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Background: Surgery is among the most neglected parts of healthcare systems in low‐ and middle‐income countries. Ethiopia has launched a national strategic plan to address challenges in the surgical system. This study aimed to assess surgical capacity in two Ethiopian regions to inform priority areas for improvement. Methods: A mixed‐methods study was conducted using two tools adapted from the Lancet Commission's Surgical Assessment Tools: a quantitative Hospital Assessment Tool and a qualitative semistructured interview tool. Fifteen hospitals selected by the Federal Ministry of Health were surveyed in the Tigray and Amhara regions to assess the surgical system across five domains: service delivery, infrastructure, workforce, information management and financing. Results: Service delivery was low across hospitals with a mean(s.d.) of 5(6) surgical cases per week and a narrow range of procedures performed. Hospitals reported varying availability of basic infrastructure, including constant availability of electricity (9 of 15) and running water (5 of 15). Unavailable or broken diagnostic equipment was also common. The majority of surgical and anaesthesia services were provided by non‐physician clinicians, with little continuing education available. All hospitals tracked patient‐level data regularly and eight of 15 hospitals reported surgical volume data during the assessment, but research activities were limited. Hospital financing specified for surgery was rare and the majority of patients must pay out of pocket for care. Conclusion: Results from this study will inform programmes to simultaneously improve each of the health system domains in Ethiopia; this is required if better access to and quality of surgery, anaesthesia and obstetric services are to be achieved. Much to be done still [ABSTRACT FROM AUTHOR]

Abstract: Subchondral fractures are a common cause of joint pain that may ultimately lead to articular collapse and the need for arthroplasty. This type of fracture has been reported at multiple joints throughout the body. While clinical and radiographic resolution can be achieved, progressive bone collapse can occur and lead to a variety of complications. Understanding the pertinent imaging findings can aid in the early evaluation of subchondral fractures and in the prevention of their associated complications., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Organizational learning is critical for delivering safe, high-quality surgical care, especially in low- and middle-income countries (LMICs) where perioperative outcomes remain poor. While current investments in LMICs prioritize physical infrastructure, equipment, and staffing, investments in organizational learning are equally important to support innovation, creativity, and continuous improvement of surgical quality. This study aims to assess the extent to which health facilities in Tanzania's Lake Zone perform as learning organizations from the perspectives of surgical providers. The insights gained from this study can motivate future quality improvement initiatives and investments to improve surgical outcomes. We conducted a cross-sectional analysis using data from an adapted survey to explore the key components of organizational learning, including a supportive learning environment, effective learning processes, and encouraging leadership. Our sample included surgical team members and leaders at 20 facilities (health centers, district hospitals, and regional hospitals). We calculated the average of the responses at individual facilities. Responses that were 5+ on a 7-point scale or 4+ on a 5-point scale were considered positive. We examined the variation in responses by facility characteristics using a one-way ANOVA or Student's t-test. We used univariate and multiple regression to assess relationships between facility characteristics and perceptions of organizational learning. Ninety-eight surgical providers and leaders participated in the survey. The mean facility positive response rate was 95.1% (SD 6.1%). Time for reflection was the least favorable domain with a score of 62.5% (SD 35.8%). There was variation by facility characteristics including differences in time for reflection when comparing by level of care (P = .02) and location (P = .01), and differences in trying new approaches (P = .008), capacity building (P = .008), and information transfer (P = .01) when comparing public versus faith-based facilities. In multivariable analysis, suburban centers had less time for reflection than urban facilities (adjusted difference = -0.48; 95% CI: -0.95, -0.01; P = .046). Surgical team members reported more positive responses compared to surgical team leaders. We found a high overall positive response rate in characterizing organizational learning in surgery in 20 health facilities in Tanzania's Lake Zone. Our findings identify areas for improvement and provide a baseline for assessing the effectiveness of change initiatives. Future research should focus on validating the adapted survey and exploring the impact of strong learning environments on surgical outcomes in LMICs. Organizational learning is crucial in surgery and further research, funding, and policy work should be dedicated to improving learning cultures in health facilities., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Background: Strengthening health systems through planned safety and quality improvement initiatives is an imperative to achieve more equitable, resilient, and effective care. And yet, years of organizational behavior research demonstrate that change initiatives often fall short because managers fail to account for organizational readiness for change. This finding remains true especially among surgical safety and quality improvement initiatives in low-income countries and middle-income countries. In this study, our aim was to psychometrically assess the construct validity and internal consistency of the Safe Surgery Organizational Readiness Tool (SSORT), a short survey tool designed to provide change leaders with insight into facility infrastructure that supports learning and readiness to undertake change., Materials and Methods: To demonstrate generalizability and achieve a large sample size ( n =1706) to conduct exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), a collaboration between seven surgical and anesthesia safety and quality improvement initiatives was formed. Collected survey data from health care workers were divided into pilot, exploration, and confirmation samples. The pilot sample was used to assess feasibility. The exploration sample was used to conduct EFA, while the confirmation sample was used to conduct CFA. Factor internal consistency was assessed using Cronbach's alpha coefficient., Results: Results of the EFA retained 9 of the 16 proposed factors associated with readiness to change. CFA results of the identified 9 factor model, measured by 28 survey items, demonstrated excellent fit to data. These factors (appropriateness, resistance to change, team efficacy, team learning orientation, team valence, communication about change, learning environment, vision for sustainability, and facility capacity) were also found to be internally consistent., Conclusion: Our findings suggest that communication, team learning, and supportive environment are components of change readiness that can be reliably measured prior to implementation of projects that promote surgical safety and quality improvement in low-income countries and middle-income countries. Future research can link performance on identified factors to outcomes that matter most to patients., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Building health research capacity in low- and middle-income countries is essential to achieving universal access to safe, high-quality healthcare. It can enable healthcare workers to conduct locally relevant research and apply findings to strengthen their health delivery systems. However, lack of funding, experience, know-how, and weak research infrastructures hinders their ability. Understanding research capacity, engagement, and contextual factors that either promote or obstruct research efforts by healthcare workers can inform national strategies aimed at building research capacity., Methods: We used a convergent mixed-methods study design to understand research capacity and research engagement of healthcare workers in Tanzania's public health system, including the barriers, motivators, and facilitators to conducting research. Our sample included 462 randomly selected healthcare workers from 45 facilities. We conducted surveys and interviews to capture data in five categories: (1) healthcare workers research capacity; (2) research engagement; (3) barriers, motivators, and facilitators; (4) interest in conducting research; and (5) institutional research capacity. We assessed quantitative and qualitative data using frequency and thematic analysis, respectively; we merged the data to identify recurring and unifying concepts., Results: Respondents reported low experience and confidence in quantitative (34% and 28.7%, respectively) and qualitative research methods (34.5% and 19.6%, respectively). Less than half (44%) of healthcare workers engaged in research. Engagement in research was positively associated with: working at a District Hospital or above (p = 0.006), having a university degree or more (p = 0.007), and previous research experience (p = 0.001); it was negatively associated with female sex (p = 0.033). Barriers to conducting research included lack of research funding, time, skills, opportunities to practice, and research infrastructure. Motivators and facilitators included a desire to address health problems, professional development, and local and international collaborations. Almost all healthcare workers (92%) indicated interest in building their research capacity., Conclusion: Individual and institutional research capacity and engagement among healthcare workers in Tanzania is low, despite high interest for capacity building. We propose a fourfold pathway for building research capacity in Tanzania through (1) high-quality research training and mentorship; (2) strengthening research infrastructure, funding, and coordination; (3) implementing policies and strategies that stimulate engagement; and (4) strengthening local and international collaborations., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: COVID-19 has dramatically affected the delivery of health care and technical assistance. This is true in Tanzania, where maternal mortality and surgical infection rates are significantly higher than in high-income countries. This paper describes lessons learned about the optimal application of in-person and virtual mentorship in the Safe Surgery 2020 program to improve the quality of surgical services in Tanzania before and after the COVID-19 pandemic., Methods: From January 2018 through December 2020, Safe Surgery 2020 supported 40 health facilities in Tanzania's Lake Zone to improve the quality of surgical care. A blended surgical mentorship model, employing both onsite and virtual mentorship, was central to the program's capacity development approach. With COVID-19, the program pivoted to full virtual mentorship. Through continuous learning and adaptation processes, including a human-centered design workshop, surveys assessing mentors' confidence with different competencies, and focus group discussions with mentors, mentees and safe surgery program staff, the program distilled the optimal use of mentorship models., Results: Developing complex surgical skills, addressing contextual considerations, problem-solving, and building trusting relationships were best suited to in-person mentorship, whereas virtual mentorship was most effective in supporting mentees' quality improvement projects, data use, case discussions, and reinforcing clinical practices. Leading successful virtual learning required enhanced facilitation skills and active engagement of health facility leadership., Conclusions: In-person and virtual mentorship offer distinct benefits and complement each other when combined. Investing more in-person mentorship at the beginning of programs allows for the establishment of trust that is foundational to effective mentorship., Competing Interests: The Program in Global Surgery and Social Change, Jhpiego, and Assist International received funding from the GE Foundation for the Safe Surgery 2020 project. Laura Fitzgerald, Leopold Tibyehabwa, John Varallo, Edwin Ernest, Margaret Mary Bertram, Shehnaz Alidina, Stella Mshana, Dorcas Simba, Kevin Charles, Victoria Smith, Monica Cainer, Augustino Hellar, and Adam Katoto had financial support from GE Foundation for the submitted work. Laura Fitzgerald, Leopold Tibyehabwa, John Varallo, Edwin Ernest, Margaret Mary Bertram, Stella Mshana, Dorcas Simba, Kevin Charles, Augustino Hellar, and Adam Katoto declare financial support from ELMA Philanthropies. Anmol Patted has nothing to declare., (© 2023 Jhpiego Corporation.)

Background: A well-qualified workforce is critical to effective functioning of health systems and populations; however, skill gaps present a challenge in low-resource settings. While an emerging body of evidence suggests that mentorship can improve quality, access, and systems in African health settings by building the capacity of health providers, less is known about its implementation in surgery. We studied a novel surgical mentorship intervention as part of a safe surgery intervention (Safe Surgery 2020) in five rural Ethiopian facilities to understand factors affecting implementation of surgical mentorship in resource-constrained settings., Methods: We designed a convergent mixed-methods study to understand the experiences of mentees, mentors, hospital leaders, and external stakeholders with the mentorship intervention. Quantitative data was collected through a survey (n = 25) and qualitative data through in-depth interviews (n = 26) in 2018 to gather information on (1) intervention characteristics including areas of mentorship, mentee-mentor relationships, and mentor characteristics, (2) organizational context including facilitators and barriers to implementation, (3) perceived impact, and (4) respondent characteristics. We analyzed the quantitative and qualitative data using frequency analysis and the constant comparison method, respectively; we integrated findings to identify themes., Results: All mentees (100%) experienced the intervention as positive. Participants perceived impact as: safer and more frequent surgical procedures, collegial bonds between mentees and mentors, empowerment among mentees, and a culture of continuous learning. Over 70% of all mentees reported their confidence and job satisfaction increased. Supportive intervention characteristics included a systems focus, psychologically safe mentee-mentor relationships, and mentor characteristics including generosity with time and knowledge, understanding of local context, and interpersonal skills. Supportive organizational context included a receptive implementation climate. Intervention challenges included insufficient clinical training, inadequate mentor support, and inadequate dose. Organizational context challenges included resource constraints and a lack of common understanding of the intervention., Conclusion: We offer lessons for intervention designers, policy makers, and practitioners about optimizing surgical mentorship interventions in resource-constrained settings. We attribute the intervention's success to its holistic approach, a receptive climate, and effective mentee-mentor relationships. These qualities, along with policy support and adapting the intervention through user feedback are important for successful implementation., (© 2022. The Author(s).)

Background: Maternal sepsis accounts for significant morbidity and mortality in lower income countries, and caesarean delivery, while often necessary, augments the risk of maternal sepsis. The aim of this study was to investigate the effect of Safe Surgery 2020 surgical safety checklist (SSC) implementation on post-caesarean sepsis in Tanzania., Methods: We conducted a study in 20 facilities in Tanzania's Lake Zone as part of the Safe Surgery 2020 intervention. We prospectively collected data on SSC adherence and maternal sepsis outcomes from 1341 caesarian deliveries. The primary outcome measure was maternal sepsis rate. The primary predictor was SSC adherence. Multivariable logistic regression was used to estimate independent associations between SSC adherence and maternal sepsis., Results: Higher SSC adherence was associated with lower rates of maternal sepsis (<25% adherence: 5.0%; >75% adherence: 0.7%). Wound class and facility type were significantly associated with development of maternal sepsis (Wound class: Clean-Contaminated 3.7%, Contaminated/Dirty 20%, P = 0.018) (Facility Type: Health Centre 5.9%, District Hospital 4.5%, Regional Referral Hospital 1.7%, P = 0.018). In multivariable analysis, after controlling for wound class and facility type, higher SSC adherence was associated with lower rates of maternal sepsis, with an adjusted odds ratio of 0.17 per percentage point increase in SSC adherence (95% CI: 0.04, 0.79; P = 0.024)., Conclusions: Adherence to the SSC may reduce maternal morbidity during caesarean delivery, reinforcing the assumption that surgical quality interventions improve maternal outcomes. Future studies should continue to explore additional synergies between surgical and maternal quality improvement., (© 2021. Société Internationale de Chirurgie.)

Background: Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania's Lake Zone to distil implementation lessons for low-resource settings., Methods: We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers., Results: Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum., Conclusion: Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions., Competing Interests: Competing interests: SA, SSA, EB, MC, PC, IC, ADM, EE, LF, GCG, MG, AH, DTJ, AK, LK, StK, SaK, TNL, EM, SM, AM, GM, ChaR, CheR, HS, DS, VS, CS, MS, LT, AT, JV, TW and NZ had financial support from GE Foundation for the submitted work. EE, AH, GCG, AK, LF, SM, DS, LT, AT and JV declare financial support from ELMA Philanthropies. DB is employed by GE Foundation, which funded this work. NAK reports that he is the Director of Health, Social Welfare and Nutrition Services at PO-RALG in Tanzania. SM reports that she is the Acting Assistant Director NCDs, at the Ministry of Health, Community Development, Gender, Elderly and Children in Tanzania. Both institutions are party to the MoU under which the Safe Surgery 2020 intervention (the subject of the study/assessment) is implemented., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Despite ongoing maternal health interventions, maternal deaths in Tanzania remain high. One of the main causes of maternal mortality includes postoperative infections. Surgical site infection (SSI) rates are higher in low/middle-income countries (LMICs), such as Tanzania, compared with high-income countries. We evaluated the impact of a multicomponent safe surgery intervention in Tanzania, hypothesising it would (1) increase adherence to safety practices, such as the WHO Surgical Safety Checklist (SSC), (2) reduce SSI rates following caesarean section (CS) and (3) reduce CS-related perioperative mortality rates (POMRs)., Methods: We conducted a pre-cross-sectional/post-cross-sectional study design to evaluate WHO SSC utilisation, SSI rates and CS-related POMR before and 18 months after implementation. Our interventions included training of inter-professional surgical teams, promoting use of the WHO SSC and introducing an infection prevention (IP) bundle for all CS patients. We assessed use of WHO SSC and SSI rates through random sampling of 279 individual CS patient files. We reviewed registers and ward round reports to obtain the number of CS performed and CS-related deaths. We compared proportions of individuals with a characteristic of interest during pre-implementation and post implementation using the two-proportion z-test at p≤0.05 using STATA V.15., Results: The SSC utilisation rate for CS increased from 3.7% (5 out of 136) to 95.1% (136 out of 143) with p<0.001. Likewise, the proportion of women with SSI after CS reduced from 14% during baseline to 1% (p=0.002). The change in SSI rate after the implementation of the safe surgery interventions is statistically significant (p<0.001). The CS-related POMR decreased by 38.5% (p=0.6) after the implementation of safe surgery interventions., Conclusion: Our findings show that our intervention led to improved utilisation of the WHO SSC, reduced SSIs and a drop in CS-related POMR. We recommend replication of the interventions in other LMICs., Competing Interests: Competing interests: The authors declare no competing interests., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Safe, high-quality surgical care in many African countries is a critical need. Challenges include availability of surgical providers, improving quality of care, and building workforce capacity. Despite growing evidence that mentoring is effective in African healthcare settings, less is known about its role in surgery. We examined a multimodal approach to mentorship as part of a safe surgery intervention (Safe Surgery 2020) to improve surgical quality. Our goal was to distill lessons for policy makers, intervention designers, and practitioners on key elements of a successful surgical mentorship program., Methods: We used a convergent, mixed-methods design to examine the experiences of mentees, mentors, and facility leaders with mentorship at 10 health facilities in Tanzania's Lake Zone. A multidisciplinary team of mentors worked with surgical providers over 17 months using in-person mentorship, telementoring, and WhatsApp. We conducted surveys, in-depth interviews, and focus groups to capture data in four categories: (1) satisfaction with mentorship; (2) perceived impact; (3) elements of a successful mentoring program; and (4) challenges to implementing mentorship. We analyzed quantitative data using frequency analysis and qualitative data using the constant comparison method. Recurrent and unifying concepts were identified through merging the qualitative and quantitative data., Results: Overall, 96% of mentees experienced the intervention as positive, 88% were satisfied, and 100% supported continuing the intervention in the future. Mentees, mentors, and facility leaders perceived improvements in surgical practice, the surgical ecosystem, and in reducing postsurgical infections. Several themes related to the intervention's success emerged: (1) the intervention's design, including its multimodality, side-by-side mentorship, and standardization of practices; (2) the mentee-mentor relationship, including a friendly, safe, non-hierarchical, team relationship, as well as mentors' understanding of the local context; and (3) mentorship characteristics, including non-judgmental feedback, experience, and accessibility. Challenges included resistance to change, shortage of providers, mentorship dose, and logistics., Conclusions: Our study suggests a multimodal mentorship approach is promising in building the capacity of surgical providers. By distilling the experiences of the mentees, mentors, and facility leaders, our lessons provide a foundation for future efforts to establish effective surgical mentorship programs that build provider capacity and ultimately improve surgical quality., (© 2021. The Author(s).)

Fractures and dislocations of the elbow are a common cause of emergency department visits each year. Radiography remains the bedrock of an initial injury assessment, and recognition of distinctive injury patterns based on fracture location, morphology, and severity, guides optimal clinical decision-making. This article reviews basic elbow anatomy, frequently seen fractures and injury patterns, and highlights how these findings influence surgical planning and patient management., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Access to safe, high-quality surgical care in sub-Saharan Africa is a critical gap. Interventions to improve surgical quality have been developed, but research on their implementation is still at a nascent stage. We retrospectively applied the Exploration, Preparation, Implementation, Sustainment framework to characterize the implementation of Safe Surgery 2020, a multicomponent intervention to improve surgical quality., Methods: We used a longitudinal, qualitative research design to examine Safe Surgery 2020 in 10 health facilities in Tanzania's Lake Zone. We used documentation analysis with confirmatory key informant interviews (n = 6) to describe the exploration and preparation phases. We conducted interviews with health facility leaders and surgical team members at 1, 6, and 12 months (n = 101) post initiation to characterize the implementation phase. Data were analyzed using the constant comparison method., Results: In the exploration phase, research, expert consultation, and scoping activities revealed the need for a multicomponent intervention to improve surgical quality. In the preparation phase, onsite visits identified priorities and barriers to implementation to adapt the intervention components and curriculum. In the active implementation phase, 4 themes related to the inner organizational context-vision for safe surgery, existing surgical practices, leadership support, and resilience-and 3 themes related to the intervention-innovation-value fit, holistic approach, and buy-in-facilitated or hindered implementation. Interviewees perceived improvements in teamwork and communication and intra- and inter-facility learning, and their need to deliver safe surgery evolved during the implementation period., Conclusions: Examining implementation through the exploration, preparation, implementation, and sustainment phases offers insights into the implementation of interventions to improve surgical quality and promote sustainability., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority., Objective: To evaluate the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) on (1) adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) incidence of maternal sepsis, postoperative sepsis, and surgical site infection., Methods: We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania's Lake Zone, across a 3-month pre-intervention period in 2018 and 3-month post-intervention period in 2019. SS2020 is a multicomponent intervention to support four surgical quality areas: (i) leadership and teamwork, (ii) evidence-based surgery, anesthesia and equipment sterilization practices, (iii) data completeness and (iv) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10 000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or cesarean delivery), postoperative sepsis and SSIs prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact., Results: Safety practices improved significantly by an additional 20.5% (95% confidence interval (CI), 7.2-33.7%; P = 0.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7-60.8%; P = 0.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1-1.9%; P = 0.02). Documentation completeness improved by 41.8% (95% CI, 27.4-56.1%; P < 0.001) for sepsis and 22.3% (95% CI, 4.7-39.8%; P = 0.01) for SSIs., Conclusion: Our findings demonstrate the benefit of the SS2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low-resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Quality in Health Care.)

Rupture of the distal biceps tendon is becoming increasingly diagnosed due to an active aging population and an increase in diagnostic imaging opportunities. While physical exam may help in diagnosis, magnetic resonance imaging (MRI) is particularly useful in evaluating chronic rupture. Although partial tears can be managed conservatively, the gold standard treatment for a chronic distal biceps tear is anatomic reinsertion with additional use of an allograft or autograft. No study has highlighted the normal appearance and postsurgical complications seen on MRI associated with allograft or autograft usage. Clinicians and radiologists may be unaware of the normal and abnormal post-operative imaging findings and their clinical relevance. The purpose of this manuscript is to discuss the epidemiology, clinical presentation, and preoperative MRI findings of distal biceps ruptures necessitating reconstruction, to explain distal biceps tendon surgical reconstruction technique with allograft or autograft usage, to display the normal and abnormal post-operative MRI findings, and to review the clinical outcomes associated with the procedure.

Background: Recent efforts to increase access to safe and high-quality surgical care in low- and middle-income countries have proven successful. However, multiple facilities implementing the same safety and quality improvement interventions may not all achieve successful outcomes. This heterogeneity could be explained, in part, by pre-intervention organizational characteristics and lack of readiness of surgical facilities. In this study, we describe the process of developing and content validating the Safe Surgery Organizational Readiness Tool., Materials and Methods: The new tool was developed in two stages. First, qualitative results from a Safe Surgery 2020 intervention were combined with findings from a literature review of organizational readiness and change. Second, through iterative discussions and expert review, the Safe Surgery Organizational Readiness Tool was content validated., Results: The Safe Surgery Organizational Readiness Tool includes 14 domains and 56 items measuring the readiness of surgical facilities in low- and middle-income countries to implement surgical safety and quality improvement interventions. This multi-dimensional and multi-level tool offers insights into facility members' beliefs and attitudes at the individual, team, and facility levels. A panel review affirmed the content validity of the Safe Surgery Organizational Readiness Tool., Conclusion: The Safe Surgery Organizational Readiness Tool is a theory- and evidence-based tool that can be used by change agents and facility leaders in low- and middle-income countries to assess the baseline readiness of surgical facilities to implement surgical safety and quality improvement interventions. Next steps include assessing the reliability and validity of the Safe Surgery Organizational Readiness Tool, likely resulting in refinements., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The need to expand and better engage patients in primary care improvement persists., Purpose: Recognizing a continuum of forms of engagement, this study focused on identifying lessons for optimizing patient partnerships, wherein engagement is characterized by shared decision-making and practice improvement codesign., Methodology: Twenty-three semistructured interviews with providers and patients involved in improvement efforts in seven U.S. primary care practices in the Academic Innovations Collaborative (AIC). The AIC aimed to implement primary care improvement, emphasizing patient engagement in the process. Data were analyzed thematically., Results: Sites varied in their achievement of patient partnerships, encountering material, technical, and sociocultural obstacles. Time was a challenge for all sites, as was engaging a diversity of patients. Technical training on improvement processes and shared learning "on the job" were important. External, organizational, and individual-level resources helped overcome sociocultural challenges: The AIC drove provider buy-in, a team-based improvement approach helped shift relationships from providers and recipients toward teammates, and individual qualities and behaviors that flattened hierarchies and strengthened interpersonal relationships further enhanced "teamness." A key factor influencing progress toward transformative partnerships was a strong shared learning journey, characterized by frequent interactions, proximity to improvement decision-making, and learning together from the "lived experience" of practice improvement. Teams came to value not only patients' knowledge but also changes wrought by working collaboratively over time., Conclusion: Establishing practice improvement partnerships remains challenging, but partnering with patients on improvement journeys offers distinctive gains for high-quality patient-centered care., Practice Implications: Engaging diverse patient partners requires significant disruption to organizational norms and routines, and the trend toward team-based primary care offers a fertile context for patient partnerships. Material, technical, and sociocultural resources should be evaluated not only for whether they overcome specific challenges but also for how they enhance the shared learning journey., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc.)

Background: Working in partnership with the Cambodian Ministry of Health, the Safe Surgery 2020 initiative (SS2020) supports the prioritization of surgery and mobilization of resources to target limited workforce capacity. An evaluation study was conducted to assess the impact of SS2020 on intervention hospitals in Cambodia., Objective: To understand the impact of the SS2020 program on intervention hospitals in Cambodia by assessing the changes in key surgical performance indicators before and after the intervention, identifying key barriers and facilitators to adoption of learnings, and discovering lessons on the uptake and diffusion of this initiative in Cambodia and other similar contexts., Methods: This study is a convergent mixed-methods evaluation of a one-year multicomponent SS2020 intervention. Surgical observations were conducted in 8 intervention hospitals at baseline and endline to evaluate pre and post adherence to 20 safety, teamwork, and communication items. Fifteen focus groups were conducted in all intervention sites at endline to assess key facilitators and barriers to positive impact., Results: There was significant improvement in 19 of 20 indicators assessed during surgical observations. Among the highest performing indicators were safety items; among the lowest were communication items. Participants self-reported improved knowledge and positive behavior change after the intervention. Institutional change and direct patient impact were not widely reported. Most participants had favorable views of the mentorship model and were eager for the program to continue implementation., Conclusions: The results provide evidence that change in surgical ecosystems can be achieved on a short timeline with limited resources. The hub-and-spoke mentorship model can be successful in improving knowledge and changing behavior in surgical safety. Workforce development is important to improving surgical systems, but greater financial and human resources are needed. Ministry support in adopting, leading, and scaling is crucial to the continued success of safe surgery interventions in Cambodia.

Background: Postoperative mortality rate is one of six surgical indicators identified by the Lancet Commission on Global Surgery for monitoring access to high-quality surgical care. The primary aim of this study was to measure the postoperative mortality rate in Tanzania's Lake Zone to provide a baseline for surgical strengthening efforts. The secondary aim was to measure the effect of Safe Surgery 2020, a multi-component intervention to improve surgical quality, on postoperative mortality after 10 months., Methods: We prospectively collected data on postoperative mortality from 20 health centers, district hospitals, and regional hospitals in Tanzania's Lake Zone over two time periods: pre-intervention (February to April 2018) and post-intervention (March to May 2019). We analyzed postoperative mortality rates by procedure type. We used logistic regression to determine the impact of Safe Surgery 2020 on postoperative mortality., Results: The overall average in-hospital non-obstetric postoperative mortality rate for all surgery procedures was 2.62%. The postoperative mortality rates for laparotomy were 3.92% and for cesarean delivery was 0.24%. Logistic regression demonstrated no difference in the postoperative mortality rate after the Safe Surgery 2020 intervention., Conclusions: Our results inform national surgical planning in Tanzania by providing a sub-national baseline estimate of postoperative mortality rates for multiple surgical procedures and serve as a basis from which to measure the impact of future surgical quality interventions. Our study showed no improvement in postoperative mortality after implementation of Safe Surgery 2020, possibly due to low power to detect change.

Background: Strengthening surgical services in resource-constrained settings is contingent on using high-quality data to inform decision making at clinical, facility, and policy levels. However, the evidence is sparse on gaps in paper-based medical record quality for surgical and obstetric patients in low-resource settings., Objective: We aim to examine surgical and obstetric patient medical record data quality in health facilities as part of a surgical system strengthening initiative in northern Tanzania., Methods: To measure the incidence of Surgical Site Infections (SSIs), sepsis and maternal sepsis surgical and obstetric inpatients were followed prospectively, over three months in ten primary, district, and regional health facilities in northern Tanzania. Between April 22nd to May 1st, 2018, we retrospectively reviewed paper-based medical records of surgical and obstetric patients diagnosed with SSIs, post-operative sepsis, and maternal sepsis in the three-month follow-up period. A data quality assessment tool with18 data elements related to documentation of SSIs and sepsis diagnosis, their respective symptoms and vital signs, inpatient daily monitoring indicators, and demographic information was developed and used to assess the completeness of patient medical records., Results: Among the 157 patients diagnosed with SSI and sepsis, we found and reviewed 68% of all medical records. Among records reviewed, approximately one third (34%) and one quarter (23%) included documentation of SSI and sepsis diagnoses, respectively. 6% of reviewed records included documentation of all SSI and sepsis diagnoses, symptoms and vital signs, inpatient daily monitoring indicators, and demographic data., Conclusions: Strengthening data quality and record-keeping is essential for surgical team communication, continuity of care, and patient safety, especially in low resource settings where paper-based records are the primary means of data collection. High-quality primary health information provides facilities with actionable data for improving surgical and obstetric care quality at the facility level.

Background: The principle of workplace based assessment (WBA) is to assess trainees at work with feedback integrated into the program simultaneously. A student driven WBA model was introduced and perception evaluation of this teaching method was done subsequently by taking feedback from the faculty as well as the postgraduate trainees (PGs) of a residency program., Methods: Descriptive multimethod study was conducted. A WBA program was designed for PGs in Chemical Pathology on Moodle and forms utilized were case-based discussion (CBD), direct observation of practical skills (DOPS) and evaluation of clinical events (ECE). Consented assessors and PGs were trained on WBA through a workshop. Pretest and posttest to assess PGs knowledge before and after WBA were conducted. Every time a WBA form was filled, perception of PGs and assessors towards WBA, time taken to conduct single WBA and feedback were recorded. Faculty and PGs qualitative feedback on perception of WBA was taken via interviews. WBA tools data and qualitative feedback were used to evaluate the acceptability and feasibility of the new tools., Results: Six eligible PGs and seventeen assessors participated in this study. A total of 79 CBDs (assessors n = 7 and PGs n = 6), 12 ECEs (assessors n = 6 and PGs n = 5), and 20 DOPS (assessors n = 6 and PGs n = 6) were documented. PGs average pretest score was 55.6%, which was improved to 96.4% in posttest; p value< 0.05. Scores of annual assessment before and after implementation of WBA also showed significant improvement, p value 0.039, Overall mean time taken to evaluate PG's was 12.6 ± 9.9 min and feedback time 9.2 ± 7.4 min. Mean WBA process satisfaction of assessors and PGs on Likert scale of 1 to 10 was 8 ± 1 and 8.3 ± 0.8 respectively., Conclusion: Both assessors and fellows were satisfied with introduction and implementation of WBA. It gave the fellows opportunity to interact with assessors more often and learn from their rich experience. Gain in knowledge of PGs was identified from the statistically significant improvement in PGs' assessment scores after WBA implementation.

Background: An effective referral system is essential for a high-quality health system that provides safe surgical care while optimizing patient outcomes and ensuring efficiency. The role of referral systems in countries with under-resourced health systems is poorly understood. The aim of this study was to examine the rates, preventability, reasons and patterns of outward referrals of surgical patients across three levels of the healthcare system in Northern Tanzania., Methods: Referrals from surgical and obstetric wards were assessed at 20 health facilities in five rural regions prospectively over 3 months. Trained physician data collectors used data collection forms to capture referral details daily from hospital referral letters and through discussions with clinicians and nurses. Referrals were deemed preventable if the presenting condition was one that should be managed at the referring facility level per the national surgical, obstetric and anaesthesia plan but was referred., Results: Seven hundred forty-three total outward referrals were recorded during the study period. The referral rate was highest at regional hospitals (2.9%), followed by district hospitals (1.9%) and health centers (1.5%). About 35% of all referrals were preventable, with the highest rate from regional hospitals (70%). The most common reasons for referrals were staff-related (76%), followed by equipment (55%) and drugs or supplies (21%). Patient preference accounted for 1% of referrals. Three quarters of referrals (77%) were to the zonal hospital, followed by the regional hospitals (17%) and district hospitals (12%). The most common reason for referral to zonal (84%) and regional level (66%) hospitals was need for specialist care while the most common reason for referral to district level hospitals was non-functional imaging diagnostic equipment (28%)., Conclusions: Improving the referral system in Tanzania, in order to improve quality and efficiency of patient care, will require significant investments in human resources and equipment to meet the recommended standards at each level of care. Specifically, improving access to specialists at regional referral and district hospitals is likely to reduce the number of preventable referrals to higher level hospitals, thereby reducing overcrowding at higher-level hospitals and improving the efficiency of the health system.

Background: Infrastructure development and upgrading to support safe surgical services in primary health care facilities is an important step in the journey towards achieving Universal Health Coverage (UHC). Quality health service provision together with equitable geographic access and service delivery are important components that constitute UHC. Tanzania has been investing in infrastructure development to offer essential safe surgery close to communities at affordable costs while ensuring better outcomes. This study aimed to understand the public sector's efforts to improve the infrastructure of primary health facilities between 2005 and 2019. We assessed the construction rates, geographic coverage, and physical status of each facility, surgical safety and services rendered in public primary health facilities., Methods: Data was collected from existing policy reports, the Services Availability and Readiness Assessment (SARA) tool (physical status), the Health Facility Registry (HFR), implementation reports on infrastructure development from the 26 regions and 185 district councils across the country (covering assessment of physical infrastructure, waste management systems and inventories for ambulances) and Comprehensive Emergence Obstetric Care (CEMONC) signal functions assessment tool. Data was descriptively analyzed so as to understand the distribution of primary health care facilities and their status (old, new, upgraded, under construction, renovated and equipped), and the service provided, including essential surgical services., Results: Of 5072 (518 are Health Centers and 4554 are Dispensaries) existing public primary health care facilities, the majority (46%) had a physical status of A (good state), 33% (1693) had physical status of B (minor renovation needed) and the remaining facilities had physical status of C up to F (needing major renovation). About 33% (1673) of all health facilities had piped water and 5.1% had landline telecommunication system. Between 2015 and August 2019, a total of 419 (8.3%) health facilities (Consisting of 350 health centers and 69 District Council Hospitals) were either renovated or constructed and equipped to offer safe surgery services. Of all Health Centers only 115 (22.2%) were offering the CEMONC services. Of these 115 health facilities, only 20 (17.4%) were offering the CEMONC services with all 9 - signal functions and only 17.4% had facilities that are offering safe blood transfusion services., Conclusion: This study indicates that between 2015 and 2019 there has been improvement in physical status of primary health facilities as a result constructions, upgrading and equipping the facilities to offer safe surgery and related diagnostic services. Despite the achievements, still there is a high demand for good physical statuses and functioning of primary health facilities with capacity to offer essential and safe surgical services in the country also as an important strategy towards achieving UHC. This is also inline with the National Surgical, Obstetrics and Anesthesia plan (NSOAP).

Introduction: Millions of patients worldwide suffer disability and death due to complications related to surgery. Many of these complications can be reduced by the use of the World Health Organization (WHO) Surgical Safety Checklist (SSC), a simple tool that can enhance teamwork and communication and improve patient safety. Despite the evidence on benefits of its use, introducing and sustaining the use of the checklist are challenging. We present a team-based approach employed in a low-resource setting in Tanzania, which resulted in high checklist utilization and compliance rates., Methods: We reviewed reported data from facility registers supplemented by direct observation data by mentors to evaluate the use of the WHO SSC across 40 health facilities in two regions of Tanzania between January and December 2018. We analyzed the self-reported monthly data on total number of major surgeries performed and proportion of surgeries where the checklist was used. We also analyzed the use of the SSC during direct observation by external mentors and completion rates of the SSC in a random selection of patient files during two mentorship visits between June and December 2018., Results: During the review period, the average self-reported checklist utilization rate was 79.3% (11,564 out of 14,580 major surgeries). SSC utilization increased from 0% at baseline in January 2018 to 98% in December 2018. The proportion of checklists that were completely and correctly filled out increased between the two mentor visits from 82.1 to 92.8%, but the gain was significantly greater at health centers than at hospitals (p < 0.05). Health centers (which had one or two surgical teams) self-reported a higher checklist utilization rate than hospitals (which had multiple surgical teams), i.e., 99.4% vs 68.8% (p < 0.05)., Conclusion and Recommendations: Our findings suggest that Surgical Safety Checklist implementation is feasible even in lower-resource settings. The self-reported SSC utilization rate is higher than reported in other similar settings. We attribute this finding to the team-based approach employed and the ongoing regular mentorship. We recommend use of this approach to scale-up checklist use in other regions in the country as recommended in the Ministry of Health of Tanzania's National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

Objectives: There is robust evidence that implementation of reference-based pricing (RBP) benefit design decreases spending. This paper investigates employer adoption of RBP as a strategy to improve the value of patients' healthcare choices, as well as facilitators and barriers to the adoption of RBP by employers., Study Design: We conducted a qualitative study using 12 in-depth interviews with human resources executives or their representatives at large- or medium-sized self-insured employers., Methods: Interviews were conducted and recorded over the phone between March 2017 and May 2017. Interviewees were asked about their adoption of RBP and facilitators and barriers to adoption. We applied thematic analysis to the transcripts., Results: Despite broad employer awareness of RBP's potential for cost savings, few employers are including RBP in their benefit design. The major barriers to RBP adoption were the complexity of RBP benefit design, concern that employees could face catastrophic out-of-pocket costs, lack of a business case for implementation, and concern that RBP could hurt the employer's competitiveness in the labor market. The few employers that have adopted RBP have implemented extensive, year-round employee education campaigns and invested in multipronged and proactive decision support to help employees navigate their choices., Conclusions: Unless several fundamental barriers are addressed, uptake of RBP will likely continue to be low. Our findings suggest that simplifying benefit design, providing employees protection against very high out-of-pocket costs, understanding which decision-support strategies are most effective, and enhancing the business case could facilitate wider employer adoption of RBP.

Background: Operating room (OR) crises are high-acuity events requiring rapid, coordinated management. Medical judgment and decision-making can be compromised in stressful situations, and clinicians may not experience a crisis for many years. A cognitive aid (e.g., checklist) for the most common types of crises in the OR may improve management during unexpected and rare events. While implementation strategies for innovations such as cognitive aids for routine use are becoming better understood, cognitive aids that are rarely used are not yet well understood. We examined organizational context and implementation process factors influencing the use of cognitive aids for OR crises., Methods: We conducted a cross-sectional study using a Web-based survey of individuals who had downloaded OR cognitive aids from the websites of Ariadne Labs or Stanford University between January 2013 and January 2016. In this paper, we report on the experience of 368 respondents from US hospitals and ambulatory surgical centers. We analyzed the relationship of more successful implementation (measured as reported regular cognitive aid use during applicable clinical events) with organizational context and with participation in a multi-step implementation process. We used multivariable logistic regression to identify significant predictors of reported, regular OR cognitive aid use during OR crises., Results: In the multivariable logistic regression, small facility size was associated with a fourfold increase in the odds of a facility reporting more successful implementation (p = 0.0092). Completing more implementation steps was also significantly associated with more successful implementation; each implementation step completed was associated with just over 50% higher odds of more successful implementation (p ≤ 0.0001). More successful implementation was associated with leadership support (p < 0.0001) and dedicated time to train staff (p = 0.0189). Less successful implementation was associated with resistance among clinical providers to using cognitive aids (p < 0.0001), absence of an implementation champion (p = 0.0126), and unsatisfactory content or design of the cognitive aid (p = 0.0112)., Conclusions: Successful implementation of cognitive aids in ORs was associated with a supportive organizational context and following a multi-step implementation process. Building strong organizational support and following a well-planned multi-step implementation process will likely increase the use of OR cognitive aids during intraoperative crises, which may improve patient outcomes.

Objective: To define, measure, and characterize key competencies of managing labor and delivery units in the United States and assess the associations between unit management and maternal outcomes., Methods: We developed and administered a management measurement instrument using structured telephone interviews with both the primary nurse and physician managers at 53 diverse hospitals across the United States. A trained interviewer scored the managers' interview responses based on management practices that ranged from most reactive (lowest scores) to most proactive (highest scores). We established instrument validity by conducting site visits among a subsample of 11 hospitals and established reliability using interrater comparison. Using a factor analysis, we identified three themes of management competencies: management of unit culture, patient flow, and nursing. We constructed patient-level regressions to assess the independent association between these management themes and maternal outcomes., Results: Proactive management of unit culture and nursing was associated with a significantly higher risk of primary cesarean delivery in low-risk patients (relative risk [RR] 1.30, 95% CI 1.02-1.66 and RR 1.47, 95% CI 1.13-1.92, respectively). Proactive management of unit culture was also associated with a significantly higher risk of prolonged length of stay (RR 4.13, 95% CI 1.98-8.64), postpartum hemorrhage (RR 2.57, 95% CI 1.58-4.18), and blood transfusion (RR 1.87, 95% CI 1.12-3.13). Proactive management of patient flow and nursing was associated with a significantly lower risk of prolonged length of stay (RR 0.23, 95% CI 0.12-0.46 and RR 0.27, 95% CI 0.11-0.62, respectively)., Conclusion: Labor and delivery unit management varies dramatically across and within hospitals in the United States. Some proactive management practices may be associated with increased risk of primary cesarean delivery and maternal morbidity. Other proactive management practices may be associated with decreased risk of prolonged length of stay, indicating a potential opportunity to safely improve labor and delivery unit efficiency.

Objective: To examine narrative feedback to understand surgical team perceptions about surgical safety checklists (SSCs) and their impact on the safety of surgical practice., Design: We reviewed free-text comments from surveys administered before and after SSC implementation between 2011 and 2013. We categorized feedback thematically and as positive, negative or neutral., Setting: South Carolina hospitals participating in a statewide collaborative on checklist implementation., Participants: Surgical teams from 11 hospitals offering free-text comments in both pre-and post-implementation surveys., Intervention: Implementation of the World Health Organization SSC., Main Outcome Measure: Differences in comments made before and after implementation and by provider role; types of complications averted through checklist use., Results: Before SSC implementation, the proportion of positive comments among provider roles differed significantly (P = 0.04), with more clinicians offering negative comments (87.9%, (29/33)) compared to other surgical team members (58.3% (7/12) to 60.9% (14/23)), after SSC implementation, these proportions did not significantly differ (clinicians 77.8% (14/18)), other surgical team members (50% (2/4) to 76.9% (20/26)) (P = 0.52). Distribution of negative comments differed significantly before and after implementation (P = 0.01); for example, there were more negative comments made about checklist buy-in after implementation (51.3 % (20/39)) compared to before implementation (24.5% (13/53)). Surgical team members most frequently reported that checklist use averted complications involving antibiotic administration, equipment and side/site of surgery., Conclusions: Narrative feedback suggested that SSC implementation can facilitate patient safety by averting complications; however, buy-in is a persistent challenge. Presenting information on the impact of the SSC on lives saved, teamwork and complications averted, adapting the SSC to fit the local context, demonstrating leadership support and engaging champions to promote checklist use and address concerns could improve checklist adoption and efficacy., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a meta-analysis of methodologically standardized findings from evaluations of eleven major PCMH initiatives. There was significant heterogeneity across individual evaluations in many outcomes. Across evaluations, PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care, emergency department, and inpatient visits and four quality measures. The initiatives were associated with a 1.5 percent reduction in the use of specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, and a 4.2 percent reduction in total spending (excluding pharmacy spending) and a 1.4 percent increase in breast cancer screening among higher-morbidity patients. These associations were significant. Identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care., (Project HOPE—The People-to-People Health Foundation, Inc.)

To evaluate the potential for a patient-centered medical home initiative to reduce utilization and cost while improving quality, we examined a natural experiment involving 11 primary care practices in Cincinnati, Ohio, that participated in the Aligning Forces for Quality Multi-Payer Patient Centered Medical Home pilot. Our research design involved difference-in-difference analyses, comparing changes in utilization, costs, and quality between patients attributed to pilot practices compared with those attributed to a matched comparison cohort after 2 years of active engagement by the practices. The Cincinnati pilot was associated with a reduction of ambulatory care-sensitive emergency department visits of approximately 0.7 per 1,000 member months or approximately 22.6% (p = .01). While there was a reduction in total costs of care of $7,679 per 1,000 member months, the difference did not reach statistical significance. After 2 years of the pilot, lipid testing in diabetics had increased by 2.7 percentage points (a 3.3% improvement; p < .0001). Patient-centered medical homes have the potential to improve the quality of care and reduce emergency department use but expectations for cost control in a relatively short time horizon and absent other changes may be unrealistic., (© The Author(s) 2015.)

Background: The term "medical neighborhood" refers to relationships that patient-centered medical homes (PCMHs) seek to establish with other providers to facilitate coordinated patient care. Yet, how PCMHs can accomplish this coordination is not well understood., Purpose: Drawing upon organizational theory (; ; ), we explored how PCMHs use coordination mechanisms to build and optimize their medical neighborhoods., Methodology: We used mixed methods, blending data collected via interviews and surveys with practice leaders and care coordinators at 30 months after a PCMH collaborative intervention in Colorado as well as surveys from all providers from 13 PCMHs before and 30 months after the intervention. We used thematic analysis to understand the role and use of coordination mechanisms by PCMHs and changes in the ability to coordinate and deliver care continuity., Findings: PCMHs drew on four coordination mechanisms to build relationships with their medical neighbors: interorganizational routines to improve reliability of information flow; information connectivity to facilitate continuity and safe care; boundary spanners to integrate care across silos; and communication, negotiation, and decision mechanisms to introduce shared accountability. When providers were fairly confident of the patient's diagnosis and management required sequential interactions (such as tests or procedures), PCMHs tended to coordinate care through interorganizational routines and information connectivity. When a diagnosis was less certain and required reciprocal interaction (i.e., consultation), PCMHs employed boundary spanners and communication, negotiation, and decision mechanisms., Practice Implications: Use of coordination mechanisms by PCMHs can help to improve care coordination in medical neighborhoods. All four mechanisms appear to be useful. The optimal mix of coordination mechanisms requires attention to patient context. Successfully building medical neighborhoods also requires meta-leaders, collaboration competencies, and high-quality relationships between providers in primary care, specialty care, and hospitals.

Background: Research on the effects of patient-centered medical homes on quality and cost of care is mixed, so further study is needed to understand how and in what contexts they are effective., Objective: We aimed to evaluate effects of a multi-payer pilot promoting patient-centered medical home implementation in 15 small and medium-sized primary care groups in Colorado., Design: We conducted difference-in-difference analyses, comparing changes in utilization, costs, and quality between patients attributed to pilot and non-pilot practices., Participants: Approximately 98,000 patients attributed to 15 pilot and 66 comparison practices 2 years before and 3 years after the pilot launch., Main Measures: Healthcare Effectiveness Data and Information Set (HEDIS) derived measures of diabetes care, cancer screening, utilization, and costs to payers., Key Results: At the end of two years, we found a statistically significant reduction in emergency department use by 1.4 visits per 1000 member months, or approximately 7.9 % (p = 0.02). At the end of three years, pilot practices sustained this difference with 1.6 fewer emergency department visits per 1000 member months, or a 9.3 % reduction from baseline (p = 0.01). Emergency department costs were lower in the pilot practices after two (13.9 % reduction, p < 0.001) and three years (11.8 % reduction, p = 0.001). After three years, compared to control practices, primary care visits in the pilot practices decreased significantly (1.5 % reduction, p = 0.02). The pilot was associated with increased cervical cancer screening after two (12.5 % increase, p < 0.001) and three years (9.0 % increase, p < 0.001), but lower rates of HbA1c testing in patients with diabetes (0.7 % reduction at three years, p = 0.03) and colon cancer screening (21.1 % and 18.1 % at two and three years, respectively, p < 0.001). For patients with two or more comorbidities, similar patterns of association were found, except that there was also a reduction in ambulatory care sensitive inpatient admissions (10.3 %; p = 0.05)., Conclusion: Our findings suggest that a multi-payer, patient-centered medical home initiative that provides financial and technical support to participating practices can produce sustained reductions in utilization with mixed results on process measures of quality.

Objectives: 1) Evaluate structural capabilities associated with the patient-centered medical home (PCMH) model in PCMH pilots in Colorado, Ohio, and Rhode Island; 2) evaluate changes in capabilities over 2 years in the Rhode Island pilot; and 3) evaluate facilitators and barriers to the adoption of capabilities., Study Design: We assessed structural capabilities in the 30 pilot practices using a cross-sectional study design and examined changes over 2 years in 5 Rhode Island practices using a pre/post design., Methods: We used National Committee for Quality Assurance's Physician Practice Connections-Patient-Centered Medical Home (PPC/PCMH) accreditation survey data to measure capabilities. We stratified by high and low performance based on total score and by practice size. We analyzed change from baseline to 24 months for the Rhode Island practices. We analyzed qualitative data from interviews with practice leaders to identify facilitators and barriers to building capabilities., Results: On average, practices scored 73 points (out of 100 points) for structural capabilities. High and low performers differed most on electronic prescribing, patient self-management, and care-management standards. Rhode Island practices averaged 42 points at baseline, and reached 90 points by the end of year 2. Some of the key facilitators that emerged were payment incentives, "transformation coaches," learning collaboratives, and data availability supporting performance management and quality improvement. Barriers to improvement included the extent of transformation required, technology shortcomings, slow cultural change, change fatigue, and lack of broader payment reform., Conclusions: For these early adopters, prevalence of structural capabilities was high, and performance was substantially improved for practices with initially lower capabilities. We conclude that building capabilities requires payment reform, attention to implementation, and cultural change.

This article describes the first system-wide evaluation of the Child Health Network (CHN) for the Greater Toronto Area (GTA), a partnership of 29 community and hospital care providers. The CHN performance evaluation sought to identify the impact of the network on the delivery of maternal, newborn and child health services in the GTA. CHN members identified seven criteria to be evaluated (appropriate care, accessibility, effectiveness, satisfaction, integrated and coordinated care, accountability and affordability) and then collaborated in selecting measurable indicators for each criterion. Data were compiled from administrative data sets, or collected as needed. This undertaking succeeded in providing a comprehensive assessment of the network's performance, identification of strategies to improve outcomes and network sustainability, as well as practical information that will inform the important new field of network evaluation.

The Child Health Network for the Greater Toronto Area (CHN), a network of 20 hospitals and 9 community care access centres, assessed one component of its early progress in building a regionalized system of perinatal care. Focusing on the relationship between hospital level of care and gestational age, the study showed that most births occurred at appropriately designated facilities. However, a quarter of newborns of gestational age <32 weeks were delivered at a lower level of care than is considered optimal. CHN's ongoing research will offer opportunities to assess the impact of regional models on their foremost goal--quality clinical care.

The Child Health Network (CHN) for the Greater Toronto Area (GTA) is a partnership of hospital, rehabilitation and community providers committed to developing a regional system to deliver high quality, accessible, family-centred care for mothers, newborns, children and youth. This article reviews the history and model of the CHN, assesses its achievements, and provides insights into the challenges and lessons learned by the network. Stemming from the CHN's commitment to quality, accessibility and efficiency, regionalization of maternal, newborn and children's services is emerging as a success story.