The three faces of performance measurement: improvement, accountability, and research

Interprofessional implementation of the Global Malnutrition Composite Score quality measure

Malnutrition in hospitalized patients can impact health outcomes, quality of life, and health equity. Quality improvement initiatives and quality measurement can help improve the care of those hospitalized patients with malnutrition. The new Global Malnutrition Composite Score (GMCS) was recently adopted by the Centers for Medicare & Medicaid Services (CMS) as a health equity-focused measure. Beginning in 2024, the GMCS is available for reporting through the CMS Hospital Inpatient Quality Reporting Program. The GMCS provides an opportunity to elevate the importance of patient nutrition status and evidence-based interventions throughout the interdisciplinary hospital decision-making process. To promote this opportunity, the American Society for Parenteral and Enteral Nutrition (ASPEN) held an "Interprofessional implementation of the Global Malnutrition Composite Score" webinar as part of its 2022 Malnutrition Awareness Week programming. This article summarizes the underlying rationale and significance of the GMCS measure and showcases clinical observations about integrating quality improvement and measurement into the acute care setting, as presented during the webinar.

Hospital profiling using Bayesian decision theory

For evaluating the quality of care provided by hospitals, special interest lies in the identification of performance outliers. The classification of healthcare providers as outliers or non-outliers is a decision under uncertainty, because the true quality is unknown and can only be inferred from an observed result of a quality indicator. We propose to embed the classification of healthcare providers into a Bayesian decision theoretical framework that enables the derivation of optimal decision rules with respect to the expected decision consequences. We propose paradigmatic utility functions for two typical purposes of hospital profiling: the external reporting of healthcare quality and the initiation of change in care delivery. We make use of funnel plots to illustrate and compare the resulting optimal decision rules and argue that sensitivity and specificity of the resulting decision rules should be analyzed. We then apply the proposed methodology to the area of hip replacement surgeries by analyzing data from 1,277 hospitals in Germany which performed over 180,000 such procedures in 2017. Our setting illustrates that the classification of outliers can be highly dependent upon the underlying utilities. We conclude that analyzing the classification of hospitals as a decision theoretic problem helps to derive transparent and justifiable decision rules. The methodology for classifying quality indicator results is implemented in an R package (iqtigbdt) and is available on GitHub.

Reporting unit context data to stakeholders in long-term care: a practical approach

Background

The importance of reporting research evidence to stakeholders in ways that balance complexity and usability is well-documented. However, guidance for how to accomplish this is less clear. We describe a method of developing and visualising dimension-specific scores for organisational context (context rank method). We explore perspectives of leaders in long-term care nursing homes (NHs) on two methods for reporting organisational context data: context rank method and our traditionally presented binary method—more/less favourable context.

Methods

We used a multimethod design. First, we used survey data from 4065 healthcare aides on 290 care units from 91 NHs to calculate quartiles for each of the 10 Alberta Context Tool (ACT) dimension scores, aggregated at the care unit level based on the overall sample distribution of these scores. This ordinal variable was then summed across ACT scores. Context rank scores were assessed for associations with outcomes for NH staff and for quality of care (healthcare aides’ instrumental and conceptual research use, job satisfaction, rushed care, care left undone) using regression analyses. Second, we used a qualitative descriptive approach to elicit NH leaders’ perspectives on whether the methods were understandable, meaningful, relevant, and useful. With 16 leaders, we conducted focus groups between December 2017 and June 2018: one in Nova Scotia, one in Prince Edward Island, and one in Ontario, Canada. Data were analysed using content analysis.

Results

Composite scores generated using the context rank method had positive associations with healthcare aides’ instrumental research use (p < .0067) and conceptual research use and job satisfaction (p < .0001). Associations were negative between context rank summary scores and rushed care and care left undone (p < .0001). Overall, leaders indicated that data presented by both methods had value. They liked the binary method as a starting point but appreciated the greater level of detail in the context rank method.

Conclusions

We recommend careful selection of either the binary or context rank method based on purpose and audience. If a simple, high-level overview is the goal, the binary method has value. If improvement is the goal, the context rank method will give leaders more actionable details.

Toward Population Health: Using a Learning Behavioral Health System and Measurement-Based Care to Improve Access, Care, Outcomes, and Disparities

Achieving population behavioral health is urgently needed. The mental health system struggles with enormous challenges of providing access to mental health services, improving quality and equitability of care, and ensuring good health outcomes across subpopulations. Little data exists about increasing access within highly constrained resources, staging/sequencing treatment along care pathways, or personalizing treatments. The conceptual model of the learning healthcare system offers a potential paradigm shift for addressing these challenges. In this article we present an overview of how the three constructs of population health, learning health systems, and measurement-based care are inter-related, and we provide an example of how one academic, community-based, safety net health system is approaching integrating these paradigms into its service delivery system. Implementation outcomes will be described in a subsequent publication. We close by discussing how ultimately, to meaningfully improve population behavioral health, a learning healthcare system could expand into a learning health community in order to target critical points of prevention and intervention.

Pragmatic Language Development: Analysis of Mapping Knowledge Domains on How Infants and Children Become Pragmatically Competent

New-borns are capable of recognising and producing sounds as they become phonologically competent. Following this, infants develop a system for connecting these sounds, which helps them become increasingly lexically competent over time. Their knowledge of these words grows as they develop, using words to form phrases, turning them into sentences, and ultimately becoming syntactically competent. By making sense of these linguistic elements, these three competencies are enhanced, and this is how infants become semantically competent. As infants continue to develop linguistic and non-linguistic communication behaviours, this miraculous language development becomes even more complex, enabling them to perfect their linguistic abilities while being pragmatically competent. In this study, a scientometric approach was used to examine past, present, and future trends in pragmatic language development (PLD). A total of 6455 documents were analysed from the Scopus, WOS, and Lens databases between 1950 and 2022. The analysis involved the visualisation and tabulation of eight bibliometric and eight scientometric indicators using CiteSpace 5.8.R3 and VOSviewer 1.6.18 software for data analysis. In this study, we highlight the major patterns and topics directing the research on PLD between 1950 and 2022. The themes and topics included (1) analysing PLD as a social behaviour through the lens of executive functions; (2) studying PLD as a social behaviour based on social understanding; (3) examining PLD as a social behaviour associated with autism spectrum disorder; (4) developing an understanding of PLD in academic settings through the examination of executive functions; (5) identifying pragmatic competence versus communicative competence as a social behaviour; (6) analysing pragmatic language skills in aphasic patients via epistemic stances (i.e., attitudes towards knowledge in interaction); (7) investigating PLD as a behavioural problem in the context of a foreign language; (8) assessing PLD as a behavioural problem in individuals with autism spectrum disorder; (9) assessing PLD in persons with traumatic brain injury and closed head injury as a behavioural problem; (10) identifying the role of the right hemisphere in executive functions as a cognitive substrate; (11) assessing the impact of pragmatic failure in speech acts on pragmatic competence; and (12) investigating the patterns of PLD among learning-disabled children.

From “Invented here” to “Use it everywhere!”: A Learning health system from bottom and/or top?

Introduction

Departing from a practical problem of how to use digitalization to improve care quality and efficiency, this paper investigates how the concept of Learning Health Systems (LHSs) can be applied to an existing organization. LHSs offer a vision for how healthcare can accelerate both scale‐up of innovations and quality improvements at all levels. However, aligning stakeholders at different levels to convergent development is challenging and translation and adaptation of the LHS concept to fit with the existing organization is essential.

Methods

A one‐year longitudinal action research (AR) study was conducted within five psychiatric departments at the Sahlgrenska University Hospital in Gothenburg, Sweden. Translation of the LHS concept to the local circumstances within the organization was set as the aim, to both improve practice and further scientific understanding. An AR group led the practical and scholarly work and holistic data were collected, including field notes, documents, recordings, and workshops. Data were analyzed by an insider‐outsider approach.

Results

The one‐year study is described to provide insights into the process of designing a locally adapted LHS using an AR approach. Practical needs were identified and iteratively matched with theory to form a local LHS model. A conflict between top‐down and bottom‐up views on development emerged, where higher‐level management tended to prioritize uniform solutions and developers local learning. An adapted solution to balance these approaches was negotiated, consisting of a technical and an organizational part.

Conclusions

The conflict between top‐down and bottom‐up approaches for how to implement LHSs needs to be considered both in practical work to transform care organizations and in scientific studies of LHSs. The approach to translate, rather than instrumentally implement, LHSs to real‐world settings is suggested as advantageous. Furthermore, designing such endeavors as AR projects can provide excellent conditions to create LHSs that work in practice.

Why Resilience in Health Care Systems is More than Coping with Disasters: Implications for Health Care Policy

Health care systems need to be resilient to deal with disasters like the global spread of the Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2) on top of serving the changing needs of a multi-morbid, ageing and often dispersed population. This paper identifies, discusses and augments critical dimensions of resilience retrieved from the academic literature. It pulls together an integrated concept of resilience characterised by organisational capabilities. Our concept does not focus on the micro-level like most resilience literature in health care but addresses the system level with many stakeholders involved. Distinguishing exogenous shocks to the health care system into adverse events and planned innovations provides the basis for our conclusions and insights. It becomes apparent only when dealing with planned interventions that transformative capabilities are indispensable to cope with sudden increases in health care pressures. Due to the current focus on absorptive and adaptive resilience, organisations over-rely on management capabilities that cannot generate a lasting increase in functionality. Therefore, reducing the resilience discussion to bouncing back from adverse events could deceive organisations into cultivating a suboptimal mix of organisational capabilities lacking transformative capabilities, which pave the way for a structural change that aims at a sustainably higher functionality.

Measuring and publishing quality improvement

Misalignment of measures, measurement and analysis with the goals and methods of quality improvement efforts in healthcare may create confusion and decrease effectiveness. In healthcare, measurement is used for accountability, research, and quality improvement, so distinguishing between these is an important first step. Using a case vignette, this paper focuses on using measurement for improvement to gain insight into the dynamic nature of healthcare systems and to assess the impact of interventions. This involves an understanding of the variation in the data over time. Statistical process control (SPC) charting is an effective and powerful analysis tool for this. SPC provides ongoing assessment of system functioning and enables an improvement team to assess the impact of its own interventions and external forces on the system. Once improvement work is completed, the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines is a valuable tool to describe the rationale, context, and study of the interventions. SQUIRE can be used to plan improvement work as well as structure a manuscript for publication in peer-reviewed journals.

An Environmental Scan of Canadian Quality Metrics for Patients on In-Center Hemodialysis

Background:

Quality metrics or indicators help guide quality improvement work by reporting on measurable aspects of health care upon which improvement efforts can focus. For recipients of in-center hemodialysis (ICHD) in Canada, it is unclear what ICHD quality indicators exist and whether they adequately cover different domains of health care quality.

Objectives:

To identify and evaluate current Canadian ICHD quality metrics to document a starting point for future collaborations and standardization of quality improvement in Canada.

Design:

Environmental scan of quality metrics in ICHD, and subsequent indicator evaluation using a modified Delphi approach.

Setting:

Canadian ICHD units.

Participants:

Sixteen-member pan-Canadian working group with expertise in ICHD and quality improvement.

Measurements:

We classified the existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks.

Methods:

Each metric was rated by a 5-person subcommittee using a modified Delphi approach based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for additional comments.

Results:

We identified 27 metrics that are tracked across 8 provinces, with only 9 (33%) tracked by multiple provinces (ie, more than 1 province). We rated 9 metrics (33%) as “necessary” to distinguish high-quality from low-quality care, of which only 2 were tracked by multiple provinces (proportion of patients by primary access and rate of vascular access-related bloodstream infections). Most (16/27, 59%) indicators assessed the IOM domains of safe or effective care, and none of the “necessary” indicators measured the IOM domains of timely, patient-centered, or equitable care.

Limitations:

The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals, with more representation from academic sites.

Conclusions:

Quality indicators in Canada mainly focus on safe and effective care, with little provincial overlap. These results highlight current gaps in quality of care measurement for ICHD, and this initial work should provide programs with a starting point to combine highly rated indicators with newly developed indicators into a concise balanced scorecard that supports quality improvement initiatives across all aspects of ICHD care.

Trial Registration:

not applicable.

Operational measurement of diagnostic safety: state of the science

Reducing the incidence of diagnostic errors is increasingly a priority for government, professional, and philanthropic organizations. Several obstacles to measurement of diagnostic safety have hampered progress toward this goal. Although a coordinated national strategy to measure diagnostic safety remains an aspirational goal, recent research has yielded practical guidance for healthcare organizations to start using measurement to enhance diagnostic safety. This paper, concurrently published as an Issue Brief by the Agency for Healthcare Research and Quality, issues a "call to action" for healthcare organizations to begin measurement efforts using data sources currently available to them. Our aims are to outline the state of the science and provide practical recommendations for organizations to start identifying and learning from diagnostic errors. Whether by strategically leveraging current resources or building additional capacity for data gathering, nearly all organizations can begin their journeys to measure and reduce preventable diagnostic harm.

Using a Multicountry Learning Network to Harvest and Rapidly Spread Implementation Knowledge across Programs Aimed to Reduce Mother-to-Child Transmission of HIV and Improve Nutrition: Perspectives and Lessons Learned for Similar Large-Scale Initiatives

As countries pursue UNAIDS’s 90-90-90 target for ending the AIDS epidemic, success is dependent on learning how to deliver effective care. We describe a learning network and mechanisms used to foster communication and sharing of ideas and results across 6 countries in the Partnership for HIV-Free Survival. The network used 2 forms of peer exchange, in-person and virtual, and a variety of knowledge management mechanisms to harvest and spread key learning. Key learning included valuable insights on how to design and convene a multicountry learning network, including top enablers of success and practical insights on the network’s value. The network was instrumental in accelerating learning about improving care. Our experience shows the value of creating a quality improvement–driven, multicountry learning network to accelerate the pace of improving care systems. Government ownership and adaptation of collaborative learning efforts to the country context must be considered when designing future networks.

Saving 20 000 Days and Beyond: a realist evaluation of two quality improvement campaigns to manage hospital demand in a New Zealand District Health Board

Background

The current paper reports on a realist evaluation of two consecutive quality improvement campaigns based on the Institute for Healthcare Improvement’s Breakthrough Series. The campaigns were implemented by a District Health Board to manage hospital demand in South Auckland, New Zealand. A realist evaluation design was adopted to investigate what worked in the two campaigns and under what conditions.

Methods

A mixed-methods approach was used, involving three phases of data collection. During the first phase, a review of campaign materials and relevant literature, as well as key informant interviews were undertaken to generate an initial logic model of how the campaign was expected to achieve its objective. In phase II, the model was tested against the experiences of participants in the first campaign via a questionnaire to all campaign participants, interviews with campaign sponsors and collaborative team leaders and a review of collaborative team dashboards. In phase III, the refined model was tested further against the experiences of participants in the second campaign through interviews with collaborative team leaders, case studies of four collaborative teams and a review of the overall system-level dashboard.

Results

The evaluation identified four key mechanisms through which the campaigns’ outcomes were achieved. These were characterised as ‘an organisational preparedness to change’, ‘enlisting the early adopters’, ‘strong collaborative teams’ and ‘learning from measurement’. Contextual factors that both enabled and constrained the operation of these mechanisms were also identified.

Conclusions

By focusing on the explication of a theory of how the campaigns achieved their outcomes and under what circumstances, the realist evaluation reported in this paper provides some instructive lessons for future evaluations of quality improvement initiatives.

Moving beyond hand hygiene monitoring as a marker of infection prevention performance: Development of a tailored infection control continuous quality improvement tool

BACKGROUND

Infection control practice compliance is commonly monitored by measuring hand hygiene compliance. The limitations of this approach were recognized in 1 acute health care organization that led to the development of an Infection Control Continuous Quality Improvement tool.

METHODS

The Pronovost cycle, Barriers and Mitigation tool, and Hexagon framework were used to review the existing monitoring system and develop a quality improvement data collection tool that considered the context of care delivery.

RESULTS

Barriers and opportunities for improvement including ambiguity, consistency and feasibility of expectations, the environment, knowledge, and education were combined in a monitoring tool that was piloted and modified in response to feedback. Local adaptations enabled staff to prioritize and monitor issues important in their own workplace. The tool replaced the previous system and was positively evaluated by auditors. Challenges included ensuring staff had time to train in use of the tool, time to collect the audit, and the reporting of low scores that conflicted with a target-based performance system.

CONCLUSIONS

Hand hygiene compliance monitoring alone misses other important aspects of infection control compliance. A continuous quality improvement tool was developed reflecting specific organizational needs that could be transferred or adapted to other organizations.

Evaluating learning and change in orthopaedics: What is the evidence-base?

Learning and change are key elements of clinical governance and are responsible for the progression of our specialty. Although orthopaedics has been slow to embrace quality improvement, recent years have seen global developments in surgical education, quality improvement, and patient outcome research. This review covers recent advances in the evaluation of learning and change and identifies the most important research questions that remain unanswered. Research into proxies of learning is improving but more work is required to identify the best proxy for a given procedure. Learning curves are becoming commonplace but are poorly integrated into postgraduate training curricula and there is little agreement over the most appropriate method to analyse learning curve data. With various organisations promoting centralisation of care, learning curve analysis is more important than ever before. The use of simulation in orthopaedics is developing but is yet to be formally mapped to resident training worldwide. Patient outcome research is rapidly changing, with an increased focus on quality of life measures. These are key to patients and their care. Cost-utility analysis is increasingly seen in orthopaedic manuscripts and this needs to continue to improve evidence-based care. Large-scale international, multi-centre randomised trials are gaining popularity and updated guidance on sample size estimation needs to become widespread. A global lack of surgeon equipoise will need to be addressed. Quality improvement projects frequently employ interrupted time-series analysis to evaluate change. This technique's limitations must be acknowledged, and more work is required to improve the evaluation of change in a dynamic healthcare environment where multiple interventions frequently occur. Advances in the evaluation of learning and change are needed to drive improved international surgical education and increase the reliability, validity, and importance of the conclusions drawn from orthopaedic research.

Using patient experience data to develop a patient experience toolkit to improve hospital care: a mixed-methods study

Background

Patients are increasingly being asked to provide feedback about their experience of health-care services. Within the NHS, a significant level of resource is now allocated to the collection of this feedback. However, it is not well understood whether or not, or how, health-care staff are able to use these data to make improvements to future care delivery.

Objective

To understand and enhance how hospital staff learn from and act on patient experience (PE) feedback in order to co-design, test, refine and evaluate a Patient Experience Toolkit (PET).

Design

A predominantly qualitative study with four interlinking work packages.

Setting

Three NHS trusts in the north of England, focusing on six ward-based clinical teams (two at each trust).

Methods

A scoping review and qualitative exploratory study were conducted between November 2015 and August 2016. The findings of this work fed into a participatory co-design process with ward staff and patient representatives, which led to the production of the PET. This was primarily based on activities undertaken in three workshops (over the winter of 2016/17). Then, the facilitated use of the PET took place across the six wards over a 12-month period (February 2017 to February 2018). This involved testing and refinement through an action research (AR) methodology. A large, mixed-methods, independent process evaluation was conducted over the same 12-month period.

Findings

The testing and refinement of the PET during the AR phase, with the mixed-methods evaluation running alongside it, produced noteworthy findings. The idea that current PE data can be effectively triangulated for the purpose of improvement is largely a fallacy. Rather, additional but more relational feedback had to be collected by patient representatives, an unanticipated element of the study, to provide health-care staff with data that they could work with more easily. Multidisciplinary involvement in PE initiatives is difficult to establish unless teams already work in this way. Regardless, there is merit in involving different levels of the nursing hierarchy. Consideration of patient feedback by health-care staff can be an emotive process that may be difficult initially and that needs dedicated time and sensitive management. The six ward teams engaged variably with the AR process over a 12-month period. Some teams implemented far-reaching plans, whereas other teams focused on time-minimising ‘quick wins’. The evaluation found that facilitation of the toolkit was central to its implementation. The most important factors here were the development of relationships between people and the facilitator’s ability to navigate organisational complexity.

Limitations

The settings in which the PET was tested were extremely diverse, so the influence of variable context limits hard conclusions about its success.

Conclusions

The current manner in which PE feedback is collected and used is generally not fit for the purpose of enabling health-care staff to make meaningful local improvements. The PET was co-designed with health-care staff and patient representatives but it requires skilled facilitation to achieve successful outcomes.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Identifying and resolving the frustrations of reviewing the improvement literature: The experiences of two improvement researchers

Background and aims

Summarising quality improvement (QI) research through systematic literature review has great potential to improve patient care. However, heterogeneous terminology, poor definition of QI concepts and overlap with other scientific fields can make it hard to identify and extract data from relevant literature. This report examines the compromises and pragmatic decisions that undertaking literature review in the field of QI requires and the authors propose recommendations for literature review authors in similar fields.

Methods

Two authors (EJ and JF) provide a reflective account of their experiences of conducting a systematic literature review in the field of QI. They draw on wider literature to justify the decisions they made and propose recommendations to improve the literature review process. A third collaborator, (WC) co-created the paper challenging author’s EJ and JF views and perceptions of the problems and solutions of conducting a review of literature in QI.

Results

Two main challenges were identified when conducting a review in QI. These were defining QI and selecting QI studies. Strategies to overcome these problems include: select a multi-disciplinary authorship team; review the literature to identify published QI search strategies, QI definitions and QI taxonomies; Contact experts in related fields to clarify whether a paper meets inclusion criteria; keep a reflective account of decision making; submit the protocol to a peer reviewed journal for publication.

Conclusions

The QI community should work together as a whole to create a scientific field with a shared vision of QI to enable accurate identification of QI literature. Our recommendations could be helpful for systematic reviewers wishing to evaluate complex interventions in both QI and related fields.

Patient experience feedback in UK hospitals: What types are available and what are their potential roles in quality improvement (QI)?

BACKGROUND & OBJECTIVES

The comparative uses of different types of patient experience (PE) feedback as data within quality improvement (QI) are poorly understood. This paper reviews what types are currently available and categorizes them by their characteristics in order to better understand their roles in QI.

METHODS

A scoping review of types of feedback currently available to hospital staff in the UK was undertaken. This comprised academic database searches for "measures of PE outcomes" (2000-2016), and grey literature and websites for all types of "PE feedback" potentially available (2005-2016). Through an iterative consensus process, we developed a list of characteristics and used this to present categories of similar types.

MAIN RESULTS

The scoping review returned 37 feedback types. A list of 12 characteristics was developed and applied, enabling identification of 4 categories that help understand potential use within QI-(1) Hospital-initiated (validated) quantitative surveys: for example the NHS Adult Inpatient Survey; (2) Patient-initiated qualitative feedback: for example complaints or twitter comments; (3) Hospital-initiated qualitative feedback: for example Experience Based Co-Design; (4) Other: for example Friends & Family Test. Of those routinely collected, few elicit "ready-to-use" data and those that do elicit data most suitable for measuring accountability, not for informing ward-based improvement. Guidance does exist for linking collection of feedback to QI for some feedback types in Category 3 but these types  are not routinely used.

CONCLUSION

If feedback is to be used more frequently within QI, more attention must be paid to obtaining and making available the most appropriate types.

The Efficiency of Evaluating Candidates for Living Kidney Donation: A Scoping Review

Supplemental digital content is available in the text.

Introduction

The process of evaluating candidates for living kidney donation can be inefficient. A structured review of existing information on this topic can provide a necessary foundation for quality improvement.

Methods

We conducted a scoping review to map the published literature to different themes related to an efficient donor candidate evaluation. We reviewed the websites of living donor programs to describe information provided to candidates about the nature and length of the evaluation process.

Results

We reviewed of 273 published articles and 296 websites. Surveys of living donor programs show variability in donor evaluation protocols. Computed tomography (a routinely done test for all successful candidates) may be used to assess split renal volume instead of nuclear renography when the 2 kidneys differ in size. Depending on the candidate’s estimated glomerular filtration rate, a nuclear medicine scan for measured glomerular filtration rate may not be needed. When reported, the time to complete the evaluation varied from 3 months to over a year. The potential for undesirable outcomes was reported in 23 studies, including missed opportunities for living donation and/or preemptive transplants. According to living donor websites, programs generally evaluate 1 candidate at a time when multiple come forward for assessment, and few programs describe completing most of the evaluation in a single in-person visit.

Conclusions

Data on the efficiency of the living donor evaluation are limited. Future efforts can better define, collect, and report indicators of an efficient living donor evaluation to promote quality improvement and better patient outcomes.

Translating transdermal alcohol monitoring procedures for contingency management among adults recently arrested for DWI

Recent developments in alcohol monitoring devices have made it more feasible to use contingency management (CM) procedures to reduce alcohol use. A growing body of literature is demonstrating the effectiveness of CM to reduce alcohol use among community recruited adults wearing transdermal alcohol concentration (TAC) monitoring devices. This article describes the quality improvement process aimed at adapting TAC-informed CM aimed at minimizing alcohol use and maximizing treatment completion. This extends literature to a high-risk population; adults arrested and awaiting trial (pretrial) for criminal charge of driving while intoxicated (DWI). Participants were enrolled during their orientation to pretrial supervision conditions of DWI bond release. At enrollment, participants completed a screening, brief intervention, and referral to treatment; those with high risk alcohol histories were enrolled in an 8-week CM procedure to avoid TAC readings. Four Plan-Do-Study-Act (PDSA) quality improvement cycles were conducted where the TAC cutoff for determining alcohol use, the quantity of reinforcer, and handling of tampers on the transdermal alcohol monitor were manipulated. Across four PDSA cycles, the retention for the full 8-weeks of treatment was increased. The proportion of weeks with alcohol use was not decreased across cycles, the peak TAC values observed during drinking weeks were significantly lower in Cycles 1 and 4 than 3. CM may be developed as a tool for pretrial supervision to be used to increase bond compliance of those arrested for DWI and for others as a method to identify the need for additional judicial services.

An Electronic Dashboard to Monitor Patient Flow at the Johns Hopkins Hospital: Communication of Key Performance Indicators Using the Donabedian Model

Efforts to monitoring and managing hospital capacity depend on the ability to extract relevant time-stamped data from electronic medical records and other information technologies. However, the various characterizations of patient flow, cohort decisions, sub-processes, and the diverse stakeholders requiring data visibility create further overlying complexity. We use the Donabedian model to prioritize patient flow metrics and build an electronic dashboard for enabling communication. Ten metrics were identified as key indicators including outcome (length of stay, 30-day readmission, operating room exit delays, capacity-related diversions), process (timely inpatient unit discharge, emergency department disposition), and structural metrics (occupancy, discharge volume, boarding, bed assignation duration). Dashboard users provided real-life examples of how the tool is assisting capacity improvement efforts, and user traffic data revealed an uptrend in dashboard utilization from May to October 2017 (26 to 148 views per month, respectively). Our main contributions are twofold. The former being the results and methods for selecting key performance indicators for a unit, department, and across the entire hospital (i.e., separating signal from noise). The latter being an electronic dashboard deployed and used at The Johns Hopkins Hospital to visualize these ten metrics and communicate systematically to hospital stakeholders. Integration of diverse information technology may create further opportunities for improved hospital capacity.

Quality Improvement in Health Care: The Role of Psychologists and Psychology

Quality Improvement (QI) is a health care interprofessional team activity wherein psychology as a field and individual psychologists in health care settings can and should adopt a more robust presence. The current article makes the argument for why psychology's participation in QI is good for health care, is good for our profession, and is the right thing to do for the patients and families we serve. It reviews the varied ways individual psychologists and our profession can integrate quality processes and improve health care through: (1) our approach to our daily work; (2) our roles on health care teams and involvement in organizational initiatives; (3) opportunities for teaching and scholarship; and (4) system redesign and advocacy within our health care organizations and health care environment.

Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame

Measurement of quality and safety has an important role in improving healthcare, but is susceptible to unintended consequences. One frequently made argument is that optimising the benefits from measurement requires controlling the risks of blame, but whether it is possible to do this remains unclear. We examined responses to a programme known as the NHS Safety Thermometer (NHS-ST). Measuring four common patient harms in diverse care settings with the goal of supporting local improvement, the programme explicitly eschews a role for blame. The study design was ethnographic. We conducted 115 hours of observation across 19 care organisations and conducted 126 interviews with frontline staff, senior national leaders, experts in the four harms, and the NHS-ST programme leadership and development team. We also collected and analysed relevant documents. The programme theory of the NHS-ST was based in a logic of measurement for improvement: the designers of the programme sought to avoid the appropriation of the data for any purpose other than supporting improvement. However, organisational participants - both at frontline and senior levels - were concerned that the NHS-ST functioned latently as a blame allocation device. These perceptions were influenced, first, by field-level logics of accountability and managerialism and, second, by specific features of the programme, including public reporting, financial incentives, and ambiguities about definitions that amplified the concerns. In consequence, organisational participants, while they identified some merits of the programme, tended to identify and categorise it as another example of performance management, rich in potential for blame. These findings indicate that the search to optimise the benefits of measurement by controlling the risks of blame remains challenging. They further suggest that a well-intentioned programme theory, while necessary, may not be sufficient for achieving goals for improvement in healthcare systems dominated by institutional logics that run counter to the programme theory.

Domains associated with successful quality improvement in healthcare - a nationwide case study

Background

There is a distinct difference between what we know and what we do in healthcare: a gap that is impairing the quality of the care and increasing the costs. Quality improvement efforts have been made worldwide by learning collaboratives, based on recognized continual improvement theory with limited scientific evidence. The present study of 132 quality improvement projects in Norway explores the conditions for improvement from the perspectives of the frontline healthcare professionals, and evaluates the effectiveness of the continual improvement method.

Methods

An instrument with 25 questions was developed on prior focus group interviews with improvement project members who identified features that may promote or inhibit improvement. The questionnaire was sent to 189 improvement projects initiated by the Norwegian Medical Association, and responded by 70% (132) of the improvement teams. A sub study of their final reports by a validated instrument, made us able to identify the successful projects and compare their assessments with the assessments of the other projects. A factor analysis with Varimax rotation of the 25 questions identified five domains. A multivariate regression analysis was used to evaluate the association with successful quality improvements.

Results

Two of the five domains were associated with success: Measurement and Guidance (p = 0.011), and Professional environment (p = 0.015). The organizational leadership domain was not associated with successful quality improvements (p = 0.26).

Conclusion

Our findings suggest that quality improvement projects with good guidance and focus on measurement for improvement have increased likelihood of success. The variables in these two domains are aligned with improvement theory and confirm the effectiveness of the continual improvement method provided by the learning collaborative. High performing professional environments successfully engaged in patient-centered quality improvement if they had access to: (a) knowledge of best practice provided by professional subject matter experts, (b) knowledge of current practice provided by simple measurement methods, assisted by (c) improvement knowledge experts who provided useful guidance on measurement, and made the team able to organize the improvement efforts well in spite of the difficult resource situation (time and personnel). Our findings may be used by healthcare organizations to develop effective infrastructure to support improvement and to create the conditions for making quality and safety improvement a part of everyone’s job.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2454-2) contains supplementary material, which is available to authorized users.

What role does performance information play in securing improvement in healthcare? a conceptual framework for levers of change

OBJECTIVE

Across healthcare systems, there is consensus on the need for independent and impartial assessment of performance. There is less agreement about how measurement and reporting performance improves healthcare. This paper draws on academic theories to develop a conceptual framework-one that classifies in an integrated manner the ways in which change can be leveraged by healthcare performance information.

METHODS

A synthesis of published frameworks.

RESULTS

The framework identifies eight levers for change enabled by performance information, spanning internal and external drivers, and emergent and planned processes: (1) cognitive levers provide awareness and understanding; (2) mimetic levers inform about the performance of others to encourage emulation; (3) supportive levers provide facilitation, implementation tools or models of care to actively support change; (4) formative levers develop capabilities and skills through teaching, mentoring and feedback; (5) normative levers set performance against guidelines, standards, certification and accreditation processes; (6) coercive levers use policies, regulations incentives and disincentives to force change; (7) structural levers modify the physical environment or professional cultures and routines; (8) competitive levers attract patients or funders.

CONCLUSION

This framework highlights how performance measurement and reporting can contribute to eight different levers for change. It provides guidance into how to align performance measurement and reporting into quality improvement programme.

Complementary logics of target-setting: hierarchist and experimentalist governance in the Scottish National Health Service

Where policy ends are contested and means for change are ambiguous, imposing central targets on local organisations - what we call hierarchist governance - is problematic. The concept of experimentalist governance suggests that target-setting should rather be a learning process between central regulators and local organisations. However, the relationship between experimentalist and hierarchist governance remains unclear. Existing literature suggests that the learning-oriented experimentalist logic is hard to reconcile with a hierarchist logic focussed on accountability for results. We examine whether complementary use of hierarchist and experimentalist ideas is possible. Drawing on experiences from Scotland, we find that experimentalist and hierarchist logics can co-exist in the same performance management system. Each logic served distinct roles with respect to target-setting, implementation and accountability. The emphasis on experimentalism was stronger where ends and means were contested (the case of shifting the balance of care for older people) than where both ends and means seemed obvious initially (the case of health care-associated infections, where target-setting followed a more hierarchist logic). However, governance drifted towards experimentalism when rising rates of community-acquired infections decreased clarity about effective interventions. The nature of policy issues and changes therein over time appear to be important conditions for synergies between governance logics.

Diagnosis of MS: a comparison of three different clinical settings

In order to compare a newly established diagnostic clinic with two existing clinical settings in the management of the diagnostic phase of multiple sclerosis (MS), a retrospective audit was performed over a 12-month period comparing the length of time, adherence to recently published standards and price charged in diagnosing MS in three different clinical diagnostic settings operating within the same hospital: a specifically designed demyelinating disease diagnostic clinic (DDC), a general neurology clinic (GNC) and an inpatient investigation unit (IIU). A n audit tool was created to measure the standards advocated by the UK MS Society on management of the diagnostic phase of MS. The costing tool was the price charged to health authorities. A randomized retrospective case note and referral letter review method was used. The entry criterion was a confirmed diagnosis of MS documented in the medical notes following investigation during the period A pril 1999-A pril 2001. The time between referral and first appointment favoured the DDC with a mean time of 5.9 weeks, compared to 7.7 weeks for the G NC and 10.0 weeks for the IIU. The mean times between the first appointment and receipt of results were 4.7 weeks (DDC), 18.8 weeks (GNC) and 21.2 weeks (IIU). Prices ranged from £395-£790 (DDC), £95-£380 (GNC) and £1940-£2700 (IIU). This study suggests that the UK MS Society standards are achievable in most areas without excessive additional costs and provides evidence that the DDC offers a better service than other existing models.

Should the healthcare compass in Australia point towards value-based primary healthcare?

This paper provides an overview of quality improvement in healthcare in an Australian context. Specifically, the paper considers issues around defining, quantifying, recording and incentivising quality improvement and accountability in primary healthcare. The role of newly emerging Primary Health Networks provides a context for the discussion. The paper draws on international learnings that provide a framework for examining the important elements of quality improvement among reforming primary healthcare organisations in order to support healthcare providers and offer an evidence base for policy makers and peak bodies moving forward.

How to Begin a Quality Improvement Project

Quality improvement involves a combined effort among health care staff and stakeholders to diagnose and treat problems in the health care system. However, health care professionals often lack training in quality improvement methods, which makes it challenging to participate in improvement efforts. This article familiarizes health care professionals with how to begin a quality improvement project. The initial steps involve forming an improvement team that possesses expertise in the quality of care problem, leadership, and change management. Stakeholder mapping and analysis are useful tools at this stage, and these are reviewed to help identify individuals who might have a vested interest in the project. Physician engagement is a particularly important component of project success, and the knowledge that patients/caregivers can offer as members of a quality improvement team should not be overlooked. After a team is formed, an improvement framework helps to organize the scientific process of system change. Common quality improvement frameworks include Six Sigma, Lean, and the Model for Improvement. These models are contrasted, with a focus on the Model for Improvement, because it is widely used and applicable to a variety of quality of care problems without advanced training. It involves three steps: setting aims to focus improvement, choosing a balanced set of measures to determine if improvement occurs, and testing new ideas to change the current process. These new ideas are evaluated using Plan-Do-Study-Act cycles, where knowledge is gained by testing changes and reflecting on their effect. To show the real world utility of the quality improvement methods discussed, they are applied to a hypothetical quality improvement initiative that aims to promote home dialysis (home hemodialysis and peritoneal dialysis). This provides an example that kidney health care professionals can use to begin their own quality improvement projects.

Quality Measurement in Gastroenterology: Confessions of a Realist

Clinicians are required to report their performance on an ever-increasing number of quality measures. However, it is difficult to measure health care quality and it is unclear whether broadly applying accountability measures effectively improves care. This article considers these challenges and includes recommendations that may help gastroenterologists respond to demands for increased quality measurement.

Quality Pain Management in Adult Hospitalized Patients: A Concept Evaluation

AIM

To explore the concept of quality pain management (QPM) in adult hospitalized patients.

BACKGROUND

Pain is common in hospitalized patients, and pain management remains suboptimal in some settings.

DESIGN

A concept evaluation based on Morse et al.'s method.

DATA SOURCE

Of more than 5,000 articles found, data were restricted to 37 selected key articles published in peer-reviewed journals.

REVIEW METHODS

Data were extracted from the selected articles and then synthesized according to the following: definition, characteristics, boundaries, preconditions, and outcomes.

RESULTS

QPM relates to the Structure: organizationally supported evidence-based policies, competent staff, interprofessional and specialized care, and staff accountability;

PROCESS

screening, assessment/reassessment and communication of pain and its treatment, patient/family education, individualized evidence-based treatment, embedded in safe, effective, patient-centered, timely, efficient, and equitable services; and

OUTCOMES

reduced pain severity and functional interference, decreased prevalence/severity of adverse consequences from pain or pain treatment, and increase in patient satisfaction.

CONCLUSIONS

QPM is a multifaceted concept that remains poorly defined in the literature. Studies should aim to develop valid, reliable, and operational measures of the pillars of QPM and to look at the relationship among these factors. Authors need to state how they define and what aspects of QPM they are measuring.

WITHDRAWN: Quality Measurement in Gastroenterology: Confessions of a Realist

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.cgh.2015.07.033. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Measuring experiences and outcomes of patient safety in primary care: a systematic review of available instruments

BACKGROUND

Despite the enormous potential for adverse events in primary care, the knowledge base about patient safety in this context is still sparse. The lack of appropriate measurement methods is a key factor limiting the development of research in this field.

OBJECTIVE

To identify and characterize available patient reported instruments to measure patient safety in primary care.

METHODS

We conducted a systematic literature review. We searched in bibliographic sources for empirical studies describing the development, evaluation or use of patient reported instruments assessing patient safety in primary care. Study selection and data extraction were independently conducted by two researchers.

RESULTS

We identified 28 studies reporting on 23 different instruments. Fifteen instruments were designed for paper-based self-administration, six for phone interview and two consisted in electronic reporting systems. Most instruments focused on specific aspects of patient safety, most commonly on experiences of adverse drug reactions. Face validity was assessed for 10 instruments (43%), three reported construct validity (13%) and three described reliability (13%). Responsiveness was not ascertained.

CONCLUSIONS

Although there is evidence of good psychometric properties for a reduced number of patient reported instruments, currently available instruments do not offer a comprehensive set of resources to measure the effects of interventions to improve patient safety in primary care from a patient perspective. Future research in the field should prioritize (i) the evaluation of the performance of already available instruments and (ii) the development of new instruments that enable an comprehensive assessment of patient safety at general practices.

The development and application of audit criteria for assessing knowledge exchange plans in health research grant applications

Background

Research funders expect evidence of end user engagement and impact plans in research proposals. Drawing upon existing frameworks, we developed audit criteria to help researchers and their institutions assess the knowledge exchange plans of health research proposals.

Findings

Criteria clustered around five themes: problem definition; involvement of research users; public and patient engagement; dissemination and implementation; and planning, management and evaluation of knowledge exchange. We applied these to a sample of grant applications from one research institution in the United Kingdom to demonstrate feasibility.

Conclusion

Our criteria may be useful as a tool for researcher self-assessment and for research institutions to assess the quality of knowledge exchange plans and identify areas for systematic improvement.

Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool

The measurement and examination of adverse events (AEs) that occur in children during hospital admissions is essential if we are to prevent, reduce or ameliorate the harm experienced. The UK Paediatric Trigger Tool (UKPTT) is a method of retrospective case note review that measures harm in hospitalised children.

OBJECTIVES

To examine the harm resulting from the processes of healthcare in hospitalised children from centres providing data to the National Health Service (NHS) Institute UKPTT data portal, to understand the positive predictive values of triggers and to make recommendations for the further development of the trigger tool.

SETTING

25 hospitals across the UK, including secondary, tertiary and quaternary paediatric centres.

PARTICIPANTS

Randomly selected children who were admitted to hospital for longer than 24 h.

OUTCOME MEASURES

The primary outcome measure was the rate of harm (the percentage of children experiencing one or more AEs during a hospital admission). Secondary measures were the severity of harm and performance of triggers.

RESULTS

Data from 3992 patient admissions were reviewed across the hospitals and submitted to the trigger tool portal from February 2008 to November 2011. At least one AE was reported for 567 (14.2%) patients, with 211 (5.3%) experiencing more than one event. There were 1001 AEs identified. Where harm occurred, it was considered temporary for 923 (92.2%) AEs; however, 43 (4.3%) AEs resulted in the need for life-sustaining interventions, 18 (1.8%) AEs led to permanent harm and for 17 children (1.7% of AEs) the AE was believed to have contributed to death.

CONCLUSIONS

There is a significant, measurable level of harm experienced by children admitted to hospitals in the UK. While most of this harm is temporary, some of it is serious. The UKPTT offers organisations the means to measure and examine the AEs occurring in their hospital in order to reduce harm.

Measuring the quality of renal care: things to keep in mind when selecting and using quality indicators

This educational paper discusses a variety of indicators that can be used to measure the quality of care in renal medicine. Based on what aspect of care they reflect, indicators can be grouped into four main categories: structure, process, surrogate outcome and outcome indicators. Each category has its own advantages and disadvantages, and we give some pointers on how to balance these pros and cons while taking into account the aim of the measurement initiative. Especially within initiatives that link payment or reputation to indicator measurement, this balancing should be done with utmost care to avoid potential, unintended consequences. Furthermore, we suggest consideration of (i) a causal chain-i.e. subsequent aspects of care connected by evidence-based links-as a starting point for composing a performance indicator set and (ii) adequate case-mix adjustment, not only of (surrogate) outcomes, but also of process indicators in order to obtain fair comparisons between facilities and within facilities over time.

'Not another safety culture survey': using the Canadian patient safety climate survey (Can-PSCS) to measure provider perceptions of PSC across health settings

Background

The importance of a strong safety culture for enhancing patient safety has been stated for over a decade in healthcare. However, this complex construct continues to face definitional and measurement challenges. Continuing improvements in the measurement of this construct are necessary for enhancing the utility of patient safety climate surveys (PSCS) in research and in practice. This study examines the revised Canadian PSCS (Can-PSCS) for use across a range of care settings.

Methods

Confirmatory factor analytical approaches are used to extensively test the Can-PSCS. Initial and cross-validation samples include 13 126 and 6324 direct care providers from 119 and 35 health settings across Canada, respectively.

Results

Results support a parsimonious model of direct care provider perceptions of patient safety climate (PSC) with 19 items in six dimensions: (1) organisational leadership support for safety; (2) incident follow-up; (3) supervisory leadership for safety; (4) unit learning culture; (5) enabling open communication I: judgement-free environment; (6) enabling open communication II: job repercussions of error. Results also support the validity of the Can-PSCS across a range of care settings.

Conclusions

The Can-PSCS has several advantages: (1) it is a theory-based instrument with a small number of actionable dimensions central to the construct of PSC; (2) it has robust psychometric properties; (3) it is validated for use across a range of care settings, therefore suitable for use in regionalised health delivery systems and can help to raise expectations about acceptable levels of PSC across the system; (4) it has been tested in a publicly funded universal health insurance system and may be suitable for similar international systems.

What is the NHS Safety Thermometer?

The English National Health Service (NHS) announced a new programme to incentivize use of the NHS Safety Thermometer (NHS ST) in the NHS Operating Framework for 2012/13. For the first time, the NHS is using the Commissioning for Quality and Innovation (CQUIN) scheme, a contract lever, to incentivize ALL providers of NHS care to measure four common complications (harms) using the NHS ST in a proactive way on one day per month. This national CQUIN scheme provides financial reward for the collection of baseline data with a view to incentivizing the achievement of improvement goals in later years. In this paper, we describe the rationale for this large-scale data collection, the purpose of the instrument and its potential contribution to our current understanding of patient safety. It is not a comprehensive description of the method or preliminary data. This will be published separately. The focus of the NHS ST on pressure ulcers, falls, catheters and urine infection and venous thromboembolism is broadly applicable to patients across all healthcare settings, but is specifically pertinent to older people who, experiencing more healthcare intervention, are at risk of not one but multiple harms. In this paper, we also describe an innovative patient-level composite measure of the absence of harm from the four identified, termed as “harmfreecare” which is unique to the NHS ST and is under development to raise standards for patient safety.

Evaluation and measurement for improvement in service-level quality improvement initiatives

The National Health Service (NHS) in England, as with other health services worldwide, currently faces the need to reduce costs and to improve the quality of patient care. Evidence gathered through effective and appropriate measurement and evaluation, is essential to achieving this. Through interviews with service improvement managers and analysis of comments in a seminar of NHS staff involved in health service improvement, we found a lack of understanding regarding the definition and methodology of both measurement and evaluation, which decreases the likelihood that NHS staff will be competent to commission or provide these skills. In addition, we highlight the importance of managers assessing their organizations' ‘readiness’ to undergo change before embarking on a quality improvement (QI) initiative, to ensure that the initiative's impact can be adequately judged. We provide definitions of measurement for improvement and of evaluation, and propose a comparative framework from which to gauge an appropriate approach. Examples of two large-scale QI initiatives are also given, along with descriptions of some of their problems and solutions, to illustrate the use of the framework. We recommend that health service managers use the framework to determine the most appropriate approach to evaluation and measurement for improvement for their context, to ensure that their decisions are evidence based.

Systems of service: reflections on the moral foundations of improvement

Providing clinical care is above all a service; in that sense, the medical profession aspires to Aristotelian phronesis, or prudence-being 'capable of action with regard to things that are good and bad for man.' This intense commitment to service encourages healthcare providers to gravitate towards one or another epistemology as their preferred moral pathway to better care. One such epistemology, the 'snail' perspective, places particular value on knowing whether newly devised clinical interventions are both effective and safe before applying them, mainly through rigorous experimental (deductive) studies, which contribute to the body of established scientific knowledge (episteme). Another (the 'evangelist' perspective) places particular value on the experiential learning gained from applying new clinical interventions, which contributes to professional know--how (techne). From the 'snail' point of view, implementing clinical interventions before their efficacy and safety are rigorously established is morally suspect because it can result in ineffective, wasteful and potentially harmful actions. Conversely, from the 'evangelist' point of view, demanding 'hard' proof of efficacy and safety before implementing every intervention is morally suspect because it can delay and obstruct the on-the-ground learning seen as being urgently needed to fix ineffective, inefficient and sometimes dangerous existing clinical practices. Two different moral syndromes--sets of interlocked values--underlie these perspectives; both are arguably essential for better care. Although it is not clear how best to leverage their combined strengths, a true symbiotic relationship between the two appears to be developing, one that leaves the two syndromes intact but softens their epistemological edges and supports active, close, respectful interaction between them.

Scottish Antimicrobial Prescribing Group (SAPG): development and impact of the Scottish National Antimicrobial Stewardship Programme

In 2008, the Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP) was published by the Scottish Government. One of the key actions was initiation of the Scottish Antimicrobial Prescribing Group (SAPG), hosted within the Scottish Medicines Consortium, to take forward national implementation of the key recommendations of this action plan. The primary objective of SAPG is to co-ordinate and deliver a national framework or programme of work for antimicrobial stewardship. This programme, led by SAPG, is delivered by NHS National Services Scotland (Health Protection Scotland and Information Services Division), NHS Quality Improvement Scotland, and NHS National Education Scotland as well as NHS board Antimicrobial Management Teams. Between 2008 and 2010, SAPG has achieved a number of early successes, which are the subject of this review: (i) through measures to optimise prescribing in hospital and primary care, combined with infection prevention measures, SAPG has contributed significantly to reducing Clostridium difficile infection rates in Scotland; (ii) there has been engagement of all key stakeholders at local and national levels to ensure an integrated approach to antimicrobial stewardship within the wider healthcare-associated infection agenda; (iii) development and implementation of data management systems to support quality improvement; (iv) development of training materials on antimicrobial stewardship for healthcare professionals; and (v) improving clinical management of infections (e.g. community-acquired pneumonia) through quality improvement methodology. The early successes achieved by SAPG demonstrate that this delivery model is effective and provides the leadership and focus required to implement antimicrobial stewardship to improve antimicrobial prescribing and infection management across NHS Scotland.