Evidence-based quality improvement: the state of the science

Brief verbal intervention to address inappropriate prescriptions of chinese patent medicines among western practitioners in primary health care (BRAVERY): a study protocol for an unannounced standardized patient experiment with a factorial design randomized controlled trial in China

INTRODUCTION

Chinese patent medicines, produced using advanced pharmaceutical techniques and available in various forms, including powders, granules, tablets, pills, and capsules, finds extensive utilization among Western medicine practitioners in primary healthcare (WMP-PHC). However, the inappropriate overprescribing of these medicines has led to significant resource waste and raised considerable concerns. Therefore, we aim to address related knowledge gaps by employing unannounced standardized patients (USPs) as a method, for both measurement and intervention research. Specifically, in this paper, we present a study protocol that aims to develop and evaluate the effectiveness of brief verbal interventions (BVI) delivered by USPs, with the objective of improving the appropriate prescription of Chinese patent medicines. The study aims to equip patients with simple and easily implementable interventions to enhance the appropriate prescription of Chinese patent medicines. Furthermore, The findings from this study will provide valuable insights for policymakers, enabling them to comprehend the current levels of inappropriate Chinese patent medicines prescription and develop targeted policy interventions.

METHODS AND ANALYSIS

We will record a total of 576 encounters in primary healthcare (PHC) facilities across two cities in China. The data will be randomized using a 2 × 2 × 2 × 2 factorial design randomized controlled trial (RCT), which includes factors such as financial incentives, knowledge and skills, prescribing habits, and patient expectation. USPs will collect data, including retrieving prescriptions and documenting the process of medical encounters. The primary outcome evaluation focuses on the appropriateness of Chinese patent medicines prescriptions. Secondary outcomes include the quality of the consultation process, patient satisfaction, cost information, service time, and appropriateness of antibiotic prescriptions. Descriptive analysis will be performed for the survey results, and the difference in outcomes between interventions and control providers will be compared and statistically tested using generalized linear mixed model (GLMM).

TRIAL REGISTRATION NUMBER

The study has been registered at the China Clinical Trials Registry (ChiCTR2300077913) on 23 November 2023.

Changing practice in cystic fibrosis: Implementing objective medication adherence data at every consultation, a learning health system and quality improvement collaborative

Background

Medication adherence data are an important quality indicator in cystic fibrosis (CF) care, yet real-time objective data are not routinely available. An online application (CFHealthHub) has been designed to deliver these data to people with CF and their clinical team. Adoption of this innovation is the focus of an National Health Service England-funded learning health system and Quality Improvement Collaborative (QIC). This study applies the capability, opportunity, and motivation model of behavior change to assess whether the QIC had supported healthcare professionals' uptake of accessing patient adherence data.

Method

This was a mixed-method study, treating each multidisciplinary team as an individual case. Click analytic data from CFHealthHub were collected between January 1, 2018, and September 22, 2019. Thirteen healthcare practitioners participated in semi-structured interviews, before and after establishing the QIC. Qualitative data were analyzed using the behavior change model.

Results

The cases showed varied improvement trajectories. While two cases reported reduced barriers, one faced persistent challenges. Participation in the QIC led to enhanced confidence in the platform's utility. Reduced capability, opportunity, and motivation barriers correlated with increased uptake, demonstrating value in integrating behavior change theory into QICs.

Conclusion

QICs can successfully reduce barriers and enable uptake of e-health innovations such as adherence monitoring technology. However, ongoing multi-level strategies are needed to embed changes. Further research should explore sustainability mechanisms and their impact on patient outcomes.

Assessing patient autonomy in the context of TeamBirth, a quality improvement intervention to improve shared decision-making during labor and birth

BACKGROUND

Respectful maternity care includes shared decision-making (SDM). However, research on SDM is lacking from the intrapartum period and instruments to measure it have only recently been developed. TeamBirth is a quality improvement initiative that uses team huddles to improve SDM during labor and birth. Team huddles are structured meetings including the patient and full care team when the patient's preferences, care plans, and expectations for when the next huddle will occur are reviewed.

METHODS

We used patient survey data (n = 1253) from a prospective observational study at four U.S. hospitals to examine the relationship between TeamBirth huddles and SDM. We measured SDM using the Mother's Autonomy in Decision-Making (MADM) scale. Linear regression models were used to assess the association between any exposure to huddles and the MADM score and between the number of huddles and the MADM score.

RESULTS

In our multivariable model, experiencing a huddle was significantly associated with a 3.13-point higher MADM score. When compared with receiving one huddle, experiencing 6+ huddles yielded a 3.64-point higher MADM score.

DISCUSSION

Patients reporting at least one TeamBirth huddle experienced significantly higher SDM, as measured by the MADM scale. Our findings align with prior research that found actively involving the patient in their care by creating structured opportunities to discuss preferences and choices enables SDM. We also demonstrated that MADM is sensitive to hospital-based quality improvement, suggesting that future labor and birth interventions might adopt MADM as a patient-reported experience measure.

How Does Management Matter for Hospital Performance? Evidence From the Global Hospital Management Survey in China

BACKGROUND

Improving healthcare productivity and efficiency through effective management practice is crucial in the healthcare sector. However, the evidence on how management practices affect hospital performance is mixed and limited in the public health system. The objectives of this study are (1) locating Chinese public hospitals' management ability in the global health system community, and (2) investigating how public hospital's management practice is correlated to the objective and subjective performances.

METHODS

Using the World Management Survey (WMS) methodology, the national Global Hospital Management Survey-China (GHMS-China) was conducted from 2014 to 2016 to measure Chinese hospitals' management practices. This study utilized a national representative hospital sample from the GHMS-China and used multi-variable linear regression model to examine the association between hospital performance and management practices. This study mainly focused on the clinical outcomes for acute myocardial infarction (AMI), heart failure (HF), pneumonia children (PC), and coronary artery bypass grafting (CABG), as well as satisfaction measurements including staff turnover and subjective ratings from patient and staff.

RESULTS

Hospitals with higher management scores have significantly lower mortality rates on AMI, lower complication rates on CABG and shorter average length of stay (LoS) for PC patients. Hospital management and subjective performance also shows a positive correlation, with a significant increase of inpatient satisfaction rating by 0.72 scores (95% CI: 0.28,1.16; P=0.001). This relationship is more pronounced in hospitals with larger bed capacities, greater competition, more autonomy, and in sub-sample group of hospitals with superior management practice. The potential mechanisms through which hospital management can foster performance include attracting more talented clinical staffs, providing more valuable and continuous training opportunities, as well as providing more standardized clinical care service.

CONCLUSION

Better management practice is correlated to superior hospital performance in Chinese Public Health Service System. Future studies with religious and causality study design are warranted.

Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS, 2010-2023

BACKGROUND

Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear.

AIM

To identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010-2023, and to conduct a structured quality assessment.

METHODS

We drew on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance to inform the design and reporting of our study. We identified relevant programmes using multiple search strategies of grey literature, research databases and other sources. Programmes that met a prespecified definition of improvement programme, that focused on intrapartum care and that had a retrievable evaluation report were subject to structured assessment using selected features of programme quality.

RESULTS

We identified 1434 records via databases and other sources. 14 major initiatives in English maternity services could not be quality assessed due to lack of a retrievable evaluation report. Quality assessment of the 15 improvement programmes meeting our criteria for assessment found highly variable quality and reporting. Programme specification was variable and mostly low quality. Only eight reported the evidence base for their interventions. Description of implementation support was poor and none reported customisation for challenged services. None reported reduction of inequalities as an explicit goal. Only seven made use of explicit patient and public involvement practices, and only six explicitly used published theories/models/frameworks to guide implementation. Programmes varied in their reporting of the planning, scope and design of evaluation, with weak designs evident.

CONCLUSIONS

Poor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes.

The Impact of Pandemic-Driven Care Redesign on Hospital Efficiency

Purpose

This study aims to identify medical care transformations during the COVID-19 pandemic and to assess the economic efficiency of these care transformations.

Methods

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviewing and Meta-Analysis (PRISMA) guidelines. The databases used in the search protocol included PubMed, RSCI, and Google Scholar.

Results

Ten eligible studies in English and one publication in Russian were identified. In general, the following changes in organization of health care processes since 2020 are observed: hospital at home, telemedicine (physician-to-patient), and the adoption of new information communication technologies within physician-to-physician and physician-to-nurse communication. Earlier trends, such as (a) wider use of electronic devices, (b) adoption of Lean techniques, (c) the incorporation of patient and other customer experience feedback, and (d) the implementation of clinical decision support systems and automation of workflow, tend to be preserved.

Conclusion

The most common changes in hospital care organization and the respective impacts of workflow changes (ie, workflow interventions, redesign, and transformations) on the efficiency of hospital care were summarized and avenues for future research and policy implications were discussed. The pandemic demonstrated a need for building more resilient and adaptive healthcare systems, enhancing crisis preparedness along with rapid and effective responses.

How well are we collecting umbilical cord lactate and gas samples?

AIMS

The aim of this study is to measure staff compliance with the local umbilical cord lactate (UCL) sampling guideline and investigate the quality of paired UCG samples at a tertiary maternity unit.

METHODS

We performed a retrospective consecutive sampling of 100 babies delivered via emergency caesarean section and 50 babies with each of all other guideline-based indications for UCL sampling born on and before 31 December 2021. Data were extracted from physical and electronic records. Compliance with guideline-based indications for UCL at birth was measured. The proportion of valid UCG samples was calculated. Samples were considered invalid under the following cases: (i) inadvertently collecting from the same vessel, (ii) switching arterial and venous samples, (iii) collecting from only one vessel or (iv) committing errors during sample collection and handling.

RESULTS

Of the samples collected at birth from 321 babies, 280 (87%) had UCL. Small for gestational age and concerns about fetal well-being in labour were indications associated with poorer compliance, 66% and 78%, respectively. About 99 (44%) babies of 226 babies with UCG performed had valid UCG samples. The most common reasons for invalid samples were collection and handling errors (22%) and inadvertent collection from the same vessel (15%).

CONCLUSIONS

Generally, compliance with the guidelines is good. However, invalid UCG samples were more frequent than expected.

Barriers and facilitators to health professionals' engagement in quality improvement initiatives: a mixed-methods systematic review

Quality improvement (QI) initiatives in healthcare are crucial for enhancing service quality and healthcare outcomes. The success of these initiatives depends on the active engagement of healthcare professionals, which can be influenced by several factors within the healthcare system. This systematic review synthesized the factors influencing healthcare professionals' engagement in QI projects, focusing on identifying both barriers and facilitators. A mixed methods systematic review (MMSR) was conducted using the JBI methodology for MMSR. Databases such as MEDLINE, CINAHL, Scopus, and Embase were searched for studies that explored barriers and facilitators to QI engagement of health professionals in the clinical setting. Methodological quality was assessed using the Mixed-Methods Appraisal Tool (MMAT). The extracted data were synthesized using the JBI convergent integrated approach to MMSR. Eighteen studies (seven qualitative, nine quantitative, and two mixed-methods) published between 2007 and 2023 were included in the review. The analysis revealed barriers and facilitators to engagement in QI initiatives at different levels of the health system. At the QI program level, the engagement of health professionals to QI was influenced by the approach to QI, evidence underpinning the QI initiative, QI knowledge and training, and access to QI specialists. At the health professional level, barriers and facilitators were related to their organizational role, motivation, perceptions about QI, and collaborations with individuals and groups. At the organizational level, factors related to culture and climate, leadership, available resources (including human resource and workload, infrastructure, and incentives), and institutional priorities influenced health professionals' participation in QI. This review highlights the complex interplay of organizational, individual, and QI program level factors that influence the engagement of healthcare professionals in QI. Overcoming these complex barriers and leveraging facilitators is crucial for enhancing participation in QI efforts. The findings underscore the need for a multi-level strategy that focuses on creating a conducive organizational culture, providing robust leadership, and ensuring adequate resources and training for healthcare professionals. Such strategies hold the potential to enhance the effectiveness and sustainability of QI initiatives in healthcare settings.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study

OBJECTIVES

To implement an early rehabilitation bundle in two Canadian PICUs.

DESIGN AND SETTING

Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2).

PATIENTS

All children under 18 years old admitted to the PICU were eligible for the intervention.

INTERVENTIONS

A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement.

CONCLUSIONS

A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Implementing a Family-Centered Rounds Intervention Using Novel Mentor-Trios

BACKGROUND AND OBJECTIVES

Patient and Family Centered I-PASS (PFC I-PASS) emphasizes family and nurse engagement, health literacy, and structured communication on family-centered rounds organized around the I-PASS framework (Illness severity-Patient summary-Action items-Situational awareness-Synthesis by receiver). We assessed adherence, safety, and experience after implementing PFC I-PASS using a novel "Mentor-Trio" implementation approach with multidisciplinary parent-nurse-physician teams coaching sites.

METHODS

Hybrid Type II effectiveness-implementation study from 2/29/19-3/13/22 with ≥3 months of baseline and 12 months of postimplementation data collection/site across 21 US community and tertiary pediatric teaching hospitals. We conducted rounds observations and surveyed nurses, physicians, and Arabic/Chinese/English/Spanish-speaking patients/parents.

RESULTS

We conducted 4557 rounds observations and received 2285 patient/family, 1240 resident, 819 nurse, and 378 attending surveys. Adherence to all I-PASS components, bedside rounding, written rounds summaries, family and nurse engagement, and plain language improved post-implementation (13.0%-60.8% absolute increase by item), all P < .05. Except for written summary, improvements sustained 12 months post-implementation. Resident-reported harms/1000-resident-days were unchanged overall but decreased in larger hospitals (116.9 to 86.3 to 72.3 pre versus early- versus late-implementation, P = .006), hospitals with greater nurse engagement on rounds (110.6 to 73.3 to 65.3, P < .001), and greater adherence to I-PASS structure (95.3 to 73.6 to 72.3, P < .05). Twelve of 12 measures of staff safety climate improved (eg, "excellent"/"very good" safety grade improved from 80.4% to 86.3% to 88.0%), all P < .05. Patient/family experience and teaching were unchanged.

CONCLUSIONS

Hospitals successfully used Mentor-Trios to implement PFC I-PASS. Family/nurse engagement, safety climate, and harms improved in larger hospitals and hospitals with better nurse engagement and intervention adherence. Patient/family experience and teaching were not affected.

What are Effective Strategies to Reduce Low-Value Care? An Analysis of 121 Randomized Deimplementation Studies

BACKGROUND

Low-value care is healthcare leading to no or little clinical benefit for the patient. The best (combinations of) interventions to reduce low-value care are unclear.

PURPOSE

To provide an overview of randomized controlled trials (RCTs) evaluating deimplementation strategies, to quantify the effectiveness and describe different combinations of strategies.

METHODS

Analysis of 121 RCTs (1990-2019) evaluating a strategy to reduce low-value care, identified by a systematic review. Deimplementation strategies were described and associations between strategy characteristics and effectiveness explored.

RESULTS

Of 109 trials comparing deimplementation to usual care, 75 (69%) reported a significant reduction of low-value healthcare practices. Seventy-three trials included in a quantitative analysis showed a median relative reduction of 17% (IQR 7%-42%). The effectiveness of deimplementation strategies was not associated with the number and types of interventions applied.

CONCLUSIONS AND IMPLICATIONS

Most deimplementation strategies achieved a considerable reduction of low-value care. We found no signs that a particular type or number of interventions works best for deimplementation. Future deimplementation studies should map relevant contextual factors, such as the workplace culture or economic factors. Interventions should be tailored to these factors and provide details regarding sustainability of the effect.

Practice facilitation for scale up of clinical decision support for hypertension management: study protocol for a cluster randomized control trial

BACKGROUND

Only half of patients with hypertension have adequately controlled blood pressure. Clinical decision support (CDS) has the potential to overcome barriers to delivering guideline-recommended care and improve hypertension management. However, optimal strategies for scaling CDS have not been well established, particularly in small, independent primary care practices which often lack the resources to effectively change practice routines. Practice facilitation is an implementation strategy that has been shown to support process changes. Our objective is to evaluate whether practice facilitation provided with hypertension-focused CDS can lead to improvements in blood pressure control for patients seen in small primary care practices.

METHODS/DESIGN

We will conduct a cluster randomized control trial to compare the effect of hypertension-focused CDS plus practice facilitation on BP control, as compared to CDS alone. The practice facilitation intervention will include an initial training in the CDS and a review of current guidelines along with follow-up for coaching and integration support. We will randomize 46 small primary care practices in New York City who use the same electronic health record vendor to intervention or control. All patients with hypertension seen at these practices will be included in the evaluation. We will also assess implementation of CDS in all practices and practice facilitation in the intervention group.

DISCUSSION

The results of this study will inform optimal implementation of CDS into small primary care practices, where much of care delivery occurs in the U.S. Additionally, our assessment of barriers and facilitators to implementation will support future scaling of the intervention.

CLINICALTRIALS

gov Identifier: NCT05588466.

Enhancing speech-language pathology head and neck cancer service provision in rural Australia: Using a plan, do, study, act approach

PURPOSE

People with head and neck cancer (HNC) require ongoing speech-language pathology (SLP) services into the post-acute recovery phase of care. However, there are recognised service inequities/barriers for people from rural areas who are unable to access SLP services locally, necessitating travel to metropolitan centres. This study implemented strategies to assist rural speech-language pathologists to work to full scope of practice and support post-acute rehabilitation services for people with HNC.

METHOD

The study involved five SLP departments within a rural health referral network (one tertiary cancer centre, four rural sites). It involved a Plan-Do-Study-Act (PDSA) method, across two six month cycles, to achieve implementation of a model to support local SLP delivery of HNC care. Data collected included service activity, consumer feedback from people accessing local care, staff perceptions of the model and changes to local SLP service capabilities.

RESULT

Staff identified four objectives for change across the two PDSA cycles including resource development, upskilling/training and improving communication, and handover processes. In cycle 1, multiple resources were developed such as an eLearning program for training and skill development. In cycle 2, a pilot trial of a shared-care model was implemented, which successfully supported a transfer of care to local services for eight people with HNC. The majority of consumers accessing HNC care locally were satisfied with the service and would recommend future people with HNC receive similar care.

CONCLUSION

The PDSA process supported development and implementation of a model enabling local speech-language pathologists to offer post-acute care for people with HNC. This model helps rural people with HNC to access care closer to home by supporting rural clinicians to work to full scope of practice.

Assessing the quality of reporting on quality improvement initiatives in plastic surgery: A systematic review

BACKGROUND

There has been a recent increase in the number and complexity of quality improvement studies in plastic surgery. To assist with the development of thorough quality improvement reporting practices, with the goal of improving the transferability of these initiatives, we conducted a systematic review of studies describing the implementation of quality improvement initiatives in plastic surgery. We used the SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guideline to appraise the quality of reporting of these initiatives.

METHODS

English-language articles published in Embase, MEDLINE, CINAHL, and the Cochrane databases were searched. Quantitative studies evaluating the implementation of quality improvement initiatives in plastic surgery were included. The primary endpoint of interest in this review was the distribution of studies per SQUIRE 2.0 criteria scores in proportions. Abstract screening, full-text screening, and data extraction were completed independently and in duplicate by the review team.

RESULTS

We screened 7046 studies, of which 103 full texts were assessed, and 50 met inclusion criteria. In our assessment, only 7 studies (14%) met all 18 SQUIRE 2.0 criteria. SQUIRE 2.0 criteria that were met most frequently were abstract, problem description, rationale, and specific aims. The lowest SQUIRE 2.0 scores appeared in funding, conclusion, and interpretation criteria.

CONCLUSIONS

Improvements in QI reporting in plastic surgery, especially in the realm of funding, costs, strategic trade-offs, project sustainability, and potential for spread to other contexts, will further advance the transferability of QI initiatives, which could lead to significant strides in improving patient care.

Supporting the Pursuit of Quality Improvement Publication: What Your Organization Can Do Now

Many health care organizations encourage frontline staff to pursue quality improvement (QI), local spread of those improvements, and publication of their work. Although much has been written about building and sustaining a culture of continuous QI, less is known about how to support success in QI rigor, credibility, spread, and publication. In this perspective article, we offer QI leaders practical suggestions to identify challenges in publishing QI and strategies to overcome these challenges. Health care organizations can assist QI teams with publication by intentionally formalizing scholarship early in their QI project work, providing accountability, and connecting the QI team to necessary resources. A carefully designed program supporting QI publication can both improve the rigor of QI work and enhance the professional development of QI professionals.

Barriers and facilitators to the implementation and adoption of improvement coaching: A qualitative evidence synthesis

BACKGROUND

Healthcare organisations and teams perform improvement activities to facilitate high-quality healthcare. The use of an improvement coach who provides support and guidance to the healthcare team may facilitate improvement activities; however, no systematic review exists on the facilitators and barriers to implementing an improvement coach.

AIMS

We conducted a qualitative evidence synthesis to examine the facilitators and barriers to the implementation of improvement coaching.

METHODS

We searched MEDLINE® , Embase and CINAHL. The final search was in March 2021. The screening eligibility criteria included the following: interdisciplinary team receiving the coaching, improvement coaching, designs with a qualitative component and primary purpose of evaluating practice facilitation in OECD countries. An ecologically-informed consolidated framework for implementation research (CFIR) served as the framework for coding. Patterns of barriers and facilitators across domains were identified through matrix analysis. Risk of bias was assessed using Critical Appraisal Skills Program. PRISMA reporting guidelines served as a guide for reporting this review.

RESULTS

Nineteen studies with a qualitative component met the inclusion criteria. Four themes of barriers and facilitators crossed multiple CFIR domains: adaptability (e.g. making adjustments to the project; process, or approach); knowledge and skills (e.g. understanding of content and process for the project); engagement (e.g. willingness to be involved in the process) and resources (e.g. assets required to complete the improvement process).

CONCLUSION

Improvement coaching is a complex intervention that influences the context, healthcare team being coached and improvement activities. Improvement coaches should understand how to minimise barriers and promote facilitators that are unique to each improvement project across the domains. Limitations of the study are related to the nature of the intervention including potential publication bias given quality improvement focus; the variety of terms similar to improvement coaching or selection of framework.

Quality Improvement Initiative to Improve Timing of Enteral Feeds in Pediatric Acute Pancreatitis

BACKGROUND

Acute pancreatitis (AP) represents a significant disease burden in the pediatric population. The management of AP includes fluid resuscitation, pain management, and early enteral feeds. Contrary to old dogma, early enteral feeding has been shown to improve outcomes and reduce hospital length of stay (LOS), yet uptake of this approach has not been standardized. Our aim was to standardize the management of AP, increasing the percentage of patients receiving early enteral nutrition from 40% to 65% within 12 months.

METHODS

Between January 2013 and September 2021, we conducted a quality improvement initiative among patients hospitalized with AP. Interventions included the development of a clinical care pathway, integration of an AP order set, and physician education. Our primary outcome was the percentage of patients receiving enteral nutrition within 48 hours of admission, and our secondary outcome was hospital LOS. Balancing measures included hospital readmission rates.

RESULTS

A total of 652 patients were admitted for AP during the project, of which 322 (49%) were included after pathway implementation. Before pathway development, the percentage of patients receiving early enteral nutrition was 40%, which increased significantly to 84% after our interventions. This improvement remained stable. Median LOS decreased significantly from 5.5 to 4 days during this timeframe. Our balancing measure of readmission rates did not change during the project period.

CONCLUSIONS

Through multiple interventions, including the implementation of an AP clinical pathway, we significantly increased the proportion of patients receiving early enteral nutrition and decreased hospital LOS without increasing hospital readmission rates.

Evidence-Based Quality Improvement: a Scoping Review of the Literature

BACKGROUND

Quality improvement (QI) initiatives often reflect approaches based on anecdotal evidence, but it is unclear how initiatives can best incorporate scientific literature and methods into the QI process. Review of studies of QI initiatives that aim to systematically incorporate evidence review (termed evidence-based quality improvement (EBQI)) may provide a basis for further methodological development.

METHODS

In this scoping review (registration: https://osf.io/hr5bj ) of EBQI, we searched the databases PubMed, CINAHL, and SCOPUS. The review addressed three central questions: How is EBQI defined? How is evidence used to inform evidence-informed QI initiatives? What is the effectiveness of EBQI?

RESULTS

We identified 211 publications meeting inclusion criteria. In total, 170 publications explicitly used the term "EBQI." Published definitions emphasized relying on evidence throughout the QI process. We reviewed a subset of 67 evaluations of QI initiatives in primary care, including both studies that used the term "EBQI" with those that described an evidence-based initiative without using EBQI terminology. The most frequently reported EBQI components included use of evidence to identify previously tested effective QI interventions; engaging stakeholders; iterative intervention development; partnering with frontline clinicians; and data-driven evaluation of the QI intervention. Effectiveness estimates were positive but varied in size in ten studies that provided data on patient health outcomes.

CONCLUSIONS

EBQI is a promising strategy for integrating relevant prior scientific findings and methods systematically in the QI process, from the initial developmental phase of the IQ initiative through to its evaluation. Future QI researchers and practitioners can use these findings as the basis for further development of QI initiatives.

Improving quality of surgical and anaesthesia care in sub-Saharan Africa: a systematic review of hospital-based quality improvement interventions

OBJECTIVES

To systematically review existing literature on hospital-based quality improvement studies in sub-Saharan Africa that aim to improve surgical and anaesthesia care, capturing clinical, process and implementation outcomes in order to evaluate the impact of the intervention and implementation learning.

DESIGN

We conducted a systematic literature review and narrative synthesis.

SETTING

Literature on hospital-based quality improvement studies in sub-Saharan Africa reviewed until 31 December 2021.

PARTICIPANTS

MEDLINE, EMBASE, Global Health, CINAHL, Web of Science databases and grey literature were searched.

INTERVENTION

We extracted data on intervention characteristics and how the intervention was delivered and evaluated.

PRIMARY AND SECONDARY OUTCOME MEASURES

Importantly, we assessed whether clinical, process and implementation outcomes were collected and separately categorised the outcomes under the Institute of Medicine quality domains. Risk of bias was not assessed.

RESULTS

Of 1573 articles identified, 49 were included from 17/48 sub-Saharan African countries, 16 of which were low-income or lower middle-income countries. Almost two-thirds of the studies took place in East Africa (31/49, 63.2%). The most common intervention focus was reduction of surgical site infection (12/49, 24.5%) and use of a surgical safety checklist (14/49, 28.6%). Use of implementation and quality improvement science methods were rare. Over half the studies measured clinical outcomes (29/49, 59.2%), with the most commonly reported ones being perioperative mortality (13/29, 44.8%) and surgical site infection rate (14/29, 48.3%). Process and implementation outcomes were reported in over two thirds of the studies (34/49, 69.4% and 35, 71.4%, respectively). The most studied quality domain was safety (44/49, 89.8%), with efficiency (4/49, 8.2%) and equitability (2/49, 4.1%) the least studied domains.

CONCLUSIONS

There are few hospital-based studies that focus on improving the quality of surgical and anaesthesia care in sub-Saharan Africa. Use of implementation and quality improvement methodologies remain low, and some quality domains are neglected.

PROSPERO REGISTRATION NUMBER

CRD42019125570.

Systems analysis and improvement approach to optimize outpatient mental health treatment cascades in Mozambique (SAIA-MH): study protocol for a cluster randomized trial

BACKGROUND

Significant investments are being made to close the mental health (MH) treatment gap, which often exceeds 90% in many low- and middle-income countries (LMICs). However, limited attention has been paid to patient quality of care in nascent and evolving LMIC MH systems. In system assessments across sub-Saharan Africa, MH loss-to-follow-up often exceeds 50% and sub-optimal medication adherence often exceeds 60%. This study aims to fill a gap of evidence-based implementation strategies targeting the optimization of MH treatment cascades in LMICs by testing a low-cost multicomponent implementation strategy integrated into routine government MH care in Mozambique.

METHODS

Using a cluster-randomized trial design, 16 clinics (8 intervention and 8 control) providing primary MH care will be randomized to the Systems Analysis and Improvement Approach for Mental Health (SAIA-MH) or an attentional placebo control. SAIA-MH is a multicomponent implementation strategy blending external facilitation, clinical consultation, and provider team meetings with system-engineering tools in an overall continuous quality improvement framework. Following a 6-month baseline period, intervention facilities will implement the SAIA-MH strategy for a 2-year intensive implementation period, followed by a 1-year sustainment phase. Primary outcomes will be the proportion of all patients diagnosed with a MH condition and receiving pharmaceutical-based treatment who achieve functional improvement, adherence to medication, and retention in MH care. The Consolidated Framework for Implementation Research (CFIR) will be used to assess determinants of implementation success. Specific Aim 1b will include the evaluation of mechanisms of the SAIA-MH strategy using longitudinal structural equation modeling as well as specific aim 2 estimating cost and cost-effectiveness of scaling-up SAIA-MH in Mozambique to provincial and national levels.

DISCUSSION

This study is innovative in being the first, to our knowledge, to test a multicomponent implementation strategy for MH care cascade optimization in LMICs. By design, SAIA-MH is a low-cost strategy to generate contextually relevant solutions to barriers to effective primary MH care, and thus focuses on system improvements that can be sustained over the long term. Since SAIA-MH is integrated into routine government MH service delivery, this pragmatic trial has the potential to inform potential SAIA-MH scale-up in Mozambique and other similar LMICs.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT05103033 ; 11/2/2021.

Statistical Approaches for Quantifying the Quality of Neurosurgical Care

BACKGROUND

Quantifying quality of health care can provide valuable information to patients, providers, and policy makers. However, the observational nature of measuring quality complicates assessments.

METHODS

We describe a conceptual model for defining quality and its implications about the data collected, how to make inferences about quality, and the assumptions required to provide statistically valid estimates. Twenty-one binary or polytomous quality measures collected from 101,051 adult Medicaid beneficiaries aged 18-64 years with schizophrenia from 5 U.S. states show methodology. A categorical principal components analysis establishes dimensionality of quality, and item response theory models characterize the relationship between each quality measure and a unidimensional quality construct. Latent regression models estimate racial/ethnic and geographic quality disparities.

RESULTS

More than 90% of beneficiaries filled at least 1 antipsychotic prescription and 19% were hospitalized for schizophrenia during a 12-month observational period in our multistate cohort with approximately 2/3 nonwhite beneficiaries. Four quality constructs emerged: inpatient, emergency room, pharmacologic/ambulatory, and ambulatory only. Using a 2-parameter logistic model, pharmacologic/ambulatory care quality varied from -2.35 to 1.26 (higher = better quality). Black and Latinx beneficiaries had lower pharmacologic/ambulatory quality compared with whites. Race/ethnicity modified the association of state and pharmacologic/ambulatory care quality in latent regression modeling. Average quality ranged from -0.28 (95% confidence interval, -2.15 to 1.04) for blacks in New Jersey to 0.46 [95% confidence interval, -0.89 to 1.40] for whites in Michigan.

CONCLUSIONS

By combining multiple quality measures using item response theory models, a composite measure can be estimated that has more statistical power to detect differences among subjects than the observed mean per subject.

The effectiveness of person-centred quality improvement strategies on the management and control of hypertension in primary care: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of person-centred quality improvement strategies on the management and control of adults with hypertension in primary care.

METHODS

A systematic review and meta-analysis was conducted using the Medline, Cochrane Central Register for Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature, and APA PsycINFO databases (January 1980 to March 2020). Randomized controlled trials that evaluated person-centred quality improvement strategies for the management and control of essential hypertension among adults ( ≥ 18 years) in primary care were included. Random effects models were used to estimate weighted mean differences (WMD) for the change in systolic and diastolic blood pressures (SBP, DBP) from baseline; risk ratios (RR) were calculated for the proportion of participants achieving target blood pressures, for each quality improvement strategy assessed. A qualitative review of the implementation details of the interventions was conducted to identify common components of interventions that were effective in improving blood pressure outcomes.

RESULTS

Eight studies were included (total of 5654 patients). Findings favour use of person-centred quality improvement interventions over usual care (RR = 1.23 [95% CI: 1.01; 1.48]) for improving blood pressure outcomes. Self-management (RR = 1.43 [95% CI: 1.23; 1.65]) had the greatest effects on blood pressure targets. Clinician education resulted in the greatest SBP reduction (WMD:6.09 mmHg [95% CI: 2.32; 9.85]), while patient education and patient reminder systems (both WMD:4.86 mmHg [95% CI: 0.88; 8.83]) saw the most improvements in DBP. While interventions varied in their strategy implementation, common features of effective interventions included tailored communication with patients, use of health information technology, and multidisciplinary collaboration.

CONCLUSION

Person-centred quality improvement strategies were effective in improving blood pressure outcomes. Further research is needed regarding the context of implementing interventions to provide greater insight into the components of a person-centred quality improvement intervention most effective in improving hypertension outcomes.

Factors Associated With Medical Staff's Engagement and Perception of a Quality Improvement Program for Acute Coronary Syndromes in Hospitals: A Nationally Representative Mixed-Methods Study in China

Background Medical staff represent critical stakeholders in the process of implementing a quality improvement (QI) program. Few studies, however, have examined factors that influence medical staff engagement and perception regarding QI programs. Methods and Results We conducted a nationally representative survey of a QI program in 6 cities in China. Quantitative data were analyzed using multilevel mixed-effects linear regression models, and qualitative data were analyzed using the framework method. The engagement of medical staff was significantly related to knowledge scores regarding the specific content of chest pain center accreditation (β=0.42; 95% CI, 0.27-0.57). Higher scores for inner motivation (odds ratio [OR], 1.79; 95% CI, 1.18-2.72) and resource support (OR, 1.52; 95% CI, 1.02-2.24) and lower scores for implementation barriers (OR, 0.81; 95% CI, 0.67-0.98) were associated with improved treatment behaviors among medical staff. Resource support (OR, 4.52; 95% CI, 2.99-6.84) and lower complexity (OR, 0.81; 95% CI, 0.65-1.00) had positive effects on medical staff satisfaction, and respondents with improved treatment behaviors were more satisfied with the QI program. Similar findings were found for factors that influenced medical staff's assessment of QI program sustainability. The qualitative analysis further confirmed and supplemented the findings of quantitative analysis. Conclusions Clarifying and addressing factors associated with medical staff's engagement and perception of QI programs will allow further improvements in quality of care for patients with acute coronary syndrome. These findings may also be applicable to other QI programs in China and other low- and middle-income countries. Registration URL: https://www.chictr.org.cn/; Unique identifier: Chi-CTR2100043319.

Effectiveness of Quality Improvement Coaching on Process Outcomes in Health Care Settings: A Systematic Review

BACKGROUND

A culture of improvement is an important feature of high-quality health care systems. However, health care teams often need support to translate quality improvement (QI) activities into practice. One method of support is consultation from a QI coach. The literature suggests that coaching interventions have a positive impact on clinical outcomes. However, the impact of coaching on specific process outcomes, like adoption of clinical care activities, is unknown. Identifying the process outcomes for which QI coaching is most effective could provide specific guidance on when to employ this strategy.

METHODS

We searched multiple databases from inception through July 2021. Studies that addressed the effects of QI coaching on process of care outcomes were included. Two reviewers independently extracted study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE.

RESULTS

We identified 1983 articles, of which 23 cluster-randomized trials met eligibility criteria. All but two took place in a primary care setting. Overall, interventions typically targeted multiple simultaneous processes of care activities. We found that coaching probably has a beneficial effect on composite process of care outcomes (n = 9) and ordering of labs and vital signs (n = 6), and possibly has a beneficial effect on changes in organizational process of care (n = 5), appropriate documentation (n = 5), and delivery of appropriate counseling (n = 3). We did not perform meta-analyses because of conceptual heterogeneity around intervention design and outcomes; rather, we synthesized the data narratively. Due to imprecision, inconsistency, and high risk of bias of the included studies, we judged the certainty of these results as low or very low.

CONCLUSION

QI coaching interventions may affect certain processes of care activities such as ordering of labs and vital signs. Future research that advances the identification of when QI coaching is most beneficial for health care teams seeking to implement improvement processes in pursuit of high-quality care will support efficient use of QI resources.

PROTOCOL REGISTRATION

This study was registered and followed a published protocol (PROSPERO: CRD42020165069).

Bridging the Silos: A Comparative Analysis of Implementation Science and Improvement Science

Background

Implementation science and improvement science have similar goals of improving health care services for better patient and population outcomes, yet historically there has been limited exchange between the two fields. Implementation science was born out of the recognition that research findings and effective practices should be more systematically disseminated and applied in various settings to achieve improved health and welfare of populations. Improvement science has grown out of the wider quality improvement movement, but a fundamental difference between quality improvement and improvement science is that the former generates knowledge for local improvement, whereas the latter is aimed at producing generalizable scientific knowledge.

Objectives

The first objective of this paper is to characterise and contrast implementation science and improvement science. The second objective, building on the first, is to highlight aspects of improvement science that potentially could inform implementation science and vice versa.

Methods

We used a critical literature review approach. Search methods included systematic literature searches in PubMed, CINAHL, and PsycINFO until October 2021; reviewing references in identified articles and books; and the authors' own cross-disciplinary knowledge of key literature.

Findings

The comparative analysis of the fields of implementation science and improvement science centred on six categories: (1) influences; (2) ontology, epistemology and methodology; (3) identified problem; (4) potential solutions; (5) analytical tools; and (6) knowledge production and use. The two fields have different origins and draw mostly on different sources of knowledge, but they have a shared goal of using scientific methods to understand and explain how health care services can be improved for their users. Both describe problems in terms of a gap or chasm between current and optimal care delivery and consider similar strategies to address the problems. Both apply a range of analytical tools to analyse problems and facilitate appropriate solutions.

Conclusions

Implementation science and improvement science have similar endpoints but different starting points and academic perspectives. To bridge the silos between the fields, increased collaboration between implementation and improvement scholars will help to clarify the differences and connections between the science and practice of improvement, to expand scientific application of quality improvement tools, to further address contextual influences on implementation and improvement efforts, and to share and use theory to support strategy development, delivery and evaluation.

Embedded trials within national clinical audit programmes: A qualitative interview study of enablers and barriers

Background

Audit and feedback entails systematic documentation of clinical performance based on explicit criteria or standards which is then fed back to professionals in a structured manner. There are potential significant returns on investment from partnerships between existing clinical audit programmes in coordinated programmes of research to test ways of improving the effect of their feedback to drive greater improvements in health care delivery and population outcomes. We explored barriers to and enablers of embedding audit and feedback trials within clinical audit programmes.

Methods

We purposively recruited participants with varied experience in embedded trials in audit programmes. We conducted qualitative semi-structured interviews, guided by behavioural theory, with researchers, clinical audit programme staff and health care professionals. Recorded interviews were transcribed, and data coded and thematically analysed.

Results

We interviewed 31 participants (9 feedback researchers, 14 audit staff and 8 healthcare professionals, many having dual roles). We identified barriers and enablers for all 14 theoretical domains but no relationship between domains and participant role. We identified four optimal conditions for sustainable collaboration from the perspectives of stakeholders: resources, that is, recognition that audit programmes need to create capacity to participate in research, and research must be adapted to fit within each programme’s constraints; logistics, namely, that partnerships need to address data sharing and audit quality, while securing research funding to ensure operational success; leadership, that is, enthusiastic and engaged audit programme leaders must motivate their team and engage local stakeholders; and relationships, meaning that trust between researchers and audit programmes must be established over time by identifying shared priorities and meeting each partner’s needs.

Conclusion

Successfully embedding research within clinical audit programmes is likely to require compromise, logistical expertise, leadership and trusting relationships to overcome perceived risks and fully realise benefits.

Increased Accuracy to c-Fos-Positive Neuron Counting

There is not a described method to count the core label of c-Fos-positive neurons, avoiding false-positive and false-negative results. The aim of this manuscript is to provide guidelines for a secure and accurate method to calculate a threshold to select which core of c-Fos-positive neurons marked by immunofluorescence has to be scored. A background percentage was calculated by dividing the intensity value (0 to 255) of the core of c-Fos-positive neurons by its surrounding background from the 8-bit images obtained in a previous study. Using the background percentage from 20% up to 98%, raising 2% once for each score, as threshold to choose which core has to be counted, a script was written for the R program to count the number of the c-Fos-positive neurons and the comparison between control and experimental groups. The differences of the average number of the core counted c-Fos-positive neurons between control and experimental groups, at all thresholds studied, showed a rising value related to an increase of the background percentage threshold as well as a decrease of its p value related to an increase of the threshold of background percentage. For the smallest thresholds (high intensity of label), the differences between groups are suppressed (false negative). However, for the biggest thresholds (nonspecific label), these differences are always the same (false positive). Therefore, to avoid the false-negative and the false-positive values, it was chosen as the threshold of 62% the inflection point of the linear regression, which is equally different from the biggest and smallest values of the differences between groups.

Adoption of Innovation in Herpes Simplex Virus Keratitis

Herpes simplex keratitis, caused primarily by human herpes simplex virus type 1 (HSV-1), remains the most common infectious cause of unilateral blindness and vision impairment in the industrialized world. Major advances in the care of HSV keratitis have been driven in large part by the landmark Herpetic Eye Disease Study randomized clinical trials, which were among the first in ophthalmology to reflect emerging trial conventions, including multicenter subject enrollment, double-masking, placebo controls, and a priori sample size determinations. The results of these trials now form much of the evidence basis for the management of this disease. However, management patterns in clinical practice often deviate from evidence-based care. These perceived quality gaps have given rise to the evolving field of implementation science, which is concerned with the methods of promoting the application of evidence-based medicine within routine care. To overcome variations in the quality and consistency of care for HSV keratitis, a range of clinical- and technology-based innovations are proposed. The most pressing needs include the following: a rational and tractable disease classification scheme that provides an immediate link between the anatomical localization of disease (corneal epithelial, stromal, or endothelial) and the appropriate treatment, and the actualization of an electronic medical record system capable of providing evidence-based treatment algorithms at relevant points of care. The latter would also input data to population-wide disease registries to identify implementation-rich targets for quality improvement, education, and research. These innovations may allow us to reduce the human and economic burdens of this highly morbid, and often blinding, disease.

Building an advocacy model to improve the dementia-capability of health plans in California

BACKGROUND

Given the high and growing prevalence of Alzheimer's disease and related dementias, and the intensity of this population's care needs, it is imperative that healthcare systems increase their capacity to effectively serve people living with dementia (PLwD). The Dementia Cal MediConnect (Dementia CMC) project proposes an advocacy model that may foster dementia-capable systems change.

METHODS

The Dementia CMC project was a 5-year partnership (2013-2018) between local Alzheimer's organizations and 10 managed care health plans (HPs) in California's duals demonstration. It used an advocacy model with the following steps: (1) Identify dementia-capable best practices to set as systems change indicators; (2) Identify and leverage public policies in support of systems change indicators; (3) Identify and engage champions; (4) Develop and advocate for a business case to improve dementia care; (5) Identify gaps in dementia-capable practices; (6) Provide technical assistance, tools, and staff training to address the gaps in dementia-capable practices; and (7) Track systems change. Systems change data were collected through participant observation with HPs and interviews with key informants representing partnering organizations or government entities.

RESULTS

Participating HPs reported making systems changes toward more dementia-capable practices such as: better pathways for detection and diagnosis; better identification, assessment, support, and engagement of caregivers; and improved systems of referral to community-based organizations (CBOs), including Alzheimer's CBOs. Some indicators of systems change were inconclusive due to flawed assumptions around HP's care coordination, and the availability of common electronic health records between HPs and providers.

CONCLUSION

The application of this advocacy model in California has led to systems changes that can improve care for PLwD and their caregivers and should be replicated to expand the dementia-capability of other health systems. Continued efforts to refine indicators are needed to capture systems change in complex and changing health systems.

Different approaches to making and testing change in healthcare

Greg Ogrinc and colleagues call for greater exploitation of the synergies between quality improvement and implementation science in improving care

Improving the Quality of Inpatient Discharge Instructions: An Evaluation and Implementation of Best Practices

OBJECTIVES

Little is known about whether improving the quality of written discharge instructions can result in improved readmission rates and whether there are differences in the quality of discharge instructions based on provider and patient characteristics. We set out to determine provider characteristics associated with high quality discharge instructions and whether redesigned discharge instructions would lead to improvement in their quality and reduce hospital readmission rates.

METHODS

We instituted sequential interventions of educational outreach and a redesigned discharge instructions template and evaluated their quality using 11 metrics based on established best practices and subsequent 30-day readmission rates.

RESULTS

In total, 225 randomly selected charts were reviewed during a 15-month period. An average of 5.36 quality metrics were completed before our interventions, which increased to 5.61 after educational outreach and 7.16 after the template was redesigned. The risk standardized 30-day readmission rate fluctuated from a baseline of 10.48% to 12.71% and 10.97% following each intervention, respectively. Medical students completed significantly more quality metrics than interns, residents, or attendings (P < 0.05 for all) and residents completed significantly more than attendings (P = 0.014).

CONCLUSIONS

Although an education intervention was ineffective in improving discharge instruction quality, a redesigned discharge instructions template did improve the quality of patient discharge instructions. Neither intervention led to a meaningful change in readmission rates. We also found significant differences in the quality of discharge instructions based on the level of training of the author of the discharge instructions.

Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks

Purpose

As a discipline, health organisation and management is focused on health-specific, collective behaviours and activities, whose empirical and theoretical scholarship remains under-utilised in the field of implementation science. This under-engagement between fields potentially constrains the understanding of mechanisms influencing the implementation of evidence-based innovations in health care. The aim of this viewpoint article is to examine how a selection of theories, models and frameworks (theoretical approaches) have been applied to better understand phenomena at the micro, meso and macro systems levels for the implementation of health care innovations. The purpose of which is to illustrate the potential applicability and complementarity of embedding health organisation and management scholarship within the study of implementation science.

Design/methodology/approach

The authors begin by introducing the two fields, before exploring how exemplary theories, models and frameworks have been applied to study the implementation of innovations in the health organisation and management literature. In this viewpoint article, the authors briefly reviewed a targeted collection of articles published in the Journal of Health Organization and Management (as a proxy for the broader literature) and identified the theories, models and frameworks they applied in implementation studies. The authors then present a more detailed exploration of three interdisciplinary theories and how they were applied across three different levels of health systems: normalization process theory (NPT) at the micro individual and interpersonal level; institutional logics at the meso organisational level; and complexity theory at the macro policy level. These examples are used to illustrate practical considerations when implementing change in health care organisations that can and have been used across various levels of the health system beyond these presented examples.

Findings

Within the Journal of Health Organization and Management, the authors identified 31 implementation articles, utilising 34 theories, models or frameworks published in the last five years. As an example of how theories, models and frameworks can be applied at the micro individual and interpersonal levels, behavioural theories originating from psychology and sociology (e.g. NPT) were used to guide the selection of appropriate implementation strategies or explain implementation outcomes based on identified barriers and enablers to implementing innovations of interest. Projects aiming to implement change at the meso organisational level can learn from the application of theories such as institutional logics, which help elucidate how relationships at the macro and micro-level have a powerful influence on successful or unsuccessful organisational action. At the macro policy level, complexity theory represented a promising direction for implementation science by considering health care organisations as complex adaptive systems.

Originality/value

This paper illustrates the utility of a range of theories, models and frameworks for implementation science, from a health organisation and management standpoint. The authors’ viewpoint article suggests that increased crossovers could contribute to strengthening both disciplines and our understanding of how to support the implementation of evidence-based innovations in health care.

Implementation science protocol for a participatory, theory-informed implementation research programme in the context of health system strengthening in sub-Saharan Africa (ASSET-ImplementER)

OBJECTIVES

ASSET (Health System Strengthening in sub-Saharan Africa) is a health system strengthening (HSS) programme involving eight work-packages (ie, a research study that addresses a specific need for HSS) that aims to develop solutions that support high-quality care. Here we present the protocol for the implementation science (IS) theme within ASSET (ASSET-ImplmentER) that aims to understand what HSS interventions work, for whom and how, and how IS methodologies can be adapted to improve the HSS interventions within resource-poor contexts.

SETTINGS

Publicly funded health facilities in rural and urban areas in in Ethiopia, South Africa, Sierra Leone, and Zimbabwe.

PARTICIPANTS

Research staff including principal investigators, coinvestigators, field staff, PhD students, and research assistants.

INTERVENTIONS

Work-packages use a mixed-methods effectiveness-effectiveness hybrid designs. At the end of the pre-implementation phase, a workshop is held whereby the IS theme, jointly with ASSET work-packages apply IS determinant frameworks to research findings to identify factors that influence the effectiveness of delivering evidence-informed care. Determinants are used to select a set of HSS interventions for further evaluation, where work-packages also theorise selective mechanisms.In the piloting and rolling implementation phase, work-packages pilot the HSS interventions. An iterative process then begins involving evaluation, reflection and adaptation. Throughout this phase, IS determinant frameworks are applied to monitor and identify barriers/enablers to implementation. Selective mechanisms of action are also investigated. Implementation outcomes are evaluated using qualitative and quantitative methods. The psychometric properties of outcome measures including acceptability, appropriateness and feasibility are also evaluated. In a final workshop, work-packages come together, to reflect and explore the utility of the selected IS methods and provide suggestions for future use.Structured templates are used to organise and analyse common and heterogeneous patterns across work-packages. Qualitative data are analysed using thematic analysis and quantitative data are analysed using means and proportions.

CONCLUSIONS

We use a novel combination of IS methods at a programmatic level to facilitate comparisons of determinants and mechanisms that influence the effectiveness of HSS interventions in achieving implementation outcomes across different contexts. The study also contributes conceptual development and clarification at the underdeveloped interface of IS, HSS and global health.The ASSET-ImplementER theme is considered minimal risk as we only interview researchers involved in the different work-packages. To this effect we have received approval from King's College London Ethics Committee for research that is considered minimal risk (Reference number: MRA-20/21-21772).

Implementing Improvements: Opportunities to Integrate Quality Improvement and Implementation Science

In hospitals, improvers and implementers use quality improvement science (QIS) and less frequently implementation research (IR) to improve health care and health outcomes. Narrowly defined quality improvement (QI) guided by QIS focuses on transforming systems of care to improve health care quality and delivery and IR focuses on developing approaches to close the gap between what is known (research findings) and what is practiced (by clinicians). However, QI regularly involves implementing evidence and IR consistently addresses organizational and setting-level factors. The disciplines share a common end goal, namely, to improve health outcomes, and work to understand and change the same actors in the same settings often encountering and addressing the same challenges. QIS has its origins in industry and IR in behavioral science and health services research. Despite overlap in purpose, the 2 sciences have evolved separately. Thought leaders in QIS and IR have argued the need for improved collaboration between the disciplines. The Veterans Health Administration's Quality Enhancement Research Initiative has successfully employed QIS methods to implement evidence-based practices more rapidly into clinical practice, but similar formal collaborations between QIS and IR are not widespread in other health care systems. Acute care teams are well positioned to improve care delivery and implement the latest evidence. We provide an overview of QIS and IR; examine the key characteristics of QIS and IR, including strengths and limitations of each discipline; and present specific recommendations for integration and collaboration between the 2 approaches to improve the impact of QI and implementation efforts in the hospital setting.

Process mapping in healthcare: a systematic review

INTRODUCTION

Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare.

METHODS

We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach.

RESULTS

The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions.

CONCLUSION

The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM.

TRIAL REGISTRATION

Prospero ID: CRD42017082140.

Improving quality and performance in substance use treatment programs: What is being done and why is it so hard?

SUMMARY

As states plan to implement system-wide change of any kind, it is important to understand program directors' perspectives on challenges they face. This is especially true with quality improvement reforms. Much research has focused on quality improvement in medicine, but there is a gap in our knowledge about programs that treat individuals with drug or alcohol use. From 2007 to 2016, Maine contracted with selected substance use treatment programs using financial incentives to improve quality, with focus on treatment access, engagement, retention, and completion as measures of quality. Using surveys and in-depth interviews, this research documents strategies that programs used to improve performance and challenges faced in implementing reforms. Only programs that received federal block grant funding through the state to provide substance use treatment were eligible for an incentive contract, creating a natural experiment with non-block grant programs (non-incentive). Directors were interviewed in incentive (n=13) and non-incentive programs (n=12).

FINDINGS

Thematic analysis revealed that: 1) programs focused on QI, but those eligible for incentives focused on different quality measures, 2) most of the reforms in both groups targeted improving treatment access and retention, and 3) programs faced substantial challenges in undertaking reforms. Despite efforts, many programs could not meet quality measures consistently over time and faced barriers over which they had little control.

APPLICATIONS

Policy makers and program administrators will benefit from knowing the challenges of undertaking QI initiatives and provide support for the programs.

Enhancing the translation of health behaviour change research into practice: a selective conceptual review of the synergy between implementation science and health psychology

Health psychology is at the forefront of developing and disseminating evidence, theories, and methods that have improved the understanding of health behaviour change. However, current dissemination approaches may be insufficient for promoting broader application and impact of this evidence to benefit the health of patients and the public. Nevertheless, behaviour change theory/methods typically directed towards health behaviours are now used in implementation science to understand and support behaviour change in individuals at different health system levels whose own behaviour impacts delivering evidence-based health behaviour change interventions. Despite contributing to implementation science, health psychology is perhaps doing less to draw from it. A redoubled focus on implementation science in health psychology could provide novel prospects for enhancing the impact of health behaviour change evidence. We report a Health Psychology Review-specific review-of-reviews of trials of health behaviour change interventions published from inception to April 2020. We identified 34 reviews and assessed whether implementation readiness of behaviour change interventions was discussed. We then narratively review how implementation science has integrated theory/methods from health psychology and related discipline. Finally, we demonstrate how greater synergy between implementation science and health psychology could promote greater follow-through on advances made in the science of health behaviour change.

Co-design and feasibility of a pharmacist-led minor ailment service

BACKGROUND

Community pharmacies provide an appropriate setting to deliver minor ailment services (MASs). Many community pharmacy services have been developed previously without stakeholder involvement. As a result, implementation of services may fail to produce the expected impact. The aim of this research was to co-design and test the feasibility of an Australian MAS for minor ailment presentations.

METHODS

This study used co-design methodology which included two phases: (1) a focus group with stakeholders to allow the conceptualization of the service and agreement on service elements; (2) a literature review of clinical guidelines and three working meetings with a team of editors and general practitioners for the development of treatment pathways. Following this, a study evaluating the feasibility of the co-designed service was undertaken. The qualitative part of the methodology associated with the feasibility study comprised semi-structured interviews with MAS pharmacists, observation and completion of a tool by change facilitators identifying barriers and facilitators to service delivery. Qualitative data obtained for all phases were analysed using thematic analysis.

RESULTS

The developed service included the following components: (i) an in-pharmacy consultation between the patient and pharmacist, (ii) treatment pathways accessible to pharmacists on the internet to guide consultations, (iii) existing digital communication systems used by general practice to exchange patient information, (iv) training, and (v) change facilitation. As a result of feasibility testing, twenty-six implementation factors were identified for practice change, with the main change being the simplification of the pharmacist-patient consultation and data collection processes.

CONCLUSIONS

An Australian MAS was generated as a result of co-design, while testing revealed that the co-designed service was feasible. As a result of integrating the views of multiple stakeholders, the designed MAS has been adapted to suit healthcare practices, which may increase the acceptance and impact of MAS when implemented into practice.

Comparing quality of primary healthcare between public and private providers in China: study protocol of a cross-sectional study using unannounced standardised patients in seven provinces of China

INTRODUCTION

The Chinese government has encouraged the development of private sector in delivering healthcare, including primary healthcare (PHC) in the new round of national health reform since 2009. However, the debate about the role of the private sector in achieving universal health coverage continues with poor support from theories and empirical evidence. This study intends to compare the quality of PHC services between the private and public providers in seven provinces in China, using unannounced standardised patients (USPs).

METHODS

We are developing and validating 13 USP cases most commonly observed in the PHC setting. Six domains of quality will be assessed by the USP: effectiveness, safety, patient centredness, efficiency, timeliness and equity. The USP will make 2200 visits to 705 public and 521 private PHC institutions across seven provinces, following a multistage clustered sample design. Using each USP-provider encounter as the analytical unit, we will first descriptively compare the raw differences in quality between the private and public providers and then analyse the association of ownership types and quality, using propensity score weighting.

ETHICS AND DISSEMINATION

The study was primarily funded by the National Natural Science Foundation of China (#71974211, #71874116 and # 72074163) and was also supported by the China Medical Board (#16-260, #18-300 and #18-301), and have received ethical approval from Sun Yat-sen University (#2019-024). The validated USP tool and the data collected in this study will be freely available for the public after the primary analysis of the study.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry: #ChiCTR2000032773.

Effect of collaborative quality improvement on stillbirths, neonatal mortality and newborn care practices in hospitals of Telangana and Andhra Pradesh, India: evidence from a quasi-experimental mixed-methods study

Background

Improving quality of care is a key priority to reduce neonatal mortality and stillbirths. The Safe Care, Saving Lives programme aimed to improve care in newborn care units and labour wards of 60 public and private hospitals in Telangana and Andhra Pradesh, India, using a collaborative quality improvement approach. Our external evaluation of this programme aimed to evaluate programme effects on implementation of maternal and newborn care practices, and impact on stillbirths, 7- and 28-day neonatal mortality rate in labour wards and neonatal care units. We also aimed to evaluate programme implementation and mechanisms of change.

Methods

We used a quasi-experimental plausibility design with a nested process evaluation. We evaluated effects on stillbirths, mortality and secondary outcomes relating to adherence to 20 evidence-based intrapartum and newborn care practices, comparing survey data from 29 hospitals receiving the intervention to 31 hospitals expected to receive the intervention later, using a difference-in-difference analysis. We analysed programme implementation data and conducted 42 semi-structured interviews in four case studies to describe implementation and address four theory-driven questions to explain the quantitative results.

Results

Only 7 of the 29 intervention hospitals were engaged in the intervention for its entire duration. There was no evidence of an effect of the intervention on stillbirths [DiD − 1.3 percentage points, 95% CI − 2.6–0.1], on neonatal mortality at age 7 days [DiD − 1.6, 95% CI − 9–6.2] or 28 days [DiD − 3.0, 95% CI − 12.9—6.9] or on adherence to target evidence-based intrapartum and newborn care practices. The process evaluation identified challenges in engaging leaders; challenges in developing capacity for quality improvement; and challenges in activating mechanisms of change at the unit level, rather than for a few individuals, and in sustaining these through the creation of new social norms.

Conclusion

Despite careful planning and substantial resources, the intervention was not feasible for implementation on a large scale. Greater focus is required on strategies to engage leadership. Quality improvement may need to be accompanied by clinical training. Further research is also needed on quality improvement using a health systems perspective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-020-01058-z.

Reducing Unnecessary Noninvasive Testing for Inpatients With Unstable Angina: The RUNIT Protocol

Background

Routine inpatient transthoracic echocardiography (TTE) for patients with unstable angina is common, but it anecdotally adds little value to clinical care. A practice audit at our academic hospital demonstrated that 61.5% of patients with troponin-negative chest pain (TNCP) had normal left ventriculography (LVG) during coronary angiography and normal TTE on the same admission (duplicate testing).

Methods

We developed the Reducing Non-Invasive Testing (RUNIT) protocol, a clinical algorithm applied by clinical nurses to patient with TNCP. We performed a prospective assessment of rate of duplicate testing before and after intervention. If patients met certain simple clinical criteria, their TTE was cancelled (RUNIT positive). Patients then proceeded to have either coronary angiography with LVG or noninvasive risk stratification. We aimed to reduce duplicate testing by 25% over a 1-year period. Balancing measures included pathology on ordered TTEs, 30-day readmission, length of stay, and number of LVG.

Results

Among 254 patients admitted with TNCP over 12 months, we reduced duplicate testing from 61.5% (before intervention) to 34% (P = 0.001). There was no clinical difference in 30-day readmission (0.9% vs 0.7%), and length of stay was significantly shorter in RUNIT positive (3.48 vs 4.16 days, P = 0.02). The majority of duplicate TTEs did not reveal any management-informing pathology. RUNIT-positive patients underwent more LVG than RUNIT-negative patients (78.3% vs 62.8%, P = 0.008).

Conclusion

We achieved a sustained reduction in reflexive TTE ordering in patients with TNCP, and we discuss the potential of nursing-led interventions to address other areas of low value care in cardiology.

The Antipsychotic Medication Management Fidelity Scale: Psychometric properties

The paper describes the Antipsychotic Medication Management Fidelity Scale and its psychometric properties, including interrater reliability, frequency distribution, sensitivity to change and feasibility. Fidelity assessors conducted fidelity reviews four times over 18 months at eight sites receiving implementation support for evidence-based antipsychotic medication management. Data analyses shows good to fair interrater reliability, adequate sensitivity to change over time and good feasibility. At 18 months, item ratings varied from poor to full fidelity on most items. Use of the scale can assess fidelity to evidence-based guidelines for antipsychotic medication management and guide efforts to improve practice. Further research should improve and better calibrate some items, and improve the procedures for access to information.Trial registration: ClinicalTrials.gov Identifier: NCT03271242.

The Cultural Politics of 'Implementation Science'

Despite the growing profile of 'implementation science', its status as a field of study remains ambiguous. Implementation science originates in the evidence-based movement and attempts to broaden the scope of evidence-based medicine to improve 'clinical effectiveness' and close the 'implementation gap'. To achieve this agenda, implementation science draws on methodologies from the social sciences to emphasise coherence between qualitative and quantitative approaches. In so doing, we ask if this is at the expense of ignoring the dominating tendencies of the evidence-based movement and consider if some of the methodologies being drawn on should be considered irreconcilable with evidence-based methodologies.

A short cultural history of the UK Renal Registry 1995-2020

The Renal Association UK Renal Registry (UKRR), established in 1995, has reflected the development of Nephrology within the NHS over 25 years. It has been gradually enlarged to provide a formal agency for a range of consensus initiatives. It remains the source of the national epidemiology of renal replacement, feeding NHS infrastructures and Health Services Research. An extension into acute and chronic kidney disorders is in hand. As a template for medical audit it has contributed to a quality improvement ethos derived from several methodologies. It now offers a multifaceted virtual platform for special interest groups and patient-centricity. Its transformation demonstrates one of the compromises that have permitted specialty development within the inconstant envelope of the NHS.

If not always a bellwether, the clarity, form and scale of kidney disease provision still qualifies the UKRR as a demonstrator of healthcare possibilities to Medicine, Clinical Informatics and the NHS.

Replication Research Series-Paper 1 : A concept analysis and meta-narrative review established a comprehensive theoretical definition of replication research to improve its use

OBJECTIVES

The aim of this study is to clarify the concept of replication research to improve its appropriate use by researchers, editors, research funders, and decision makers.

STUDY DESIGN AND SETTING

We combined concept analysis and metanarrative review methods to synthetize knowledge on replication research from various scientific fields. We used multiple search strategies to identify the relevant literature published before April 2018. We summarized the data by seeking commonalities and differences in underlying conceptual and theoretical assumptions in the literature.

RESULTS

A total of 153 articles from various disciplines were included. The analysis led to the identification of three major definitions of replication: the repetition of a previous study, the extension of a previous study, and the road-testing of a theory. Attributes, conditions required to conduct replication studies, concerns related to the interpretation of replication studies, and diverse replication research typologies were synthesized, combined, and analyzed. Based on this metanarrative review, a comprehensive theoretical definition of replication research was formulated.

CONCLUSION

This study can support the adoption of a shared understanding and recognition of the indispensable nature of replication research for the sound development of knowledge in all research fields.

From kamishibai card to key card: a family-targeted quality improvement initiative to reduce paediatric central line-associated bloodstream infections

Background

Central line-associated bloodstream infections (CLABSIs) are major contributors to preventable harm in the inpatient paediatric setting. Despite multiple guidelines to reduce CLABSI, sustaining reliable central line maintenance bundle compliance remains elusive. We identified frontline and family engagement as key drivers for this initiative. The baseline CLABSI rate for all our paediatric inpatient units (January 2016–January 2017) was 1.71/1000 central line days with maintenance bundle compliance at 87.9% (monthly range 44%–100%).

Objective

To reduce CLABSI by increasing central line maintenance bundle compliance to greater than 90% using kamishibai card (K-card) audits and family ‘key card’ education.

Methods

We transitioned our central line maintenance bundle audits from checklists to directly observed K-card audits. K-cards list the central line maintenance bundle elements to be reviewed with frontline staff. Key cards are cue cards developed using a plain-language summary of CLABSI K-cards and used by frontline staff to educate families. Key cards were distributed to families of children with central lines to simultaneously engage patients, families and frontline staff after a successful implementation of the K-card audit process. A survey was used to obtain feedback from families.

Results

In the postintervention period (February 2017–December 2019), our CLABSI rate was 0.63/1000 central line days, and maintenance bundle compliance improved to 97.1% (monthly range 86%–100%, p<0.001). Of the 45 family surveys distributed, 20 (44%) were returned. Nineteen respondents (95%) reported being extremely satisfied with the key card programme and provided positive comments.

Conclusion

Combining the key card programme with K-card audits was associated with improved maintenance bundle compliance and a reduction in CLABSI. This programme has the potential for use in multiple healthcare improvement initiatives.

Association of guideline publication and delays to treatment in pediatric status epilepticus

Objective

To determine whether publication of evidence on delays in time to treatment shortens time to treatment in pediatric refractory convulsive status epilepticus (rSE), we compared time to treatment before (2011–2014) and after (2015–2019) publication of evidence of delays in treatment of rSE in the Pediatric Status Epilepticus Research Group (pSERG) as assessed by patient interviews and record review.

Methods

We performed a retrospective analysis of a prospectively collected dataset from June 2011 to September 2019 on pediatric patients (1 month–21 years of age) with rSE.

Results

We studied 328 patients (56% male) with median (25th–75th percentile [p₂₅–p₇₅]) age of 3.8 (1.3–9.4) years. There were no differences in the median (p₂₅–p₇₅) time to first benzodiazepine (BZD) (20 [5–52.5] vs 15 [5–38] minutes, p = 0.3919), time to first non-BZD antiseizure medication (68 [34.5–163.5] vs 65 [33–142] minutes, p = 0.7328), and time to first continuous infusion (186 [124.2–571] vs 160 [89.5–495] minutes, p = 0.2236). Among 157 patients with out-of-hospital onset whose time to hospital arrival was available, the proportion who received at least 1 BZD before hospital arrival increased after publication of evidence of delays (41 of 81 [50.6%] vs 57 of 76 [75%], p = 0.0018), and the odds ratio (OR) was also increased in multivariable logistic regression (OR 4.35 [95% confidence interval 1.96–10.3], p = 0.0005).

Conclusion

Publication of evidence on delays in time to treatment was not associated with improvements in time to treatment of rSE, although it was associated with an increase in the proportion of patients who received at least 1 BZD before hospital arrival.