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Background: Head and Neck Cancer (HNC) is the eighth most prevalent global cancer. Timely recognition of symptoms is crucial for reducing mortality rates. The EVolution of a patiEnt-REported symptom-based risk stratification sySTem to redesign the suspected Head and Neck cancer referral pathway (EVEREST-HN) study aims to develop and evaluate a risk stratification tool using patient reported symptoms, which will be populated remotely in the community before the patient is seen by the clinician to hasten HNC diagnosis. EVEREST-HN will design a patient SYmptom iNput Clinical (SYNC) system to gather patient symptom data and calculate a risk score to aid clinicians in identifying high-risk cases. This identification potentially allows for high-risk patients to be seen sooner, thereby improving patient outcomes., Methods: Three workshop sessions were conducted involving a total of 17 unique participants, with several contributing to multiple sessions: nine in the co-design session, six in the validation session, and nine in the evaluation session. The co-design session employed online collaboration with patients' representatives. Thematic analysis was used to identify requirements and concerns informing the development of a low-fidelity prototype. The validation session assessed whether the prototype aligned with patient expectations. In the evaluation session, participants interacted with an online prototype and provided further feedback., Results: During the co-design workshop, participants emphasized the need for a concise and clear SYNC system questionnaire for reporting suspected HNC symptoms. Concerns were raised about questionnaire length, language clarity, and the inclusion of probing questions. Participants suggested concise questions using lay language, incorporating visual aids for topics like alcohol and tobacco use, and making the sexual activity question optional. Recommendations included diverse language options, hard copies for non-English speakers, and phone call options for those uncomfortable with screen-based technology. The validation workshop confirmed that the prototype reflected participants' ideas. Feedback highlighted the need for call-back features to help those not confident with technology and the need to present symptom questions first before social background questions. Feedback from the evaluation demonstrated a commitment to efficiency, and continuous improvement., Conclusion: This study aims to develop the SYNC system to enhance efficiency of suspected HNC referrals. The workshops highlighted the importance of end-user inclusiveness in the system development life cycle, with collaboration with stakeholders and repeated feedback, providing crucial insights for ensuring the SYNC system effectively addresses the needs and concerns of patients in the context of HNC diagnosis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Introduction: Between 2009/2010 and 2019/2020, England witnessed an increase in suspected head and neck cancer (sHNC) referrals from 140 to 404 patients per 100 000 population. 1 in 10 patients are not seen within the 2-week target, contributing to patient anxiety. We will develop a pathway for sHNC referrals, based on the Head and Neck Cancer Risk Calculator. The evolution of a patient-reported symptom-based risk stratification system to redesign the sHNC referral pathway (EVEREST-HN) Programme comprises six work packages (WPs). This protocol describes WP1 and WP2. WP1 will obtain an understanding of language to optimise the SYmptom iNput Clinical (SYNC) system patient-reported symptom questionnaire for sHNC referrals and outline requirements for the SYNC system. WP2 will codesign key elements of the SYNC system, including the SYNC Questionnaire, and accompanying behaviour change materials., Methods and Analysis: WP1 will be conducted at three acute National Health Service (NHS) trusts with variation in service delivery models and ensuring a broad mixture of social, economic and cultural backgrounds of participants. Up to 150 patients with sHNC (n=50 per site) and 15 clinicians (n=5 per site) will be recruited. WP1 will use qualitative methods including interviews, observation and recordings of consultations. Rapid qualitative analysis and inductive thematic analysis will be used to analyse the data. WP2 will recruit lay patient representatives to participate in online focus groups (n=8 per focus group), think-aloud technique and experience-based codesign and will be analysed using qualitative and quantitative approaches., Ethics and Dissemination: The committee for clinical research at The Royal Marsden, a research ethics committee and the Health Research Authority approved this protocol. All participants will give informed consent. Ethical issues of working with patients on an urgent cancer diagnostic pathway have been considered. Findings will be disseminated via journal publications, conference presentations and public engagement activities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable., Aim: To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England., Design: Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews ( n  = 50), patient and carer interviews ( n  = 31) and record review ( n  = 60)., Setting: Three Trusts, one orthopaedic and one older person ward in each., Results: Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling., Limitations: Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted., Conclusions: (1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling., Future Work: (1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English., Study Registration: This study is registered as PROSPERO CRD42020184458., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Background: Falls are the most common safety incident reported by acute hospitals. In England national guidance recommends delivery of a multifactorial falls risk assessment (MFRA) and interventions tailored to address individual falls risk factors. However, there is variation in how these practices are implemented. This study aimed to explore the variation by examining what supports or constrains delivery of MFRAs and tailored interventions in acute hospitals., Methods: A realist review of literature was conducted with searches completed in three stages: (1) to construct hypotheses in the form of Context, Mechanism, Outcome configurations (CMOc) about how MFRAs and interventions are delivered, (2) to scope the breadth and depth of evidence available in Embase to test the CMOcs, and (3) following prioritisation of CMOcs, to refine search strategies for use in multiple databases. Citations were managed in EndNote; titles, abstracts, and full texts were screened, with 10% independently screened by two reviewers., Results: Two CMOcs were prioritised for testing labelled: Facilitation via MFRA tools, and Patient Participation in interventions. Analysis indicated that MFRA tools can prompt action, but the number and type of falls risk factors included in tools differ across organisations leading to variation in practice. Furthermore, the extent to which tools work as prompts is influenced by complex ward conditions such as changes in patient condition, bed swaps, and availability of falls prevention interventions. Patient participation in falls prevention interventions is more likely where patient directed messaging takes individual circumstances into account, e.g., not wanting to disturb nurses by using the call bell. However, interactions that elicit individual circumstances can be resource intensive and patients with cognitive impairment may not be able to participate despite appropriately directed messaging., Conclusions: Organisations should consider how tools can be developed in ways that better support consistent and comprehensive identification of patients' individual falls risk factors and the complex ward conditions that can disrupt how tools work as facilitators. Ward staff should be supported to deliver patient directed messaging that is informed by their individual circumstances to encourage participation in falls prevention interventions, where appropriate., Trial Registration: PROSPERO: CRD42020184458., (© 2023. The Author(s).)

Inpatient falls are an international patient safety concern, accounting for 30-40% of reported safety incidents in acute hospitals. They can cause both physical (e.g. hip fractures) and non-physical harm (e.g. reduced confidence) to patients. We used an approach known as a realist review to identify theories about what interventions might work for whom in what contexts, focusing on what supports and constrains effective use of multifactorial falls risk assessment and falls prevention interventions. One of these theories suggested that staff will integrate recommended practices into their work routines if falls risk assessment tools, including health IT, are quick and easy to use and facilitate existing work routines. Synthesis of empirical studies undertaken in the process of testing and refining this theory has implications for the design of health IT, suggesting that while health IT can support falls prevention through automation, such tools should also allow for incorporation of clinical judgement., (©2022 AMIA - All rights reserved.)

Background: Dashboards can support data-driven quality improvements in health care. They visualize data in ways intended to ease cognitive load and support data comprehension, but how they are best integrated into working practices needs further investigation., Objective: This paper reports the findings of a realist evaluation of a web-based quality dashboard (QualDash) developed to support the use of national audit data in quality improvement., Methods: QualDash was co-designed with data users and installed in 8 clinical services (3 pediatric intensive care units and 5 cardiology services) across 5 health care organizations (sites A-E) in England between July and December 2019. Champions were identified to support adoption. Data to evaluate QualDash were collected between July 2019 and August 2021 and consisted of 148.5 hours of observations including hospital wards and clinical governance meetings, log files that captured the extent of use of QualDash over 12 months, and a questionnaire designed to assess the dashboard's perceived usefulness and ease of use. Guided by the principles of realist evaluation, data were analyzed to understand how, why, and in what circumstances QualDash supported the use of national audit data in quality improvement., Results: The observations revealed that variation across sites in the amount and type of resources available to support data use, alongside staff interactions with QualDash, shaped its use and impact. Sites resourced with skilled audit support staff and established reporting systems (sites A and C) continued to use existing processes to report data. A number of constraints influenced use of QualDash in these sites including that some dashboard metrics were not configured in line with user expectations and staff were not fully aware how QualDash could be used to facilitate their work. In less well-resourced services, QualDash automated parts of their reporting process, streamlining the work of audit support staff (site B), and, in some cases, highlighted issues with data completeness that the service worked to address (site E). Questionnaire responses received from 23 participants indicated that QualDash was perceived as useful and easy to use despite its variable use in practice., Conclusions: Web-based dashboards have the potential to support data-driven improvement, providing access to visualizations that can help users address key questions about care quality. Findings from this study point to ways in which dashboard design might be improved to optimize use and impact in different contexts; this includes using data meaningful to stakeholders in the co-design process and actively engaging staff knowledgeable about current data use and routines in the scrutiny of the dashboard metrics and functions. In addition, consideration should be given to the processes of data collection and upload that underpin the quality of the data visualized and consequently its potential to stimulate quality improvement., International Registered Report Identifier (irrid): RR2-10.1136/bmjopen-2019-033208., (©Natasha Alvarado, Lynn McVey, Mai Elshehaly, Joanne Greenhalgh, Dawn Dowding, Roy Ruddle, Chris P Gale, Mamas Mamas, Patrick Doherty, Robert West, Richard Feltbower, Rebecca Randell. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 23.11.2021.)

Introduction: Falls are the most common type of safety incident reported by acute hospitals and can cause both physical (eg, hip fractures) and non-physical harm (eg, reduced confidence) to patients. It is recommended that, in order to prevent falls in hospital, patients should receive a multifactorial falls risk assessment and be provided with a multifactorial intervention, tailored to address the patient's identified individual risk factors. It is estimated that such an approach could reduce the incidence of inpatient falls by 25%-30% and reduce the annual cost of falls by up to 25%. However, there is substantial unexplained variation between hospitals in the number and type of assessments undertaken and interventions implemented., Methods and Analysis: A realist review will be undertaken to construct and test programme theories regarding (1) what supports and constrains the implementation of multifactorial falls risk assessment and tailored multifactorial falls prevention interventions in acute hospitals; and (2) how, why, in what contexts and for whom tailored multifactorial falls prevention interventions lead to a reduction in patients' falls risk. We will first identify stakeholders' theories concerning these two topics, searching Medline (1946-present) and Medline In-Process & Other Non-Indexed Citations, Health Management Information Consortium (1983-present) and CINAHL (1981-present). We will then test these theories systematically, using primary studies to determine whether empirical evidence supports, refutes or suggests a revision or addition to the identified theories., Ethics and Dissemination: The study does not require ethical approval. The review will provide evidence for how to implement multifactorial falls risk assessment and prevention strategies in acute hospital settings. This will be disseminated to academic and clinical audiences and will provide the basis for a future multi-site study through which the theories will be further refined., Systematic Review Registration: PROSPERO CRD42020184458., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Secondary use of data via integrated health information technology is fundamental to many healthcare policies and processes worldwide. However, repurposing data can be problematic and little research has been undertaken into the everyday practicalities of inter-system data sharing that helps explain why this is so, especially within (as opposed to between) organisations. In response, this article reports one of the most detailed empirical examinations undertaken to date of the work involved in repurposing healthcare data for National Clinical Audits., Methods: Fifty-four semi-structured, qualitative interviews were carried out with staff in five English National Health Service hospitals about their audit work, including 20 staff involved substantively with audit data collection. In addition, ethnographic observations took place on wards, in 'back offices' and meetings (102 h). Findings were analysed thematically and synthesised in narratives., Results: Although data were available within hospital applications for secondary use in some audit fields, which could, in theory, have been auto-populated, in practice staff regularly negotiated multiple, unintegrated systems to generate audit records. This work was complex and skilful, and involved cross-checking and double data entry, often using paper forms, to assure data quality and inform quality improvements., Conclusions: If technology is to facilitate the secondary use of healthcare data, the skilled but largely hidden labour of those who collect and recontextualise those data must be recognised. Their detailed understandings of what it takes to produce high quality data in specific contexts should inform the further development of integrated systems within organisations., (© 2021. The Author(s).)

Background: National Clinical Audits (NCAs) are a well-established quality improvement strategy used in healthcare settings. Significant resources, including clinicians' time, are invested in participating in NCAs, yet there is variation in the extent to which the resulting feedback stimulates quality improvement. The aim of this study was to explore the reasons behind this variation., Methods: We used realist evaluation to interrogate how context shapes the mechanisms through which NCAs work (or not) to stimulate quality improvement. Fifty-four interviews were conducted with doctors, nurses, audit clerks and other staff working with NCAs across five healthcare providers in England. In line with realist principles we scrutinised the data to identify how and why providers responded to NCA feedback (mechanisms), the circumstances that supported or constrained provider responses (context), and what happened as a result of the interactions between mechanisms and context (outcomes). We summarised our findings as Context+Mechanism = Outcome configurations., Results: We identified five mechanisms that explained provider interactions with NCA feedback: reputation, professionalism, competition, incentives, and professional development. Professionalism and incentives underpinned most frequent interaction with feedback, providing opportunities to stimulate quality improvement. Feedback was used routinely in these ways where it was generated from data stored in local databases before upload to NCA suppliers. Local databases enabled staff to access data easily, customise feedback and, importantly, the data were trusted as accurate, due to the skills and experience of staff supporting audit participation. Feedback produced by NCA suppliers, which included national comparator data, was used in a more limited capacity across providers. Challenges accessing supplier data in a timely way and concerns about the quality of data submitted across providers were reported to constrain use of this mode of feedback., Conclusion: The findings suggest that there are a number of mechanisms that underpin healthcare providers' interactions with NCA feedback. However, there is variation in the mode, frequency and impact of these interactions. Feedback was used most routinely, providing opportunities to stimulate quality improvement, within clinical services resourced to collect accurate data and to maintain local databases from which feedback could be customised for the needs of the service.

Healthcare organizations worldwide use quality dashboards to provide feedback to clinical teams and managers, in order to monitor care quality and stimulate quality improvement. However, there is limited evidence regarding the impact of quality dashboards and audit and feedback research focuses on feedback to individual clinicians, rather than to clinical and managerial teams. Consequently, we know little about what features a quality dashboard needs in order to provide benefit. We conducted 54 interviews across five healthcare organizations in the National Health Service in England, interviewing personnel at different levels of the organization, to understand how national (UK) clinical audit data are used for quality improvement and factors that support or constrain use of these data. The findings, organized around the themes of choosing performance indicators, assessing performance, identifying causes, communicating from ward to board, and data quality, have implications for the design of quality dashboards, which we have translated into a series of requirements., (©2019 AMIA - All rights reserved.)

Introduction: National audits are used to monitor care quality and safety and are anticipated to reduce unexplained variations in quality by stimulating quality improvement (QI). However, variation within and between providers in the extent of engagement with national audits means that the potential for national audit data to inform QI is not being realised. This study will undertake a feasibility evaluation of QualDash, a quality dashboard designed to support clinical teams and managers to explore data from two national audits, the Myocardial Ischaemia National Audit Project (MINAP) and the Paediatric Intensive Care Audit Network (PICANet)., Methods and Analysis: Realist evaluation, which involves building, testing and refining theories of how an intervention works, provides an overall framework for this feasibility study. Realist hypotheses that describe how, in what contexts, and why QualDash is expected to provide benefit will be tested across five hospitals. A controlled interrupted time series analysis, using key MINAP and PICANet measures, will provide preliminary evidence of the impact of QualDash, while ethnographic observations and interviews over 12 months will provide initial insight into contexts and mechanisms that lead to those impacts. Feasibility outcomes include the extent to which MINAP and PICANet data are used, data completeness in the audits, and the extent to which participants perceive QualDash to be useful and express the intention to continue using it after the study period., Ethics and Dissemination: The study has been approved by the University of Leeds School of Healthcare Research Ethics Committee. Study results will provide an initial understanding of how, in what contexts, and why quality dashboards lead to improvements in care quality. These will be disseminated to academic audiences, study participants, hospital IT departments and national audits. If the results show a trial is feasible, we will disseminate the QualDash software through a stepped wedge cluster randomised trial., Competing Interests: Competing interests: CG is a member of the MINAP Academic and Steering Groups. RF is the principal investigator for PICANet and RP was previously Principal Investigator for PICANet., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Context: HealthSpan Physicians (HSP), an integrated medical system in Northeast Ohio, partnered with the Young Men's Christian Association (YMCA) of Greater Cleveland to implement a referral system for the evidence-based Diabetes Prevention Program (DPP) throughout HSP. The YMCA of USA employs a cost-effective, customized version of the original DPP in which coaches take the place of in-house clinical staff. Efficacy of the YMCA DPP was shown earlier in the DEPLOY Study., Objective: To improve outcomes of metrics used in the DEPLOY Study., Design: Observational study focusing on engagement, persistence, recruitment, and adherence to the DPP. In August 2014, HSP mailed an invitation to 2200 patients identified as both Medicare eligible and at risk of prediabetes to attend no-obligation information sessions about the DPP. After these sessions, YMCA staff called interested participants and asked them to enroll in and to commit to the program. Motivation and reinforcement were provided to patients through YMCA-provided signs, brochures, and posters; the HSP Web site; and in-person conversations with primary care physicians., Main Outcome Measures: Average weight loss at the end of 16 weeks in the program and average retention through Session 9., Results: Of the 2200 patients contacted, 351 (16.0%) responded by attending the information session, and 228 enrolled in the YMCA DPP (11.3%) and persisted through at least Week 9. This result is an improvement over the 1.7% of eligible enrollees who responded to the DEPLOY Study's mailing., Conclusions: A marketing approach to implementing the YMCA DPP in an integrated medical system results in excellent outcomes., Competing Interests: Statement The author(s) have no conflicts of interest to disclose.