Trust is fundamental to the effective functioning of healthcare systems, influencing access, utilisation and adherence to evidence-based practices. While quality improvement (QI) processes are widely recognised for addressing technical challenges, their role in fostering trust and relationships within health systems remains underexplored. This study examines the relationship dynamics in QI teams and how trust-building frameworks align with adaptive processes in healthcare settings. We conducted a qualitative study involving 30 healthcare workers from six African countries, recruited through the Africa Consortium for Quality Improvement in Frontline Healthcare. Data were collected through semistructured interviews, transcribed and analysed using both inductive and deductive methods. Deductive analysis was guided by a published trust-building framework, while insights from a large language model were incorporated in addition to a traditional analysis to provide an unbiased perspective. Results identified three theoretically described dimensions of trust-building within QI teams: common goals, self-interest and gratitude/indebtedness. Common goals fostered teamwork, multidisciplinary collaboration and effective communication, while self-interest motivated personal and professional growth. Gratitude and recognition reinforced team cohesion and sustained motivation. Participants highlighted the importance of trust in achieving project success, noting that robust relationships within teams correlated with improved outcomes. The study underscores the dual nature of QI processes, which simultaneously address technical improvements and adaptive challenges, including trust and relationship-building. Trust-building, framed as an iterative process of aligning common goals, recognising contributions and addressing individual interests, complements technical QI methodologies like Plan-Do-Study-Act cycles. These findings support expanding QI frameworks to emphasise relational dynamics, contributing to more sustainable and impactful healthcare improvements. Further research should continue to explore the adaptive dimensions of QI, integrating recent research on culturally relevant frameworks prioritising kindness in healthcare systems, to enhance trust and collaboration within healthcare systems.

Measuring and enhancing the quality of patient care has become a central aspect of healthcare. Quality improvement (QI) can have many purposes, but its overall aim is to enhance patient care in a structured and systematic manner. It is essential that nurses, as part of the healthcare team, understand the importance of QI and their role in QI projects. Nurses who lead QI projects need the knowledge and skills required to do so effectively within their level of competence. • The Model for Improvement based on the Plan, Do, Study, Act (PDSA) cycle has become a framework of reference for QI. • It is important to allocate sufficient time to the planning stage of a QI project and clearly identify the issues and their root causes, what interventions to test and how to measure success. • Involving stakeholders from the outset, eliciting their views and gaining their support, is a major determinant of success. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: • How this article might improve your skills in planning a QI project. • How you could use this information to educate nursing students or colleagues about the appropriate steps in planning a QI project.

Implementation of quality improvement (QI) initiatives within community mental health settings is crucial to addressing equity-related issues affecting mental health services delivery, including for co-occurring substance use disorders. Given the growing recognition of QI interventions as an effective framework to facilitate structural change within systems of care, it is important to equip mental health providers with the knowledge and ability to execute QI initiatives that are feasible, sustainable, and integrate a health equity lens. To demystify the QI process, we describe the design and methodologies of four fellows' capstone projects conducted during the 2022-2023 academic year at the University of California, San Francisco (UCSF) Public Psychiatry Fellowship at Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG). By highlighting fellows' experiences with leading QI initiatives within community mental health settings, we discuss strategies for overcoming implementation barriers including stakeholder engagement and transparency factors, resource and time constraints, unexpected changes in direction, and lack of infrastructure for QI. Lastly, we reflect on best practices and sustainability considerations for leading QI initiatives in partnership with academic centers, departments of public health, and community mental health clinics.

The prevalence of disability caused by musculoskeletal conditions continues to increase. Little research has considered the effect of process variables of a musculoskeletal care pathway on patient outcomes. A process variable is as any modifiable factor in a pathway that can be quantified and measured and that if varied may achieve a different operational or patient outcome. The perspective of patients on what process variables are important in musculoskeletal care pathways remains unknown.

The aim of this study was to investigate which process variables are important to patients and what their experiences of these processes were during the rehabilitation of their musculoskeletal conditions.

A qualitative study using a reflexive thematic analytical approach was undertaken. Four focus groups with 12 participants were conducted. Thematic analysis was utilized on the focus group data.

Four key themes were generated: 1) Process matters; (2) Quantifying progress facilitated patient engagement; (3) Benefits of equitable access of care; and (4) Recovery made easier with navigation.

Patients with musculoskeletal conditions recognise the importance of process variables, especially timeliness, order of care, coordination of care delivery, quantifying progress, equity of access and navigation. These findings offer insights to care pathway designers as well as future research opportunities examining the effects of process variables on the outcomes of patients with musculoskeletal conditions.

Many patient safety practices are only partly established in routine clinical care, despite extensive quality improvement efforts. Implementation science can offer insights into how patient safety practices can be successfully adopted.

The objective was to examine the literature on implementation of three internationally used safety practices: medication reconciliation, antibiotic stewardship programmes and rapid response systems. We sought to identify the implementation activities, factors and outcomes reported; the combinations of factors and activities supporting successful implementation; and the implications of the current evidence base for future implementation and research.

We searched Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Education Resources Information Center from January 2011 to March 2023. We included original peer-reviewed research studies or quality improvement reports. We used an iterative, inductive approach to thematically categorise data. Descriptive statistics and hierarchical cluster analyses were performed.

From the 159 included studies, eight categories of implementation activities were identified: education; planning and preparation; method-based approach; audit and feedback; motivate and remind; resource allocation; simulation and training; and patient involvement. Most studies reported activities from multiple categories. Implementation factors included: clinical competence and collaboration; resources; readiness and engagement; external influence; organisational involvement; QI competence; and feasibility of innovation. Factors were often suggested post hoc and seldom used to guide the selection of implementation strategies. Implementation outcomes were reported as: fidelity or compliance; proxy indicator for fidelity; sustainability; acceptability; and spread. Most studies reported implementation improvement, hindering discrimination between more or less important factors and activities.

The multiple activities employed to implement patient safety practices reflect mainly method-based improvement science, and to a lesser degree determinant frameworks from implementation science. There seems to be an unexploited potential for continuous adaptation of implementation activities to address changing contexts. Research-informed guidance on how to make such adaptations could advance implementation in practice.

Quality improvement education partnerships occur when higher education and healthcare organisations collaborate to teach quality improvement. These partnerships have been used to increase pre-registration student engagement through experiential learning. However, there is limited evidence on the perspectives of higher education nursing academics and healthcare organisation participants in these quality improvement education partnerships.

To explore the experiences of quality improvement education and the use of partnerships to teach pre-registration nursing students, from the perspectives of higher education nursing academics and healthcare organisation staff.

Qualitative interviews using reflexive thematic analysis.

Higher education nursing academics and quality improvement healthcare organisation staff in Australia.

Semi-structured interviews were transcribed and transferred into NVivo software for coding. Reflexive thematic analysis was applied to determine main themes.

Fourteen interviews were conducted and there were two thematic threads identified. The first described the current state of pre-registration quality improvement education in Australia and included three themes: 1) not valuing quality improvement, 2) the nebulous nature of quality improvement, and 3) quality improvement is for others. The second thread envisioned the future of quality improvement education through partnerships and included three themes: 1) creating quality improvement cultural change, 2) preparing a quality improvement ready workforce, and 3) increasing student engagement in quality improvement.

Quality improvement education partnerships are an innovative way to engage nursing students with this content. By drawing on these partnerships as a learning tool for new nurses, there is potential to change the culture of quality improvement across higher education and healthcare organisations settings. The results in this study could be used by other health professions educators internationally to establish future quality improvement education partnerships.

Engagement in internal quality improvement (QI) within physician practices is a key avenue by which to deliver evidence-based and patient-centered care, but it can be difficult to sustain such engagement. Consequently, research is needed that identifies organizational factors associated with sustained internal QI. We utilized two waves of a national survey of physician practices to explore whether organizational innovation characteristics including organizational culture, health information technology (HIT) capacity, and Accountable Care Organization (ACO) affiliation distinguish physician practices that sustain their engagement in internal QI from those that do not.

We linked two waves of the National Survey of Healthcare Organizations and Systems (NSHOS) fielded between 2017-2018 and 2022-2023 among physician practices in the United States to assess organizational characteristics associated with sustained engagement in QI (n = 714 practices). Our final regression models incorporate survey and nonresponse weights and control for practice size and ownership.

We found that higher innovative culture scores were associated with almost three times the odds of sustained QI (OR = 2.91, p < 0.001). Although high HIT capacity was also associated with greater odds of sustained versus non-sustained QI across both survey waves, this finding was not statistically significant (OR = 1.11, p > 0.05). We did not find statistically significant support for our final hypothesis that ACO affiliation (whether commercial, Medicare, or Medicaid) was associated with sustained internal QI (OR = 1.26, p > 0.05).

Our study is the first to our knowledge to underscore the critical importance of innovative organizational culture to sustaining internal QI among physician practices. Although ACO affiliation may signal willingness to participate in QI as a means to advance evidence- and value-based care and HIT capacity may facilitate improvement activities, these characteristics may not assure sustained internal QI engagement without an organizational culture aligned with QI.

Policies that advance organizational capacity to develop a learning-oriented innovative culture could enable sustained QI engagement at the physician practice level.

Improving the quality of patient care remains a global necessity. Despite system and professional benefits, current evidence indicates that the spread of improvement principles among front-line healthcare workers remains poor.While education and training alone are unlikely to result in consistent improvement practice, coaching can play a critical role in sustainable, evidence-based improvement implementation. Peer quality improvement coaching (PQIC) places the power and agency in the shared relationship between coach and coachee to shape coachee quality improvement (QI) outcomes.Study objective was to develop and pilot an evidence-based protocol for implementation and evaluation of a PQIC for front-line staff engaged in small to intermediate improvement efforts.

We conducted a multistage case-study design and implementation process. First, a systematised literature review identified themes about the theory and practice of QI coaching (QIC). Second, these themes guided the development of a PQIC protocol. Finally, the protocol was piloted and evaluated among staff in a single-centre tertiary maternity hospital. PQIC effectiveness was assessed using evaluation tools identified in the literature.

Effectiveness; strategies and models; moderating factors and methods for evaluation of QIC emerged from the literature. Together with Bloom's taxonomy and Kirkpatrick's educational model, these themes informed the development of this PQIC protocol. It was piloted in three steps: education, coaching and evaluation. A survey revealed that the participants in the education step achieved excellent scores. Following the coaching journey, the coached multidisciplinary team leaders completed their improvement initiatives and demonstrated increased QI knowledge and skills measured by the 'IHI improvement advisor self-assessment tool' and 'IHI assessment scale for collaboratives'.

Built on established education, peer coaching and QI concepts, this evidence-based PQIC protocol adds to international evidence on how to support front-line healthcare workers in their improvement efforts. Future research needs to assess protocol effectiveness across different settings.

While researchers are crucial to the successful delivery of implementation trials, their perspectives are rarely captured in the evaluation of these trials. This qualitative study aimed to capture the experiences of a small research team coordinating a large, multisite implementation trial (the Hide and Seek Project) in the Australian healthcare setting.

A qualitative approach was used, whereby members of the Hide and Seek Project research team were invited to take part in semistructured focus groups led by an external facilitator. The focus group guide was developed to explore the experiences of the research team (including challenges and lessons learnt) as they moved through key study activities. Focus groups were transcribed verbatim and analysed using an inductive thematic approach. Barriers and facilitators identified within themes were deductively coded to domains of the updated Consolidated Framework for Implementation Research.

Participants were recruited from a research organisation based in Sydney, Australia.

A total of seven researcher and administering institution participants took part in four focus groups.

Analysis highlighted the following themes: navigating bureaucracy, distinguishing implementation trials from clinical trials, the impact of COVID-19, balancing rigour and pragmatism in implementation trials, data access and complexity of analysis, and key learnings and future directions (subthemes: building relationships with ethics committees, communicating implementation concepts, streamlining of the implementation and research approach).

Findings highlight the need for streamlining current administrative and ethical review processes, as well as procedures that allow greater flexibility for researchers to respond to challenges as they arise. Lessons learnt by the Hide and Seek Project team hold potential relevance for fellow researchers involved in coordinating implementation trials across diverse contexts.

The Danish clinical quality registries monitor and improve the quality of care, using quality indicators and defined development targets referred to as 'standards'. This study aims to investigate the fulfilment of standards in the Danish clinical quality registries in cancer care and screening.

Data was included from annual reports in the 27 Danish clinical quality registries in cancer care and screening. The most recent report from each registry was downloaded the 13 December 2023. Indicators were included if: evaluating care or screening over 12 months, presenting a well-defined standard with a desired direction and presenting the proportion and number of individuals for which the standard was fulfilled. Data were extracted on national and regional levels for the last 3 years, and fulfilment of standards was presented as the proportion of indicators that fulfilled the standard within each unit of comparison.

In total, 216 quality indicators were included. At the national and regional level, standards were fulfilled for 75% and 71%, respectively. Fulfilment within the registries varied from 5% to 100% on national and 12% to 99% on regional level. Standards were more often fulfilled for result (than process indicators) and for established (than supplemental indicators). Altogether, 43% of the standards were fulfilled across all regions delivering data for the specific indicator.

The approach to defining standards for clinical quality indicators as conservative minimum or ambitious development targets varied in the Danish clinical quality registries in cancer care and screening. This deviating behaviour seriously restrains possibilities for comparing clinical quality across cancers despite the robust infrastructure of the quality registries, limiting the possibilities for overview and prioritising resources and attention to the most urgent cancers.

Background The study aimed to understand the acceptability, satisfaction, uptake, utility and feasibility of a quality improvement (QI) intervention to improve care for coronary heart disease (CHD) patients in Australian primary care practices and identify barriers and enablers, including the impact of COVID-19. Methods Within the QUality improvement for Effectiveness of care for people Living with heart disease (QUEL) study, 26 Australian primary care practices, supported by five Primary Health Networks (PHN) participated in a 1-year QI intervention (November 2019 - November 2020). Data were collected from practices and PHNs staff via surveys and semi-structured interviews. Quantitative and qualitative data were analysed with descriptive statistics and thematic analysis, respectively. Results Feedback was received from 64 participants, including practice team members and PHN staff. Surveys were completed after each of six workshops and at the end of the study. Interviews were conducted with a subgroup of participants (n =9). Participants reported positive satisfaction with individual QI features such as learning workshops and monthly feedback reports. Overall, the intervention was well-received, with most participants expressing interest in participating in similar programs in the future. COVID-19 and lack of time were identified as common barriers, whereas team collaboration and effective leadership enabled practices' participation in the QI program. Additionally, 90% of the practices reported COVID-19 effected their participation due to vaccination rollout, telehealth set-up, and continuous operational review shifting their focus from QI. Conclusion Data-driven QI programs in primary care can boost practice staff confidence and foster increased implementation. Barriers and enablers identified can also support other practices in prioritising effective strategies for future implementation.

The findings of variants of uncertain significance (VUS) on a clinical genetic testing report pose a challenge for attending healthcare professionals (HCPs) in patient care. Here, we describe the outcomes of multidisciplinary VUS Rounds, implemented at a neurological disease tertiary care centre, which aid in interpreting and communicating VUS identified in our neurogenetics patient population.

VUS Rounds brought together genetic counsellors, molecular geneticists and scientists to evaluate VUS against genomic and phenotypic evidence and assign an internal temperature classification of 'VUS Hot', 'True VUS' or 'VUS Cold', corresponding to potential pathogenicity. Biweekly meetings were held among the committee to deliberate variant classifications, determine additional clinical management actions and discuss nuances of VUS result communication.

In total, 143 VUS identified in 72 individuals with neurological disease were curated between October 2022 and December 2023. Of these, 12.6% were classified as VUS Hot, carried by 22.2% of the individuals, allowing for prioritisation of additional evaluation to determine potential pathogenicity of the variants, such as clinical follow-up or segregation analysis. In contrast, 45.4% of VUS were Cold and could be eliminated from further consideration in the carrier's care. We thoroughly evaluated the various evidence that contributed to our VUS classifications and resulting clinical actions.

The assessment of VUS leveraging multidisciplinary collaboration allowed us to delineate required follow-up analyses for our neurology patient population. Integration of VUS Rounds into healthcare practices ensures equitable knowledge dissemination among HCPs and effective incorporation of uncertain genetic results into patient care.

Falls in the inpatient units are the most frequently reported patient safety incidents and their consequences can be devastating. Risk factors for falls are broadly categorised into two factors-'extrinsic and intrinsic' and while the effect of functional mental health conditions on falls has not been extensively studied, older adults with dementia are at a higher risk of falling. Their impact could lead to delayed functional recovery, distress, increased length of hospital stays and an increased fear of falling.Quality improvement (QI) methods have been demonstrated as one strategic approach to reducing falls in mental health older person wards. We completed QI work at Surrey and Borders Partnership NHS Foundation Trust, to reduce fall incidents in Victoria Ward-an older person ward treating people with functional mental health disorders. We generated a theory of change and then tested several change ideas developed by the team. Using this approach, outcomes resulted in a reduction in the rate of falls from 9.5 falls per 1000 bed days to 4.6 falls per 1000 bed days.

Quality improvement work is an essential feature of healthcare services, including general practice. In this study, we aimed to gain more knowledge regarding general practitioners' (GPs) motivation for such work in their practices, as well as what kind of measures were considered motivating and feasible.

We conducted five focus group interviews among Norwegian GPs between November 2021 and November 2022. We included 21 GPs of varying age, gender, experience, and geographic situation. The data were transcribed verbatim and analysed by Systematic Text Condensation, a thematic cross-case analysis.

Many GPs had a diverse and imprecise understanding of the term quality improvement, and sound routines in everyday practice were often given as examples of quality improvement measures. There was a universal attitude that quality improvement initiatives should be close to practice, professionally relevant, and sufficiently small to be manageable. The availability of professional communities, either in the GP practices or in continuous medical education groups, was important for motivation. The role of nurses and health secretaries was highlighted as essential to achieve change. Participants commonly described negative reactions to programs that were imposed by external actors without regard for the GPs' perceived needs.

GPs were motivated for quality improvement measures provided feasibility within the framework of general practice. Well-functioning professional communities, including involvement of nurses and health-secretaries, were emphasised as requisite for quality improvement. Small scale quality improvement programs suited for the needs of general practice were well received and should be further developed.

Reducing bronchopulmonary dysplasia (BPD) utilizing a single intervention has been challenging. The quality improvement (QI) bundle approach may better address BPD multifactorial risk factors.

A single-center interdisciplinary quality improvement (QI) initiative to enhance respiratory care for preterm infants born less than 30 weeks gestation.

To reduce BPD in preterm infants.

Introduce and implement a comprehensive, evidence-based respiratory care bundle within 12 months, targeting areas needing improvement in our practices.

Our preplanned improvement targets were achieved for all process measures. Overall BPD incidence did not change (45% vs. 44.3%). After the QI intervention, inborn infants had a lower BPD rate, though not statistically significant (38.7% vs. 30.3%, p = 0.22), with a significant reduction in grade 1 BPD (24.5% vs. 12.4%, p = 0.032).

Structured interdisciplinary QI work tailored to local settings can improve respiratory care and possibly amend the outcomes of infants at risk for BPD.

Quality improvement partnerships between healthcare organisations and higher education require further research to explore their potential to provide a valuable education experience for pre-registration nursing students.

Develop and validate a questionnaire for nurse academics to evaluate quality improvement content in pre-registration nursing curricula and the extent of partnership with higher education providers in developing this content. Conduct a pilot test of the questionnaire.

Use a content validity approach.

The Australian higher education sector was the setting and participants were nurse academics with knowledge of the quality improvement content taught in pre-registration nursing courses. The quality improvement collaboration (QuIC) questionnaire was informed by the literature and sent to ten quality improvement and higher education experts for content validation. Each question was scored on a Likert scale for relevance and clarity. The QuIC questionnaire was distributed by email to the 37 higher education organisations offering pre-registration programmes in Australia. Descriptive statistics were used to analyse the questionnaire data.

Eight experts completed the content validity questionnaire in full, with the QuIC questionnaire achieving an excellent content validity score of 0.94 for relevance and clarity. The QuIC questionnaire was completed by 24 participants. The results indicated that quality improvement education partnerships are only used occasionally in Australia. The education methods used to teach this content were case studies (online cases n = 11, 46%; patient cases n = 9, 38%) and the development of quality improvement education materials (n = 7, 29%).

The QuIC questionnaire demonstrates excellent relevance and clarity, and is the first in the literature to address the constructs of quality improvement education and partnerships. The pilot results provide insight into quality improvement education methods used in Australia and the presence of partnerships. These results may be used to assist in the implementation of quality improvement education partnerships into curricula across the health professions.

The United Republic of Tanzania has had a 41.4% mortality rate in the intensive care unit. In Tanzania, the Ministry of Health and Social Welfare has implemented quality improvement (QI), yet the Tanzanian health sector continues to face resource constraints, unsustainable projects and gaps in knowledge and skills, contributing to unacceptably high mortality rates for Tanzanian patients. This research aims to determine if a Critical Care Training Program incorporating QI concepts can improve technical competence and self-efficacy of providers in a critical care setting in Tanzania.

A 2-day Critical Care Training Program was developed for providers. It included the following modules: vital signs directed therapy (VSDT), cardiopulmonary and brain resuscitation (CPBR), blood glucose monitoring, introduction to critical care concepts and the QI concept of change management. For analysis, data were collected from pretests and post-tests and reported in REDCap. Descriptive statistics and paired t-tests were performed (alpha=0.05).

A total of 77 nurses and three providers attended the training. The overall score changes among participants for CPBR and VSDT were significant (p<0.001). Six out of 10 questions in CPBR demonstrated significant improved change (p<0.001). All questions in the VSDT training showed significant improvement (p<0.001). Based on hospital guidelines, 63 (95.5%) passed the CPBR evaluation and 62 (95.2%) passed VSDT.

A pre/post analysis demonstrated improvement in knowledge, skills and increased confidence towards emergencies. This study suggests a Critical Care Training Program significantly improves the knowledge among providers and that QI impacts culture of change. This research exemplifies a systematic approach to strengthening capacity of critical care delivery in limited resource settings, with implications for further innovation in other low- and middle-income countries.

Ukraine has high HIV prevalence, concentrated among people who inject drugs (PWID), mostly of opioids. Maintenance on opioid agonist therapies (OAT) is the most effective evidence-based treatment for opioid use disorder. As PWID experience high morbidity and mortality from preventable and treatable non-communicable diseases, international agencies recommend integrating OAT into primary care centers (PCC).

A randomized, type-2 hybrid implementation trial was carried out to compare outcomes of OAT integration in PCC to OAT delivery at specialty treatment centers (STC) - standard-of-care. Tele-education supporting PCC providers in managing OAT, HIV, tuberculosis and non-communicable diseases along with pay-for-performance incentives were used to facilitate implementation. Consenting patients underwent 1:2 randomization to either STC or PCC. Quality health indicators (QHIs), a composite percentage of recommended primary and specialty services accessed by patients (blood/urine tests, cancer screenings, etc.), were defined as efficacy outcomes and were assessed by participant self-report at baseline and every 6 months over 24 months and electronic chart reviews after the completion of the follow-up. The primary outcome is defined as the difference in composite QHI scores at 24 months, in which a repeated measures likelihood-based mixed model with missing at random assumptions will be used. Providers at PCC completed surveys at baseline, 12 and 24 months to assess implementation outcomes including changes in stigma and attitudes towards OAT and PWID.

Among the 1459 participants allocated to STC (N = 509) or PCC (N = 950), there were no differences in clinical and demographic characteristics. Self-reported prevalences were available for HIV (42 %), HCV (57 %), and prior tuberculosis (17 %). Study retention at 6, 12, 18, and 24 months was as 91 %, 85 %, 80 %, and 74 %, respectively.

PWID have a high prevalence of medical comorbidities and integrating OAT into primary care settings has the potential to improve the health of PWID. Findings from this study can help guide implementation of integrated care in Ukraine and throughout similar low-resource, high-burden countries in the Eastern European and Central Asian region.

Numerous studies have demonstrated that hypothermia in preterm infants correlates with increased morbidity and mortality, especially among those with very low or extremely low birth weights (VLBW/ELBW). An increasing number of healthcare facilities are implementing quality improvement (QI) bundles to lower the incidence of hypothermia at birth in this vulnerable population. However, the effectiveness and safety of these interventions have yet to be fully assessed. A meta-analysis is necessary to evaluate the efficacy and safety of QI bundles in reducing hypothermia at birth among VLBW/ELBW infants.

We searched PubMed, Embase, the Cochrane Library and Web of Science through April 22nd, 2024. Study selection, data extraction, quality evaluation and risk bias assessment were performed independently by two investigators. Meta-analysis was performed using Review Manager 5.4.1.

A total of 18 studies were included for qualitative analysis and 12 for meta-analysis. For VLBW infants, meta-analysis revealed a reduction in hypothermia and an increase in hyperthermia following the introduction of QI bundles (mild hypothermia, OR 0.22, 95% CI [0.13-0.37]; moderate hypothermia, OR 0.18, 95% CI [0.15-0.22]; hyperthermia, OR 2.79, 95% CI [1.53-5.09]). For ELBW infants, meta-analysis showed a decrease in hypothermia but no increase in hyperthermia after implementing QI bundles (mild hypothermia, OR 0.46, 95% CI [0.26-0.81]; moderate hypothermia, OR 0.21, 95% CI [0.08-0.58]; hyperthermia, OR 1.10, 95% CI [0.22-5.43]).

QI bundles effectively reduce hypothermia in VLBW/ELBW infants, but they may also increase hyperthermia, especially in VLBW infants.

Measurable improvements in the American Healthcare System have been elusive. To understand why, a survey measuring improvement capabilities in a health system was developed from a 2002 tool that measured an outdated quality improvement methodology. That survey was tested for content validity and achieved an overall representativeness content validity index of 87.5%. From the responses and discussions with the subject matter experts, 3 reasons emerged as to why a lack of improvement occurs in key metrics on a balanced scorecard. These 3 were the decentralization of improvement efforts, waning leadership attention, and presenting information rather than insights.

Nurse education plays an essential role in preparing future nurses to engage with quality improvement (QI) initiatives in their organisations and improve patient care. However, frontline nurses continue to report that a lack of QI knowledge hinders their abilities to engage in improvement work. In the UK, student nurses are now trained in QI within their degree to enable them to contribute to improvements once qualified.

This qualitative follow-up study investigated the sustainability of QI engagement in nurses who undertook QI training and a QI project during their degree and explored the factors influencing their engagement in QI once qualified.

This paper followed the COREQ criteria to report upon 10 semi-structured interviews undertaken with registered nurses and focuses on their experiences of QI engagement post-registration. The data were investigated using an inductive thematic analysis and Nvivo 14.

Five themes emerged: transition to a newly qualified nurse, QI knowledge decline, influencing factors (hierarchy, leadership, COVID-19 pandemic, data access and location), and skill transferability.

This study showed that qualified nurses can sustain their QI knowledge and remain engaged with QI where they experience positive QI leadership and were exposed to ongoing QI activity in their preceptorship year. However, a lack of QI opportunities and a culture which does not consider QI a responsibility of new nurses is seen to hinder engagement. Educational institutions and practice partners require careful collaboration to assess and develop ongoing QI learning activities that support new nurses to engage in QI.

Quality improvement (QI) is critical in facilitating advancements in patient outcomes, system efficiency and professional growth. This paper aimed to elucidate the underlying rationale and framework guiding JurongHealth Campus (JHC), a nascent Regional Health System, in developing its QI capacity and capability at all levels of the organisation.

An exhaustive analysis of high-performance management systems and effective improvement frameworks was conducted, and the principles were customised to suit the local context.A three-phased approach was applied: (1) developing the JHC QI framework; (2) building capacity through a dosing approach and (3) building capability through QI projects and initiatives using the model for improvement (MFI). Three components of the RE-AIM implementation strategy were assessed: (1) Reach-overall percentage of staff trained; (2) Effectiveness-outcomes from organisation-wide improvement projects and (3) Adoption-number of QI projects collated and presented.

The percentage of staff trained in QI increased from 11.3% to 22.0% between January 2020 and March 2024, with over 350 projects documented in the central repository. The effectiveness of the MFI was demonstrated by improving inpatient discharges before 12pm performance from 21.52% to 25.84% and reducing the 30-day inpatient readmission rate from 13.92% to 12.96%.

Four critical factors for an effective QI framework were identified: (1) establishing a common language for improvement; (2) defining distinct roles and skills for improvement at different levels of the organisation; (3) adopting a dosing approach to QI training according to the defined roles and skills and (4) building a critical mass of committed staff trained in QI practice. The pragmatic approach to developing QI capability is both scalable and applicable to emerging healthcare institutions.

For over 30 years, quality improvement (QI) methods have been used as a means of increasing the quality and safety of healthcare services, but with mixed success. One explanation highlighted in the literature for this outcome is the overemphasis on technical elements of change, and a failure to fully appreciate the human side of change. Behavioral insights (BI) is an approach that utilizes knowledge and tools from a broad range of scientific disciplines, such as neuroscience and behavioral psychology, to support behavior change. The aim of this paper is to explore the possibility of supplementing QI methods with tools and understanding from BI.

We outline a practical case that involved applying aspects BI methods into a QI program aimed at reducing the use of intravenous antibiotics in patients accessing services at a busy university hospital in Copenhagen, Denmark. We exemplify how to use BI tools to guide the analysis of staff behaviors during standard clinical processes and develop targeted interventions aimed at increasing actions and behaviors more aligned to best clinical practice.

Outcomes suggest that it is possible to combine the models and methods from BI and QI in a way that is helpful in focusing attention on the human side of change when developing strategies for change. Potential psychological barriers identified from the analysis included the following: 'default inertia,' 'decision complexity,' 'risk aversion,' and biases related to confidence, confirmation, and omission.

Future quality improvement projects could benefit from integrating models and tools from BI to guide and support behavior change.

Given the rise in demand for online, graduate degree programs there is a need to guide program planning and evaluation professionals within institutions of higher education to utilize continuous quality improvement (CQI) strategies. Using principles of design thinking and CQI, the purpose of this case study was to describe a CQI project that sought to develop a better understanding of adult students' experience progressing through their plan of study in an online doctoral program. As part of the CQI project, value stream mapping (VSM) was used to gain visibility and perspective on the actions required by faculty and staff to guide students through their plan of study. The VSM process provided information that led to conversations that furthered the CQI efforts and led to changes in the adult education program that would benefit all students. Improvement processes that lead to better quality and more positive experiences for users are valuable. This case study demonstrates the processes, challenges, lessons, and future directions in the use of VSM to better understand online graduate programs designed for adult learners.

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

The nursing profession is undergoing rapid transformation, requiring innovation in management approaches and proactive behaviors among staff. Nurse Managers play a vital role through managerial innovation, but its impacts on intensive care nurses' proactivity and locus of control remain underexplored.

This study aimed to assess the levels of Nurse Managers' managerial innovation and relate it to proactivity behaviors and locus of control orientations among intensive care nurses.

A cross-sectional correlational design was adopted, recruiting 242 intensive care nurses from Tanta University Hospital, Egypt. Participants completed standardized questionnaires measuring perceived managerial innovation, proactivity behavior, and locus of control.

Nurse Managers demonstrated moderately high innovation across all dimensions, especially in continuous learning and development (mean = 4.65) and advanced technology use (mean = 4.56). Nurses exhibited sound proactivity levels, particularly in adaptability (mean = 4.40) and planning (mean = 4.35). The majority of nurses showed an internal locus of control (64.5%). Managerial innovation had significant positive correlations with nurses' proactivity (r = 0.45, p < 0.001) and internal locus of control (r = 0.42, p < 0.001). Regression analysis revealed age, gender, experience, education, and ICU type as significant predictors of proactivity and locus of control.

Innovative nursing leadership positively influences staff's proactivity levels and perceived control over their practice. This underscores the vital role of nurse managers in creating empowering environments in intensive care.

The Healthcare Improvement and Innovation in Quality (THINQ) Collaborative is a uniquely designed program that engages undergraduate and postgraduate students to participate in improving health care and addressing important clinical problems. In 9 years, over 120 THINQ Fellows have been trained in quality improvement (QI) frameworks and methodologies focusing on research skills, social justice, leadership development, and problem-solving. Program evaluation has included surveying current and former THINQ Fellows about their experiences with the program and its subsequent impact on their careers. THINQ's research and outreach initiatives have contributed to improvements in workflows and clinical care on topics such as interdisciplinary team communication, discharge and care transition, sepsis management, and physician burnout. The THINQ Program has equipped future health care leaders to engage with and address QI issues in clinical practice. The structures, processes, and outcomes discussed here can guide other institutions in creating similar QI programs.

There is increased awareness about the need for quality improvement (QI) education for trainees within clinical training programs. However, formal integration of a QI curriculum into graduate medical education (GME) remains a work-in-progress. We describe the creation and implementation of a novel, virtual QI curriculum complemented by virtual-based workshops.

To determine the impact of a GME QI curriculum on 1) trainee QI knowledge; 2) Quality of QI projects.

The GME Quality Improvement curriculum was transitioned to an optional formal curriculum in 2020. It is led by three faculty with expertise in QI training and education. The team developed four, web-based learning modules that focused on fundamental QI concepts. These modules are completed monthly and are paired with virtual workshops that facilitate applying learned QI concepts to project development. We evaluated the effectiveness of the curriculum by assessing participants' performance on knowledge-based quizzes before and after each online module. We used IBM SPSS (version 28), to conduct a two-sided paired samples t-test, comparing each post-session test scores with their corresponding pre-session scores. The alpha, or statistical threshold significance threshold, was 0.05. Additionally, two independent judges with expertise in QI evaluated the quality of the projects presented at the annual QI showcase using a standardized scoring rubric. The poster evaluation forms included 8 questions, rated on a scale from 1 to 5. Projects were graded into 4 quartiles (poor, fair, good, excellent).

In the knowledge assessment quiz, the difference between the mean pre- and post-session quiz scores was statistically significant (p < 0.01). The average score of the quality of the projects presented at the annual showcase was 31, in the fourth quartile which was graded as "excellent" quality.

A GME-led QI curriculum was effective in improving knowledge of QI concepts and producing high-quality scholarly projects.

Nurses play an essential role in the achievement of quality depicted by the Quintuple Aim to improve clinical outcomes, patient experience, equity, provider well-being, and reduction of costs. When quality gaps occur, practice change is required and is facilitated by quality improvement (QI) and implementation science (IS) methods. QI and IS research are required to advance our understanding of the mechanisms that explain how evidence is implemented and improvements are made.

Despite past efforts of the evidence-based practice and QI movements, challenges persist in sustaining practice improvements and translating research findings to direct patient care.

The purpose of this article is to describe the Synergy for Change Model that proposes that both QI and IS research and practice be used to accelerate improvements in health care quality.

Recognizing the synergy of QI and IS practice and research will accelerate nursing's contributions to high-quality and safe care.

Although there is growing global momentum behind food systems strategies to improve planetary and human health-including nutrition-there is limited evidence of what types of food systems interventions work. Evaluating these types of interventions is challenging due to their complex and dynamic nature and lack of fit with standard evaluation methods. In this article, we draw on a portfolio of 6 evaluations of food systems interventions in Africa and South Asia that were intended to improve nutrition. We identify key methodological challenges and formulate recommendations to improve the quality of such studies. We highlight 5 challenges: a lack of evidence base to justify the intervention, the dynamic and multifaceted nature of the interventions, addressing attribution, collecting or accessing accurate and timely data, and defining and measuring appropriate outcomes. In addition to more specific guidance, we identify 6 cross-cutting recommendations, including a need to use multiple and diverse methods and flexible designs. We also note that these evaluation challenges present opportunities to develop new methods and highlight several specific needs in this space.

Transparency about the occurrence of adverse events has been a decades-long governmental priority, defining external feedback to healthcare providers as a key measure to improve the services and reduce the number of adverse events. This study aimed to explore surgeons' experiences of assessment by external bodies, with a focus on its impact on transparency, reporting and learning from serious adverse events. External bodies were defined as external inspection, police internal investigation, systems of patient injury compensation and media.

Based on a qualitative study design, 15 surgeons were recruited from four Norwegian university hospitals and examined with individual semi-structured interviews. Data were analysed by deductive content analysis.

Four overarching themes were identified, related to influence of external inspection, police investigation, patient injury compensation and media publicity, (re)presented by three categories: (1) sense of criminalisation and reinforcement of guilt, being treated as suspects, (2) lack of knowledge and competence among external bodies causing and reinforcing a sense of clashing cultures between the 'medical and the outside world' with minor influence on quality improvement and (3) involving external bodies could stimulate awareness about internal issues of quality and safety, depending on relevant competence, knowledge and communication skills.

This study found that external assessment might generate criminalisation and scapegoating, reinforcing the sense of having medical perspectives on one hand and external regulatory perspectives on the other, which might hinder efforts to improve quality and safety. External bodies could, however, inspire useful adjustment of internal routines and procedures. The study implies that the variety and interconnections between external bodies may expose the surgeons to challenging pressure. Further studies are required to investigate these challenges to quality and safety in surgery.

Triaging of obstetric patients by emergency care providers is paramount. It helps provide appropriate and timely management to prevent further injury and complications. Standardised trauma acuity scales have limited applicability in obstetric triage. Specific obstetric triage index tools improve maternal and neonatal outcomes but remain underused. The aim was to introduce a validity-tested obstetric triage tool to improve the percentage of correctly triaged patients (correctly colour-coded in accordance with triage index tool and attended to within the stipulated time interval mandated by the tool) from the baseline of 49% to more than 90% through a quality improvement (QI) process.A team of nurses, obstetricians and postgraduates did a root cause analysis to identify the possible reasons for incorrect triaging of obstetric patients using process flow mapping and fish bone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act (PDSA) cycles to address issues identified.The interventions included introduction and application of an obstetric triage index tool, training of triage nurses and residents. We implemented these interventions in eight PDSA cycles and observed outcomes by using run charts. A set of process, output and outcome indicators were used to track if changes made were leading to improvement.Proportion of correctly triaged women increased from the baseline of 49% to more than 95% over a period of 8 months from February to September 2020, and the results have been sustained in the last PDSA cycle, and the triage system is still sustained with similar results. The median triage waiting time reduced from the baseline of 40 min to less than 10 min. There was reduction in complications attributable to improper triaging such as preterm delivery, prolonged intensive care unit stay and overall morbidity. It can be thus concluded that a QI approach improved obstetric triaging in a rural maternity hospital in India.

Quality in laboratory medicine encompasses multiple components related to total quality management, including quality control (QC), quality assurance (QA), quality indicators, and quality improvement (QI). Together, they contribute to minimizing errors (pre-analytical, analytical, or post-analytical) in clinical service delivery and improving process appropriateness and efficiency. In contrast to static quality benchmarks (QC, QA, quality indicators), the QI paradigm is a continuous approach to systemic process improvement for optimizing patient safety, timeliness, effectiveness, and efficiency. Healthcare institutions have placed emphasis on applying the QI framework to identify and improve healthcare delivery. Despite QI's increasing importance, there is a lack of guidance on preparing, executing, and sustaining QI initiatives in the field of laboratory medicine. This has presented a significant barrier for clinical laboratorians to participate in and lead QI initiatives. This three-part primer series will bridge this knowledge gap by providing a guide for clinical laboratories to implement a QI project that issuccessful and sustainable. In the first article, we introduce the steps needed to prepare a QI project with focus on relevant methodology and tools related to problem identification, stakeholder engagement, root cause analysis (e.g., fishbone diagrams, Pareto charts and process mapping), and SMART aim establishment. Throughout, we describe a clinical vignette of a real QI project completed at our institution focused on serum protein electrophoresis (SPEP) utilization. This primer series is the first of its kind in laboratory medicine and will serve as a useful resource for future engagement of clinical laboratory leaders in QI initiatives.

New digital technology presents new challenges to health care on multiple levels. There are calls for further research that considers the complex factors related to digital innovations in complex health care settings to bridge the gap when moving from linear, logistic research to embracing and testing the concept of complexity. The nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework was developed to help study complexity in digital innovations.

This study aims to investigate the role of complexity in the development and deployment of innovations by retrospectively assessing challenges to 4 digital health care innovations initiated from the bottom up.

A multicase retrospective, deductive, and explorative analysis using the NASSS complexity assessment tool LONG was conducted. In total, 4 bottom-up innovations developed in Region Västra Götaland in Sweden were explored and compared to identify unique and shared complexity-related challenges.

The analysis resulted in joint insights and individual learning. Overall, the complexity was mostly found outside the actual innovation; more specifically, it related to the organization's readiness to integrate new innovations, how to manage and maintain innovations, and how to finance them. The NASSS framework sheds light on various perspectives that can either facilitate or hinder the adoption, scale-up, and spread of technological innovations. In the domain of condition or diagnosis, a well-informed understanding of the complexity related to the condition or illness (diabetes, cancer, bipolar disorders, and schizophrenia disorders) is of great importance for the innovation. The value proposition needs to be clearly described early to enable an understanding of costs and outcomes. The questions in the NASSS complexity assessment tool LONG were sometimes difficult to comprehend, not only from a language perspective but also due to a lack of understanding of the surrounding organization's system and its setting.

Even when bottom-up innovations arise within the same support organization, the complexity can vary based on the developmental phase and the unique characteristics of each project. Identifying, defining, and understanding complexity may not solve the issues but substantially improves the prospects for successful deployment. Successful innovation within complex organizations necessitates an adaptive leadership and structures to surmount cultural resistance and organizational impediments. A rigid, linear, and stepwise approach risks disregarding interconnected variables and dependencies, leading to suboptimal outcomes. Success lies in embracing the complexity with its uncertainty, nurturing creativity, and adopting a nonlinear methodology that accommodates the iterative nature of innovation processes within complex organizations.

Quality improvement (QI) interventions are designed to resolve the recurring challenges of care for older individuals, such as working conditions for staff, roles of older individuals in their own care and their families, and relevant stakeholders. Therefore, there is a need to map the impacts of QI interventions in older adult care settings and further improve health and social care systems associated with older adults.

This review aims to compile and synthesize the best available evidence regarding the effectiveness of policy and practice QI interventions in older adult care. The secondary aim is to understand the care of older individuals and QI intervention-related experiences and perspectives of stakeholders, care providers, older individuals, and their families.

The mixed methods review will follow the standard methodology used by Joanna Briggs Institute. The published studies will be searched through CINAHL, MEDLINE, PsycINFO, ASSIA, and Web of Science, and the unpublished studies through Mednar, Trove, OCLC WorldCat, and Dissertations and Theses. This review included both qualitative and quantitative analyses of patients undergoing older adult care and any health and care professionals involved in the care delivery for older adults; a broad range of QI interventions, including assistive technologies, effects of training and education, improved reporting, safety programs, and medical devices; the experiences and perspectives of staff and patients; the context of older adult care setting; and a broad range of outcomes, including patient safety. The standard procedure for reporting, that is, PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, will be followed.

A result-based convergent synthesis design will be used in which both quantitative and qualitative studies will be analyzed separately, and the results of both syntheses will be then integrated during a final (convergent) synthesis. The integration will compare the findings of quantitative and qualitative evidence using tables in light of the results of both syntheses.

This comprehensive review is expected to reflect on the insights into some QI interventions and their impact, outline some common challenges of quality for older adult care, and benefit both the practical usefulness of care service activities and the society at large.

PRR1-10.2196/56346.

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

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

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

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

NCT05057260, ISRCTN15022307.

Systems-based practice (SBP) was first introduced as a core competency in graduate medical education (GME) in 2002 by the Accreditation Council for Graduate Medical Education as part of the Outcomes Project. While inclusion of SBP content in GME has become increasingly common, there have also been well-documented stumbling blocks, including perceptions that SBP has eroded the amount of curricular time available for more medically focused competencies, is not relevant for some practice contexts, and is not introduced early enough in training. As a result, SBP learning experiences often feel disconnected from medical trainees' practical reality. In this commentary, the authors provide guidance regarding potential changes that may facilitate the evolution of SBP toward an ideal future state where graduates bring a systems science mindset to all aspects of their work. Specific suggestions include the following: (1) expanding the SBP toolbox to reflect current-day health system needs, (2) evolve the teaching methodology, (3) broadening the scope of relevant SBP content areas, and (4) emphasizing SBP as an integrated responsibility for all health care team members. Levers to enact this transformation exist and must be used to influence change at the learner, faculty, program, and clinical learning environment levels.Physicians operate within an increasingly complex health care system that highlights the intersection of health care with complex social, environmental, and relational contexts. Consequently, the role of SBP in both physician work responsibilities and educational requirements continues to expand. To meet this growing demand, GME must adapt how it supports and trains the next generation of systems thinkers, ensuring they understand how levers in the health care system directly affect health outcomes for their patients, and integrate SBP into the foundation of GME curricula in an inclusive, holistic, and unrestrained way.

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.

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

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.

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.

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.

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.

Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs.

We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author.

We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change.

Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.

Rehabilitation intervention descriptions often do not explicitly identify active ingredients or how those ingredients lead to changes in patient functioning. The Rehabilitation Treatment Specification System (RTSS) provides guidance to identify the critical aspects of any rehabilitation therapy and supported the development of standardly named ingredients and targets in voice therapy (Rehabilitation Treatment Specification System for Voice Therapy [RTSS-Voice]). This study sought to test the content validity of the RTSS-Voice and determine if the RTSS-Voice can be used to identify commonalities and differences in treatment (criterion validity) across clinicians in everyday clinical practice.

Five speech-language pathologists from different institutions videotaped one therapy session for 59 patients diagnosed with a voice or upper airway disorder. Specifications were created for each video, and iterative rounds of revisions were completed with the treating clinician and two RTSS experts until consensus was reached on each specification.

All 59 sessions were specified without the addition of any targets or ingredients. There were two frequent targets: (a) increased volition and (b) decreased strained voice quality. There were three frequent ingredients: (a) information regarding the patient's capability and motivation to perform a therapeutic behavior, (b) knowledge of results feedback, and (c) opportunities to practice voicing with improved resonance and mean airflow. Across sessions treating vocal hyperfunction, there was large variability across clinicians regarding the types and number of treatment components introduced, types of feedback provided, and vocal practice within spontaneous speech and negative practice.

The RTSS and the RTSS-Voice demonstrated strong content validity, as they comprehensively characterized 59 therapy sessions. They also demonstrated strong criterion validity, as commonalities and differences were identified in everyday voice therapy for vocal hyperfunction across multiple clinicians. Future work to translate RTSS principles and RTSS-Voice terms into clinical documentation can help to understand how clinician and patient variability impacts outcomes and bridge the research-practice gap.

https://doi.org/10.23641/asha.24796875.

The objective was to gain knowledge about how external inspections following serious incidents are played out in a Norwegian hospital context from the perspective of the inspectors, and whether stakeholders' views are involved in the inspection.

Based on a qualitative mixed methods design, 10 government bureaucrats and inspectors situated at the National Board of Health Supervision and three County Governors in Norway, were strategically recruited, and individual semi-structured interviews were conducted. Key official government documents were selected, collected, and thematically analyzed along with the interview data.

Our findings overall demonstrate two overarching themes: Theme (1) Perspectives on different external inspection approaches of responding and involving stakeholders in external inspection following serious incidents, Theme (2) Inspectors' internal work practices versus external expectations. Documents and all participants reported a development towards new approaches in external inspection, with more policies and regulatory attention to sensible involvement of stakeholders. Involvement and interaction with patients and informal caregivers could potentially inform the case complexity and the inspector's decision-making process. However, stakeholder involvement was sometimes complex and challenging due to e.g., difficult communication and interaction with patients and/or informal caregivers, due to resource demands and/or the inspector's lack of experience and/or relevant competence, different perceptions of the principle of sound professional practice, quality, and safety. The inspectors considered balancing the formal objectives and expectations, with the expectations of the public and different stakeholders (i.e. hospitals, patients and/or informal caregivers) a challenging part of their job. This balance was seen as an important part of the continuous development of ensuring public trust and legitimacy in external inspection processes.

Our study suggests that the regulatory system of external inspection and its available approaches of responding to a serious incident in the Norwegian setting is currently not designed to accommodate the complexity of needs from stakeholders at the levels of hospital organizations, patients, and informal caregivers altogether. Further studies should direct attention to how the wider system of accountability structures may support the internal work practices in the regulatory system, to better algin its formal objectives with expectations of the public.