physical environments, with notable attention to the underexplored area of caregiver experience. The third theme explored organizational and individual factors, including cognitive impairment and socioeconomic influences. The findings emphasized the importance of incorporating patients' data, recognizing its complexity and current avoidance. Finally, the role of transitional and social care and financial strategies was scrutinized, emphasizing the need for multicomponent, context-specific interventions to address DHD effectively.

CONCLUSION

This study addresses gaps in the literature, challenges prevailing solutions, and offers practical pathways for reducing DHD, contributing significantly to healthcare quality and patient outcomes. The synthesis introduces the vital CPI stage, enhancing Linderman's work and providing a pragmatic framework to eradicate delayed discharge. Future efforts will address practitioner consultations to enhance perspectives and further enrich the study.

PATIENT OR PUBLIC CONTRIBUTION

Our scoping review synthesizes and analyzes existing systematic review articles and emphasizes offering practical, actionable solutions. While our approach does not directly engage patients, it strategically focuses on extracting insights from the literature to create a CPI framework. This unique aspect is intentionally designed to yield tangible benefits for patients, service users, caregivers, and the public. Our actionable recommendations aim to improve hospital discharge processes for better healthcare outcomes and experiences. This detailed analysis goes beyond theoretical considerations and provides a practical guide to improve healthcare practices and policies.

Traditional Chinese medicine for insomnia: Recommendation mapping of the global clinical guidelines

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese Medicine (TCM) represents a rich repository of empirically-developed traditional medicines. The findings call for more rigorous study into the efficacy, safety, and mechanisms of action of TCM remedies to strengthen the evidence base.

AIM OF THE STUDY

To systematically review the quality of insomnia clinical practice guidelines that involve TCM recommendations and to summarize the certainty of evidence supporting the recommendations, strength, and consistency of recommendations, providing valuable research references for the development of future insomnia guidelines.

MATERIALS AND METHODS

We systematically searched PubMed, Web of Science, Embase, CNKI, Wanfang, Chinese Biomedical Literature Database, Chinese Medical Association, Chinese Sleep Research Society, Medsci, Medlive, British National Institute of Health and Clinical Excellence (NICE), and the International Guidelines Collaboration Network (GIN) for clinical practice guidelines on insomnia from inception to March 5, 2023. Four evaluators conducted independent assessments of the quality of the guidelines by employing the AGREE II tool. Subsequently, the guideline recommendations were consolidated and presented as evidence maps.

RESULTS

Thirteen clinical practice guidelines addressing insomnia, encompassing 211 recommendations (consisting of 127 evidence-based and 84 expert consensus recommendations), were deemed eligible for inclusion in our analysis. The evaluation results revealed an overall suboptimal quality, with the "scope and purpose" domain achieving the highest score (58.1%), while the "applicability" domain garnered the lowest score (13.0%). Specifically, it was observed that 74.8% (n = 95) of the evidence-based recommendations were supported by evidence of either very low or low certainty, in contrast to the expert consensus recommendations, which accounted for 61.9% (n = 52). We subsequently synthesized 44 recommendations into four evidence maps, focusing on proprietary Chinese medicines, Chinese medicine prescriptions, acupuncture, and massage, respectively. Notably, Chinese herbal remedies and acupuncture exhibited robust support, substantiated by high-certainty evidence, exemplified by interventions such as Xuefu Zhuyu decoction, spleen decoction, body acupuncture, and ear acupuncture, resulting in solid recommendations. Conversely, proprietary Chinese medicines needed more high-certainty evidence, predominantly yielding weak recommendations. As for other therapies, the level of certainty was predominantly categorized as low or very low. Recommendations about magnetic therapy, bathing, and fumigation relied primarily on expert consensus, needing more substantive clinical research evidence, consequently forming weak recommendations. Hot ironing and acupoint injection recommendations were weakly endorsed, primarily based on observational studies. Furthermore, interventions like qigong, gua sha, and moxibustion displayed a relatively limited number of clinical studies, necessitating further exploration to ascertain their efficacy.

CONCLUSIONS

Our analysis revealed a need for substantial improvement in the quality of all the included guidelines related to insomnia. Notably, recommendations for Traditional Chinese Medicine (TCM) treatments predominantly rely on low-certainty evidence. This study represents a pioneering effort in the utilization of recommendation mapping to both present and identify existing gaps in the evidence landscape within TCM therapies, thus setting the stage for future research initiatives. The evidence supporting TCM therapy recommendations must be fortified to achieve a more substantial level of recommendation and higher certainty. Consequently, there exists a critical and pressing demand for high-quality clinical investigations dedicated to TCM, with a specific focus on ascertaining its long-term efficacy, safety, and potential side effects in the context of insomnia treatment. These endeavors are poised to establish a robust scientific foundation to inform the development of TCM therapy recommendations within the insomnia guidelines.

Experiences in Improving the Quality of Community-Based Fever Management from Three Malaria-Endemic African Countries

The WHO affirms that trained, supervised, and supported community health workers (CHWs) can deliver high-quality health services effectively and has called for documentation of enabling factors, needs, and implementation strategies of successful CHW programs. In response, the U.S. President's Malaria Initiative Impact Malaria Project conducted a study to document implementation approaches, best practices, and lessons learned for quality improvement (QI) of community-based fever management in Madagascar, Malawi, and Mali. The team conducted 10 key informant interviews (KIIs) with individuals at national, regional, and district levels using an open-ended interview guide tailored to each level, and a desk review of documents and materials related to community-based QI. Each country's community health landscape and QI approaches were summarized into four categories identified during the KIIs (training, supervision, coaching/mentoring, and review meetings) and compared. Results found that Madagascar, Malawi, and Mali all had well-defined community health strategies that include QI, but countries could not extend their full package of community-based QI approaches to all CHWs as a result of limited human and financial resources. Vertical funding for health programs limits the scope and coverage of QI approaches, especially at the community level. Recommendations from key informants for strengthening community-based QI included integrating QI approaches to improve cost efficiency, to define roles and responsibilities more clearly, to engage communities and all health system levels in implementation, and to digitize QI tools. Increased financial and skilled human resources are needed for community-based QI activities to achieve their intended effect.

Model for Doctor of Nursing Practice Projects Based on Cross-Fertilization Between Improvement and Implementation Sciences: Protocol for Quality Improvement and Program Evaluation Studies

BACKGROUND

Hundreds of nursing professionals graduate each year from Doctor of Nursing Practice (DNP) programs, entrusted with roles as practice scholars and leaders. Graduates are tasked to lead multidisciplinary knowledge implementation projects to improve safety, quality, and key performance metrics. Nevertheless, there is a continued lack of agreement and faculty dissatisfaction with the format, focus, and results of the DNP graduation projects. The use of a wide range of models and methodologies from different sciences for knowledge implementation introduces challenges to DNP students; affects the scientific rigor of the projects; and results in the overuse, superficial use, or misuse of the models. Quality improvement (QI) and program evaluation studies are substantial investments that may lead to waste and even harm if not well conducted. Traditional QI methodologies, commonly used in DNP projects, were found to be uncertain in improving health care outcomes. The complexity of health care systems calls for cross-fertilization between improvement and implementation sciences to improve health care outcomes.

OBJECTIVE

This study describes the development, implementation, and evaluation of a hybrid model for QI and program evaluation studies to guide scholarship in the DNP program.

METHODS

The hybrid model was based on cross-fertilization between improvement and implementation sciences. The model adapted the Getting to Outcome (GTO) and Knowledge to Action (KTA) models as the overarching process models for knowledge implementation. Within each phase of the GTO and KTA models, expected barriers and facilitators for the implementation and adoption of innovation were identified based on the CFIR (Consolidated Framework for Implementation Research). Accordingly, strategies to facilitate the implementation and adoption of innovations were identified based on a refined list of implementation strategies and QI tools. The choice of these models was based on the top 5 criteria for selecting implementation science theories and frameworks. Seven DNP students used the hybrid model to conduct QI projects. Students evaluated their experiences by responding to a Qualtrics survey.

RESULTS

The hybrid model encouraged a comprehensive systematic way of thinking, provided tools essential to implementation success, emphasized the need for adaptability in implementation, maintained rigor in QI, and guided the sustainability of change initiatives. Some of the challenges faced by students included finding reliable and valid measures, attaining and maintaining staff buy-in, and competing organizational priorities.

CONCLUSIONS

Cross-fertilization between improvement and implementation sciences provided a roadmap and systematic thinking for successful QI projects in the DNP program. The integration of the CFIR with the GTO or KTA process models, enforced by the use of evidence-based implementation strategies and QI tools, reflected the complexity of health care systems and emphasized the need for adaptability in implementation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/54213.

Advancements in Understanding and Classifying Chronic Orofacial Pain: Key Insights from Biopsychosocial Models and International Classifications (ICHD-3, ICD-11, ICOP)

In exploring chronic orofacial pain (COFP), this review highlights its global impact on life quality and critiques current diagnostic systems, including the ICD-11, ICOP, and ICHD-3, for their limitations in addressing COFP's complexity. Firstly, this study outlines the global burden of chronic pain and the importance of distinguishing between different pain types for effective treatment. It then delves into the specific challenges of diagnosing COFP, emphasizing the need for a more nuanced approach that incorporates the biopsychosocial model. This review critically examines existing classification systems, highlighting their limitations in fully capturing COFP's multifaceted nature. It advocates for the integration of these systems with the DSM-5's Somatic Symptom Disorder code, proposing a unified, multidisciplinary diagnostic approach. This recommendation aims to improve chronic pain coding standardization and acknowledge the complex interplay of biological, psychological, and social factors in COFP. In conclusion, here, we highlight the need for a comprehensive, universally applicable classification system for COFP. Such a system would enable accurate diagnosis, streamline treatment strategies, and enhance communication among healthcare professionals. This advancement holds potential for significant contributions to research and patient care in this challenging field, offering a broader perspective for scientists across disciplines.

Developing contents for a digital adherence tool: A formative mixed-methods study among children and adolescents living with HIV in Tanzania

Optimal adherence (>95%) to antiretroviral treatment (ART) remains a challenge among children and adolescents living with HIV (CALHIV). Digital adherence tools (DAT) with reminder cues have proven feasible among adult people living with HIV (PLHIV), with some concerns about the risk of HIV status disclosure. We aimed to assess the needs, contents and acceptability of an SMS-based DAT among CALHIV. We first conducted a survey to understand potential barriers to using DAT among CALHIV, then tested the DAT intervention among purposively selected participants. The DAT intervention included using the Wisepill device, receiving daily reminder SMS and receiving adherence reports on how they had taken medication in the past month. The content of the reminder SMS differed over time from asking if the medication was taken to a more neutral SMS like "take care". Afterwards, we conducted exit interviews, in-depth interviews, and focus-group discussions. We analysed quantitative findings descriptively and used thematic content analysis for qualitative data. We included 142 children and 142 adolescents in the survey, and 20 of each used the intervention. Eighty-five percent (121/142) of surveyed participants indicated they would like to receive reminder SMS. Most of them (97/121-80%) of children and 94/121(78%) of adolescents would prefer to receive daily reminders. Participants who used the DAT mentioned to be happy to use the device. Ninety percent of them had good experience with receiving reminders and agreed that the SMS made them take medication. However, 25% experienced network problems. Participants preferred neutral reminder SMSs that did not mention the word 'medication', but preserved confidentiality. The provided adherence reports inspired participants to improve their adherence. None of the participants experienced unwanted disclosure or stigmatisation due to DAT. However, 5% of adolescents were concerned about being monitored daily. This study showed that DAT is acceptable and provided insight of the needed SMS content for a customized DAT for CALHIV.

The Use of Quality Improvement in the Physical Therapy Literature: A Scoping Review

INTRODUCTION

Quality improvement (QI) is a useful methodology for improving healthcare, often through iterative changes. There is no prior review on the application of QI in physical therapy (PT).

PURPOSE AND RELEVANCE

To characterize and evaluate the quality of the QI literature in PT.

METHODS

We searched four electronic databases from inception through September 1, 2022. Included publications focused on QI and included the practice of PT. Quality was assessed using the 16-point QI Minimum Quality Criteria Set (QI-MQCS) appraisal tool.

RESULTS

Seventy studies were included in the review, 60 of which were published since 2014 with most ( n = 47) from the United States. Acute care ( n = 41) was the most prevalent practice setting. Twenty-two studies (31%) did not use QI models or approaches and only nine studies referenced Revised Standards for QI Reporting Excellence guidelines. The median QI-MQCS score was 12 (range 7-15).

CONCLUSIONS/IMPLICATIONS

Quality improvement publications in the PT literature are increasing, yet there is a paucity of QI studies pertaining to most practice settings and a lack of rigor in project design and reporting. Many studies were of low-to-moderate quality and did not meet minimum reporting standards. We recommend use of models, frameworks, and reporting guidelines to improve methodologic rigor and reporting.

Development of a bilingual interdisciplinary scale assessing self-efficacy for participating in Medical Assistance in Dying

Medical Assistance in Dying (MAiD) is a complex process involving the person seeking care and their relatives. MAiD involves physical, psychosocial and spiritual needs, and consequently the involvement of an interdisciplinary team is beneficial. Therefore, updating the knowledge and skills of healthcare and social services professionals is critical. An interdisciplinary team from Laval University (Quebec, Canada) has developed a continuous training program for all health care and social services professionals who could be involved in the care of persons who request MAiD and their loved ones. It is crucial to assess whether the objectives of the continuous training program are being met, especially since this new training addresses several complex issues (legal, ethical, and clinical). Bandura's self-efficacy theory has been widely used to develop scales for assessing the impact of training programs and identifying knowledge gaps. Bandura's theory states that feeling secure in one's self-efficacy leads to self-determined motivation. Although there are various scales intended to measure self-efficacy in palliative care, none include self-efficacy for participating in the process surrounding MAiD. As a result, we aim to create a bilingual (English-French) interdisciplinary scale to assess self-efficacy for participating in the process surrounding MAiD. The scale will allow decision-makers and researchers to identify current knowledge gaps. It will also be useful for assessing the impact of current and future training programs addressing this end-of-life practice. In this work in progress, we briefly introduce the training program and the future steps in the development and validation of the scale.

Measuring quality of facility-based ITN distribution in Ghana

BACKGROUND

Continuous distribution channels are effective methods to deliver malaria interventions such as insecticide treated nets (ITNs) to pregnant women attending antenatal care clinics and children under five attending immunization visits. Facility-based and provider-based checklists were used during supportive supervision visits to measure the quality of facility-based services and interventions. This study looks at ITN distributions at health facilities in Ghana, with the aim of providing insights on how quality can be measured and monitored.

METHODS

Various quality improvement approaches for malaria services occur in Ghana. Selected indicators were analysed to highlight the similarities and differences of how the approaches measured how well the channel was doing. Generally, the approaches assessed (1) service data management, (2) logistics data management, and (3) observation of service provision (ITN issuance, malaria education, ITN use and care education). Two approaches used a binary (Yes/No) scale, and one used a Likert scale.

RESULTS

Results showed that most data reported to the national HMIS is accurate. Logistics data management remained an issue at health facilities, as results showed scores below average across facility stores, antenatal care, and immunization. Though the supervision approaches differed, overall results indicated that almost all eligible clients received ITNs, data were recorded accurately and reported on-time, and logistics was the largest challenge to optimal distribution through health facilities.

CONCLUSION

The supervision approaches provided valuable insights into the quality of facility-based ITN distribution. Ghana should continue to implement supportive supervision in their malaria agenda, with additional steps needed to improve reporting of collected data and increase the number of facilities visited for supportive supervision and the frequency. There were various supervision approaches used with no clear guidance on how to measure quality of facility-based ITN distribution, so there is also need for the global community to agree on standardized indicators and approaches to measuring quality of facility-based ITN distribution. Additionally, future studies can review the effect of multiple rounds of supervision visits on the quality of ITN distribution as well as understand the facilitators and barriers to scaling up supervision of facility-based ITN distribution.

Development and evaluation of a continuous quality improvement programme for antimicrobial stewardship in six hospitals in Uganda

BACKGROUND

Appropriate antimicrobial use is essential for antimicrobial stewardship (AMS). Ugandan hospitals are making efforts to improve antibiotic use, but improvements have not been sufficiently documented and evaluated.

METHODS

Six Ugandan hospitals implemented AMS interventions between June 2019 and July 2022. We used the WHO AMS toolkit to set-up hospital AMS programmes and implemented interventions using continuous quality improvement (CQI) techniques and targeting conditions commonly associated with antibiotic misuse, that is, urinary tract infections (UTIs), upper respiratory tract infections (URTIs) and surgical antibiotic prophylaxis (SAP). The interventions included training, mentorship and provision of clinical guidelines to support clinical decision-making. Quarterly antibiotic use surveys were conducted.

RESULTS

Data were collected for 7037 patients diagnosed with UTIs. There was an increase in the proportion of patients receiving one antibiotic for the treatment of UTI from 48% during the pre-intervention to 73.2%, p<0.01. There was a 19.2% reduction in the number of antimicrobials per patient treated for UTI p<0.01. There was an increase in use of nitrofurantoin, the first-line drug for the management of UTI. There was an increase in the use of Access antibiotics for managing UTIs from 50.4% to 53.8%. The proportion of patients receiving no antimicrobials for URTI increased from 26.3% at pre-intervention compared with 53.4% at intervention phase, p<0.01. There was a 20.7% reduction in the mean number of antimicrobials per patient for URTI from the pre-intervention to the intervention phase, from 0.8 to 0.6, respectively, p<0.001 and reduction in the number of treatment days, p=0.0163. Among patients undergoing surgery, 49.5% (2212) received SAP during the pre-intervention versus 50.5% (2169) during the intervention.

CONCLUSIONS

Using CQI approaches to focus on specific causes of inappropriate antibiotic use led to desirable overall reductions in antibiotic use for URTI and UTI.

Impact of externally facilitated continuous quality improvement cohorts on Advanced Access to support primary healthcare teams: protocol for a quasi-randomized cluster trial

BACKGROUND

Improving access to primary health care is among top priorities for many countries. Advanced Access (AA) is one of the most recommended models to improve timely access to care. Over the past 15 years, the AA model has been implemented in Canada, but the implementation of AA varies substantially among providers and clinics. Continuous quality improvement (CQI) approaches can be used to promote organizational change like AA implementation. While CQI fosters the adoption of evidence-based practices, knowledge gaps remain, about the mechanisms by which QI happens and the sustainability of the results. The general aim of the study is to analyse the implementation and effects of CQI cohorts on AA for primary care clinics. Specific objectives are: 1) Analyse the process of implementing CQI cohorts to support PHC clinics in their improvement of AA. 2) Document and compare structural organisational changes and processes of care with respect to AA within study groups (intervention and control). 3) Assess the effectiveness of CQI cohorts on AA outcomes. 4) Appreciate the sustainability of the intervention for AA processes, organisational changes and outcomes.

METHODS

Cluster-controlled trial allowing for a comprehensive and rigorous evaluation of the proposed intervention 48 multidisciplinary primary care clinics will be recruited to participate. 24 Clinics from the intervention regions will receive the CQI intervention for 18 months including three activities carried out iteratively until the clinic's improvement objectives are achieved: 1) reflective sessions and problem priorisation; 2) plan-do-study-act cycles; and 3) group mentoring. Clinics located in the control regions will receive an audit-feedback report on access. Complementary qualitative and quantitative data reflecting the quintuple aim will be collected over a period of 36 months.

RESULTS

This research will contribute to filling the gap in the generalizability of CQI interventions and accelerate the spread of effective AA improvement strategies while strengthening local QI culture within clinics. This research will have a direct impact on patients' experiences of care.

CONCLUSION

This mixed-method approach offers a unique opportunity to contribute to the scientific literature on large-scale CQI cohorts to improve AA in primary care teams and to better understand the processes of CQI.

TRIAL REGISTRATION

Clinical Trials: NCT05715151.

Analyzing a Multifactorial Fall Prevention Program Using ARIMA Models

BACKGROUND

Preventing inpatient falls is challenging for hospitals to improve and often leads to patient injury.

PURPOSE

To describe multifactorial patient-tailored interventions and to evaluate whether they were associated with a sustained decline in total and injury falls.

METHODS

A multifactorial fall prevention program was instituted over the course of several years. An interrupted time series design was used to assess the effect of each intervention on total and injury fall rates. ARIMA models were built to assess the step and ramp change.

RESULTS

Total fall rates decreased from 4.3 to 3.6 falls per 1000 patient days (16.28% decrease), and injury fall rates decreased from 1.02 to 0.8 falls per 1000 patient days (21.57% decrease). All the interventions contributed to fall reduction, with specific interventions contributing more than others.

CONCLUSIONS

Using multiple interventions that are sustained long enough to demonstrate success reduced the total fall rate and injury fall rate.

Quality improvement tools to manage deceased organ donation processes: a scoping review

OBJECTIVE

To collate and summarise the literature on the quality improvement tools that have been developed for deceased organ donation processes after circulatory determination of death and neurological determination of death.

DESIGN

Scoping review using the Joanna Briggs Institute framework.

DATA SOURCES

We searched for published (MEDLINE, Embase, PsycINFO, CINAHL, Web of Science) and unpublished literature (organ donation organisation websites worldwide). The search was initially conducted on 17 July 2021 and updated on 1 June 2022. Included articles discussed the creation and/or use of quality improvement tools to manage deceased organ donation processes. Two independent reviewers screened the references, extracted and analysed the data.

RESULTS

40 references were included in this review, and most records were written in English (n=38), originated in Canada (n=21), published between 2016 and 2022 (n=22), and were specific for donation after neurological determination of death (n=20). The tools identified included checklists, algorithms, flow charts, charts, pathways, decision tree maps and mobile apps. These tools were applied in the following phases of the organ donation process: (1) potential donor identification, (2) donor referral, (3) donor assessment and risk, (4) donor management, (5) withdrawal of life-sustaining measures, (6) death determination, (7) organ retrieval and (8) overall organ donation process.

CONCLUSIONS

We conducted a thorough investigation of the available quality improvement tools for deceased organ donation processes. The existing evidence lacks details in the report of methods used for development, testing and impact of these tools, and we could not locate tools specific for some phases of the organ donation process. Lastly, by mapping existing tools, we aim to facilitate both clinician choices among available tools, as well as research work building on existing knowledge.

Learning Collaboratives: a Strategy for Quality Improvement and Implementation in Behavioral Health

Learning collaboratives are increasingly used in behavioral health. They generally involve bringing together teams from different organizations and using experts to educate and coach the teams in quality improvement, implementing evidence-based practices, and measuring the effects. Although learning collaboratives have demonstrated some effectiveness in general health care, the evidence is less clear in behavioral health and more rigorous studies are needed. Learning collaboratives may contain a range of elements, and which elements are included in any one learning collaborative varies widely; the unique contribution of each element has not been established. This commentary seeks to clarify the concept of a learning collaborative, highlight its common elements, review evidence of its effectiveness, identify its application in behavioral health, and highlight recommendations to guide technical assistance purveyors and behavioral health providers as they employ learning collaboratives to improve behavioral health access and quality.

Transitioning to Telehealth Services in a Pediatric Diabetes Clinic During COVID-19: An Interdisciplinary Quality Improvement Initiative

COVID-19 necessitated a rapid shift to telehealth for psychologists offering consultation-liaison services in pediatric medical settings. However, little is known about how psychologists providing these services adapted to using telehealth service delivery formats. This report details how our interdisciplinary team identified declining psychosocial screener completion and psychology consultation rates as primary challenges following a shift to telehealth within a pediatric diabetes clinic. We utilized the Plan-Do-Study-Act (PDSA) quality improvement framework to improve screening and consultation rates, which initially declined during the telehealth transition. Screening and consultation rates dropped initially, but recovered to nearly pre-pandemic levels following three PDSA intervention cycles. During implementation, challenges arose related to the feasibility of patient interactions, interdisciplinary collaboration, patient engagement, and ethical issues. Clinics shifting psychology consultation-liaison services to telehealth should prioritize interdisciplinary communication, elicit perspectives from all clinic professionals, leverage the electronic health record, and develop procedures for warm handoffs and navigating ethical issues.

Improving curriculum delivery: Using a results informed quality improvement model for teen behavioral health education

Adolescence is a critical developmental stage to establish healthy decision-making processes and behavior patterns. Many interventions such as evidence-based curricula have been implemented to guide adolescents to avoid risk-taking behaviors and improve health and medical knowledge and outcomes. This study presents a participatory approach informed by the three-stage (3S) quality improvement process model to improve the quality of curriculum delivery, based on the results indicating outcomes achieved, needs for improvement, and quality assurance for maintaining the expected outcomes of an evidence-based curricula. Tests were conducted before and after the intervention. Using threshold levels and measures of change in the tests, instructors participated in guided discussion and analysis of the data to identify where and how instructional improvements should be made and where outcomes were being achieved as expected. This method was used to diagnose variation in the results and delivery and identify root causes informing actions to improve curriculum delivery and outcomes. After the facilitated discussions, pre- and post-tests from subsequent classes were analyzed. The results showed improved test item scores ranging from 2 to 69.5% and seven of 18 items obtained statistical significance following the implementation of the model described. Overall, an increase in the mean percent correct of 17.1% was found.

The Influence of Context on Implementation and Improvement: Protocol for a Mixed Methods, Secondary Analyses Study

BACKGROUND

Caring for the well-being of older adults is one of the greatest challenges in modern societies. Improving the quality of care and life for older adults and the work lives of their care providers calls for effective knowledge translation of evidence-based best practices.

OBJECTIVE

This study's purpose is to contribute to knowledge translation by better understanding the roles of organizational context (workplace environment) and facilitation (process or role) in implementation and improvement success. Our study has 2 goals: (1) to advance knowledge translation science by further developing and testing the Promoting Action on Research Implementation in Health Services framework (which outlines how implementation relies on the interplay of context, facilitation, and evidence) and (2) to advance research by optimizing implementation success via tailoring of modifiable elements of organizational context and facilitation.

METHODS

This is secondary analyses of 15 years of longitudinal data from the Translating Research in Elder Care (TREC) program's multiple data sources. This research is ongoing in long-term care (LTC) homes in western Canada. TREC data include the following: 5 waves of survey collection, 2 clinical trials, and regular ongoing outcome data for LTC residents. We will use a sequential exploratory and confirmatory mixed methods design. We will analyze qualitative and quantitative data holdings in an iterative process: (1) comprehensive reanalysis of qualitative data to derive hypotheses, (2) quantitative modeling to test hypotheses, and (3) action cycles to further refine and integrate qualitative and quantitative analyses. The research team includes 4 stakeholder panels: (1) system decision- and policy makers, (2) care home managers, (3) direct care staff, and (4) a citizen engagement group of people living with dementia and family members of LTC residents. A fifth group is our panel of external scientific advisors. Each panel will engage periodically, providing their perspectives on project direction and findings.

RESULTS

This study is funded by the Canadian Institutes of Health Research. Ethics approval was obtained from the University of Alberta (Pro00096541). The results of the secondary analyses are expected by the end of 2023.

CONCLUSIONS

The project will advance knowledge translation science by deepening our understanding of the roles of context, the interactions between context and facilitation, and their influence on resident and staff quality outcomes. Importantly, findings will inform understanding of the mechanisms by which context and facilitation affect the success of implementation and offer insights into factors that influence the implementation success of interventions in nursing homes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40611.

Evaluation of the introduction of QOF quality improvement modules in English general practice: early findings from a rapid, qualitative exploration of implementation

Background

A 2018 review of the English primary care pay-for-performance scheme, the Quality and Outcomes Framework, suggested that it should evolve to better support holistic, patient-centred care and leadership for quality improvement (QI). From 2019, as part of the vision of change, financially incentivised QI cycles (initially in prescribing safety and end-of-life care), were introduced into the scheme.

Objectives

To conduct a rapid evaluation of general practice staff attitudes, experiences and plans in relation to the implementation of the first two QI modules. This study was commissioned by NHS England and will inform development of the QI programme.

Methods

Semistructured telephone interviews were conducted with 25 practice managers from a range of practices across England. Interviews were audio recorded with consent and transcribed verbatim. Anonymised data were reflexively thematically analysed using the framework method of analysis to identify common themes across the interviews.

Results

Participants reported broadly favourable views of incentivised QI, suggesting the prescribing safety module was easier to implement than the end-of-life module. Additional staff time needed and challenges of reviewing activities with other practices were reported as concerns. Some highlighted that local flexibility and influence on subject matter may improve the effectiveness of QI. Several questioned the choices of topic, recognising greater need and potential for improving quality of care in other clinical areas.

Conclusion

Practices supported the idea of financial incentivisation of QI, however, it will be important to ensure that focus on QI cycles in specific clinical areas does not have unintended effects. A key issue will be keeping up momentum with the introduction of new modules each year which are time consuming to carry out for time poor General Practitioners (GPs)/practices.

How successful was the use of a community of practice for the implementation of evidence-based practices for heart failure within the United States Department of Veterans Affairs: Insights from a formative evaluation

Background

Communities of Practice (CoPs) are a promising approach to facilitate the implementation of evidence-based practices (EBPs) to improve care for chronic conditions like heart failure (HF). CoPs involve a complex process of acquiring and converting both explicit and tacit knowledge into clinical activities. This study describes the conceptualization, creation, capacity-building and dissemination of a CoP sustained over 9 years, and evaluates its value and impact on EBP.

Methods

In July 2006, a CoP called the Heart Failure Provider Network (HF Network) was established within the United States Department of Veterans Affairs (VA) with the overarching goal of improving the quality of care for HF patients. We assessed (formative) the HF Network in terms of its various activities (inputs) and proximal impacts (mediators) at the individual level, and its distal impacts (outcomes) at the site level including implementation of new/improved EBPs at the systemwide level.

Results

The HF Network membership grew steadily over the 9 years. The CoP has involved a total of 1341 multidisciplinary and multilevel members at all 144 VA Health Care Systems (sites). Most members were practising clinicians (n = 891, 66.4%), followed by administrators (n = 342, 25.5%), researchers (n = 70, 5.2%) and others (n = 38, 2.8%). Participation was assessed to be “active” for 70.6% versus “passive” for 29.4% of members. The distribution of active members (clinicians 64.7%, administrators 21.6%) was similar to the distribution of overall membership.

Conclusions

Survey respondents perceived the HF Network as useful in terms of its varied activities and resources relevant for patient care. Strong evidence shows that these members, particularly those who considered themselves influential in improving quality of care, noted multiple benefits of membership, which included confirmation of their own clinical practices, evidence-based changes to their practice and help in understanding facilitators and barriers in setting up or running HF clinics and other programmes. Such CoPs have strong impacts on the quality of care being delivered for both mandated and non-mandated initiatives.

Methodological Rigor and Transparency in Clinical Practice Guidelines for Nutrition Care in Critically Ill Adults: A Systematic Review Using the AGREE II and AGREE-REX Tools

Background: To evaluate the methodological quality of (1) clinical practice guidelines (CPGs) that inform nutrition care in critically ill adults using the AGREE II tool and (2) CPG recommendations for determining energy expenditure using the AGREE-REX tool. Methods: CPGs by a professional society or academic group, intended to guide nutrition care in critically ill adults, that used a systematic literature search and rated the evidence were included. Four databases and grey literature were searched from January 2011 to 19 January 2022. Five investigators assessed the methodological quality of CPGs and recommendations specific to energy expenditure determination. Scaled domain scores were calculated for AGREE II and a scaled total score for AGREE-REX. Data are presented as medians (interquartile range). Results: Eleven CPGs were included. Highest scoring domains for AGREE II were clarity of presentation (82% [76-87%]) and scope and purpose (78% [66-83%]). Lowest scoring domains were applicability (37% [32-42%]) and stakeholder involvement (46% [33-51%]). Eight (73%) CPGs provided recommendations relating to energy expenditure determination; scores were low overall (37% [36-40%]) and across individual domains. Conclusions: Nutrition CPGs for critically ill patients are developed using systematic methods but lack engagement with key stakeholders and guidance to support application. The quality of energy expenditure determination recommendations is low.

Linking resilience and regulation across system levels in healthcare – a multilevel study

Background

The Quality Improvement Regulation was introduced to the Norwegian healthcare system in 2017 as a new national regulatory framework to support local quality and safety efforts in hospitals. A research-based response to this, was to develop a study with the overall research question: How does a new healthcare regulation implemented across three system levels contribute to adaptive capacity in hospital management of quality and safety? Based on development and implementation of the Quality Improvement Regulation, this study aims to synthesize findings across macro, meso, and micro-levels in the Norwegian healthcare system.

Methods

The multilevel embedded case study collected data by documents and interviews. A synthesizing approach to findings across subunits was applied in legal dogmatic and qualitative content analysis. Setting: three governmental macro-level bodies, three meso-level County Governors and three micro-level hospitals. Participants: seven macro-level regulators, 12 meso-level chief county medical officers/inspectors and 20 micro-level hospital managers/quality advisers.

Results

Based on a multilevel investigation, three themes were discovered. All system levels considered the Quality Improvement Regulation to facilitate adaptive capacity and recognized contextual flexibility as an important regulatory feature. Participants agreed on uncertainty and variation to hamper the ability to plan and anticipate risk. However, findings identified conflicting views amongst inspectors and hospital managers about their collaboration, with different perceptions of the impact of external inspection. The study found no changes in management- or clinical practices, nor substantial change in the external inspection approach due to the new regulatory framework.

Conclusions

The Quality Improvement Regulation facilitates adaptive capacity, contradicting the assumption that regulation and resilience are “hopeless opposites”. However, governmental expectations to implementation and external inspection were not fully linked with changes in hospital management. Thus, the study identified a missing link in the current regime. We suggest that macro, meso and micro-levels should be considered collaborative partners in obtaining system-wide adaptive capacity, to ensure efficient risk regulation in quality improvement and patient safety processes. Further studies on regulatory processes could explore how hospital management and implementation are influenced by regulators’, inspectors’, and managers’ professional backgrounds, positions, and daily trade-offs to adapt to changes and maintain high quality care.

Translating mental health recovery guidelines into recovery-oriented innovations: A strategy combining implementation teams and a facilitated planning process

Recovery is the focus of mental health strategies internationally. However, little translation of recovery knowledge has occurred in mental health services. The purpose of this research is to bridge the gap between recovery guidelines and practice by developing a new implementation strategy involving the formation of implementation teams made up of different stakeholders (service users, service providers, managers, knowledge users) and facilitating a 12-meeting implementation planning process. Sevenmental health organizations across Canada successfully completed the process of translating the guidelines into a recovery-oriented innovation that was implemented. Fifty-five implementation team members were interviewed upon completion of the 12-meeting process. Findings indicate that implementation team members perceived the structured planning process as positive. Nevertheless, the language of implementation science remains difficult to understand for a non-academic audience. Key elements of the 12-meeting process included the value of consensus building among implementation team members and the subsequent shifting power relationships. While working with diverse stakeholders came with certain challenges, the process in itself was a form of system transformation. This type of engaged planning process was a significant departure from the more top-down approaches to organizational change that staff were used to.

Lessons learnt from quality improvement collaboratives in Cambodia

Currently, Cambodia uses performance-based financing (PBF) and a national quality enhancement monitoring system as key components of its strategy to achieve universal health coverage and the health-related Sustainable Development Goals. PBF is one among many strategies to improve the quality of healthcare services and its effects and limitations have been widely documented. We share lessons learnt from the use of quality improvement collaboratives, a facility-based quality improvement strategy, to amplify and complement PBF to address specific service delivery gaps, improve provider competency, and increase patient trust and satisfaction in the health system, a driver of healthcare utilisation.