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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.

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. Plain language summary Many accidental falls by older people in hospitals could be avoided. There are guidelines to prevent falls, but some hospitals are better at following them than others. This study aimed to find out why. First, we looked at research and hospitals’ falls policies for ideas about what stops falls. With advice from service users, we tested these ideas in four hospitals in England, watching how falls were prevented on wards for older people and people who need bone care, and talking to 50 staff, 28 patients and 3 carers. We found the following: Falls leadership: wards had staff called falls link practitioners who supported falls prevention, but senior nurses, not link practitioners, made the most important decisions. Sharing responsibility: patients with falls risks were monitored to try to stop falls. Because only nursing teams were always present to monitor patients, they had most responsibility for preventing falls. This limited sharing responsibility with other staff. Computer tools: nurses used computers to record prevention work, but high workloads could make this a ‘tick-box’ exercise. Computer tools reminded them to do this, although tools varied. Patients had individual falls plans, but they were also ranked more generally as high or low risk of falling, with ‘high-risk’ patients being monitored. Patient involvement: nursing staff did not have time to explain to patients how to prevent falls, but other staff could have such conversations. Many patients had problems like dementia and found it difficult to follow safety advice, although some could take steps to keep safe, with sensitive staff support. We need to involve patients, carers and different staff in falls prevention. Hospitals could develop computer systems to support this, think how to involve more ward staff, and provide guidance on helpful ways to talk with patients about falls. Scientific summary Background Inpatient falls are the most common safety incident reported by acute hospitals and can cause both physical and non-physical harm. The National Institute of Health and Care Excellence (NICE) guideline on falls in older people recommends a multifactorial falls risk assessment (MFRA) and interventions tailored to address the patient’s identified risk factors for all inpatients aged 65 years and older, or 50–64 years and judged to be at higher risk of falling due to an underlying condition. This approach is estimated to reduce the incidence of inpatient falls by 25–30%. However, there is substantial unexplained variation between hospitals in adherence to this guideline. Objectives Use secondary data to develop a theory that explains what supports and constrains routine use of MFRA and falls prevention interventions. Refine the theory through mixed method data collection across three acute hospital Trusts. Translate the theory into guidance to support MFRA and prevention and, in turn, adherence to the NICE guideline. Methods Throughout the study, we were supported by DW, the lay member of the project management group, and the Lay Research Group (a group of service users and carers who had either fallen themselves or cared for someone who fell in hospital). We first undertook a realist review. In Phase 1, systematic searches were undertaken for commentary-type articles, studies mentioning theories/conceptual models for falls risk assessment, and systematic reviews. Additionally, a search of professional/trade journals and an advanced Google search were undertaken. Titles, abstracts and full texts were screened for relevance. Data about contexts, mechanisms and outcomes were extracted from included papers, and referenced substantive theories were noted. Data were summarised in matrices, used to construct context mechanism outcome configurations (CMOcs). To determine which CMOcs should be taken forward for testing in Phase 2, the Lay Research Group and Study Steering Committee (SSC) (comprised of clinicians, academics, and a lay member, with expertise including falls prevention, risk assessment, patient safety and implementation science) ranked them, giving top rankings to statements they believed most likely to work in practice. The Lay Research Group was also asked to highly rank statements likely to have greatest impact for patients and carers. In Phase 2 of the realist review, systematic searches for the four concepts ranked highly by both the Lay Research Group and SSC were conducted across a range of databases. Titles, abstracts and full texts were screened for relevance. In Phase 3 of the realist review, data extraction was conducted using NVivo, coding sections of manuscripts to facilitate theory testing. Researchers analysed two CMOcs: one focused on implementation – facilitation – and one focused on falls risk reduction – patient participation. Narrative summaries were written and used to refine the initial CMOcs. Included texts were appraised using the mixed methods appraisal tool (MMAT). To assess strength of the body of evidence for the refined CMOcs, we used Grades of Recommendation, Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). As an additional source of evidence, we undertook an advanced Google search for the policies of 25 acute Trusts regarding falls risk assessment and prevention. We assessed adherence of these policies to the NICE guideline on falls in older people by checking whether a falls risk prediction tool was recommended; whether the approach recommended involved tailoring interventions to patients’ individual risk factors; and by looking for specific elements of the assessments undertaken (such as whether continence and cognitive impairment are assessed), as specified by NICE and captured in the National Audit of Inpatient Falls (NAIF). We then conducted a multisite case study to further refine the theories across three NHS acute Trusts in England. Trusts were selected to ensure variation in key indicators in the NAIF and in health IT, and to include both teaching and district general hospitals. In each Trust, we collected data in one older person ward and one orthopaedic ward. Data were collected through 251.25 hours of ethnographic observations of falls prevention practices, interviews with staff (n = 50), patients (n = 28) and carers (n = 3), and a review of patient clinical records (n = 60). We also received routinely collected data on the number of falls and falls-related harms. The Lay Research Group contributed to the development of the observation protocol and interview topic guides for patients and carers. Observations took place at different times of day, including night shifts, and different days of the week, including weekends. The record review extracted data on (1) whether a falls risk assessment was completed for the patient on admission and within 6 hours; (2) whether a care plan was documented for the patient and if this was completed on a day or night shift; and (3) whether the care plan was updated and if updates were completed on a day or night shift. Qualitative data analysis followed the steps of framework analysis. The Lay Research Group contributed, providing a patient perspective. Descriptive statistics were produced for the record review data, broken down by ward. Narratives were written and used to refine the CMOcs. Online presentations at each case site acted as a form of respondent validation and an opportunity to gather participants’ perspectives on the implications of the research for practice. Findings In the realist review, 78 studies were used for theory construction and 50 for theory testing. Four theory areas were explored: (1) leadership; (2) shared responsibility; (3) facilitation via MFRA tools and (4) patient participation. The leadership theory developed in the theory construction phase of the realist review suggested that where falls prevention is prioritised by organisations, for example, in organisational policy and provision of resources, falls leaders/champions (staff trained and dedicated to supporting delivery of multifactorial falls prevention strategies on their wards, e.g. by offering training and education to new staff) inspire and support delivery of the strategy in a consistent and co-ordinated way, so all eligible patients receive a MFRA and tailored intervention strategies. This theory was tested through the review of Trust policies and multisite case study. The review of Trust policies found organisational-level policies, in the main, reflect NICE guidance. The role of falls link practitioners was identified in all three sites. Link practitioners were expected to act as role models for falls reduction in their clinical areas, and provide advice and education around assessment, intervention and management of patients who had fallen or were at risk of falling. They were also expected to facilitate regular audits of falls management practice on wards and raise any patient safety concerns. However, pressures of work on wards, aggravated by coronavirus disease 2019, meant it was not always possible to fulfil such duties. Similarly, it could be difficult for them to attend the training they were entitled to. Despite these challenges, documentation of the falls risk assessment and care plan was largely consistent across sites. Ultimate responsibility for falls prevention resided with senior nurses (the ward manager or the nurse-in-charge of the shift), who would monitor, remind and support staff to deliver falls prevention practices while also being sensitive to the pressures staff were under. They had authority to make decisions related to allocation of resources, such as which patients should be moved to cohort bays (bays where patients considered to be at high risk of falling were placed, with a staff member always present), and they would escalate patient safety concerns to hospital managers. Formal training about Trusts’ falls prevention policies was provided by organisational teams for new starters on induction. Messaging was also a key strategy, for example, through visual displays and reminders about expectations and policy on wards. The initial theory of shared responsibility suggested that, where there is a culture of learning from errors, if information about patients’ falls risks is effectively communicated between ward staff (e.g. through posters/safety huddles/handovers), staff will develop a sense of shared responsibility for falls prevention and become more vigilant of patients at risk from falls, supporting implementation of multifactorial strategies to prevent falls. This theory was tested through the case study. Undertaking MFRAs was the responsibility of nurses; this documentation was rarely accessed by other professional groups. Instead, communication between professional groups was primarily verbal, both formal, for example, in multidisciplinary team meetings and safety huddles, and informal. Additionally, visual communication tools were used, such as patient bed boards, on which information about patient transfer and mobilisation needs was recorded. Symbols such as a falling leaf were also displayed to identify patients at risk of falling. However, information on bed boards was often variable or incomplete. A key falls prevention strategy across all wards was patient supervision, for example, provision of one-to-one care and use of cohort bays, responsibility for which fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared among the multidisciplinary team. The initial facilitation theory concerned MFRA tools (including health IT) that reflect best practice recommendations, are relatively quick and easy to use, and easily integrated into existing workflows. The theory stated that, where staff educated about falls risks and prevention practices had access to such tools, they will complete them with patients because they facilitate implementation of recommended practice, helping to ensure all eligible patients receive a comprehensive MFRA and appropriate interventions. This theory was tested through the realist review and case study. Review findings suggested that, where tools are clearly visible to staff in their work routines, they can prompt documentation of a falls risk assessment. Following an assessment, documentation and delivery of interventions can be constrained by changes in patient condition, movement between wards, intervention availability, and communication between different professional groups. Health IT can facilitate delivery of falls prevention practices by automating processes and reducing work for clinicians but can also introduce additional tasks. There was variation across case sites in the number and type of assessment items included in the falls risk assessment tools within the electronic health record (EHR). Nurses perceived the tools as practice prompts, but competing priorities on nurse time could reduce tool use to a tick-box exercise. While all tools identified individual patient risk factors, stratification of patients as high or low risk was used to determine which patients should receive supervision. The initial patient participation theory suggested that, where patients have capacity to engage in the MFRA process, and a patient-centred approach is taken that involves them and their carers, patients will understand their strategy and have the confidence/reassurance to participate in specific interventions, thereby reducing their risk of falling. This theory was tested through the realist review and multisite case study. Review findings suggested that interventions that encourage cognitively intact patients to participate in falls prevention practices are associated with a reduction in falls. However, patient participation in falls prevention strategies can be constrained by patients not wanting to disturb busy nurses by requesting help, not perceiving or believing they are at risk of falls, and not understanding their falls risks. Patient participation is supported by staff who understand patients’ circumstances through meaningful, directed interactions, enabling staff to personalise falls prevention messages to improve patient knowledge, skills and confidence to participate. There is little research examining patient participation interventions with cognitively impaired patients. In the case study, workload pressures meant nursing staff had little time to explain to patients why they were at risk of falling or what they could do to prevent themselves from falling, although other staff could have such conversations and pass information to nurses. Many patients had cognitive impairments, which constrained the extent to which they could participate in interventions. Wards were often not staffed sufficiently for staff to respond to patient needs, leading to patients mobilising alone, although the quality of the interaction between staff and patients (including some cognitively impaired patients) could reduce the likelihood of patients taking actions that increased their risk of falling. Participants in the case site presentations agreed with the analysis. Key themes regarding implications were (1) the need for the lessons learnt to be disseminated to all professional groups, through leaflets and training materials; and (2) the need for leaflets for patients and carers, individualised to patients, providing them with information about their falls risks and how to prevent falls. Limitations A limitation of the review is that we were only able to complete data synthesis for two CMOcs. Limitations of the case study are that our observations focused on nursing staff, as they were most present on the wards, and we were unable to access patient records prior to observations, preventing assessment of whether care plans were enacted. Additionally, we did not manage to recruit patient participants who did not speak English; while we had information sheets translated into the three most spoken non-English languages across the case sites, all patients we met could speak English. Conclusions Implications for practice (1) Leadership: There should be a clear distinction between senior nurses’ roles and falls link practitioners in relation to fall prevention; (2) shared responsibility: Trusts should consider how processes and systems, including EHRs, 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 that 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. Recommendations for research Future research on falls risk assessment and prevention should include those with cognitive impairment and patients who do not speak the main language of the country in which the research is taking place: development and mixed method and economic evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, MFRA and selection and delivery of tailored interventions mixed method and economic evaluations of cohort bays and one-to-one care, comparing this to tailored alternatives mixed method and economic evaluations of engagement support workers, volunteers, and/or carers to support falls prevention. Study registration This study is registered on 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.

Abstract 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.

Plain English summary Involving members of the public in all stages of research as equal partners is a powerful way to make research more relevant. This paper shares an example of such involvement, from a study about falls prevention in English hospitals. Developed by a team of lay people and professional researchers, the paper looks at how we worked together, drawing on evaluations we carried out about how the study took patient and public perspectives into account, and on personal reflections we wrote. Public involvement had a positive effect on the project and the individuals involved, but there were also difficulties. Positive impacts included lay people ensuring the study focused on what mattered most to patients and their families and feeling they had done right by their personal experience of the study’s subject. Negative impacts included the potential for people to feel overwhelmed by the changes in organisations or in wider society needed to address the issues being explored by a research study, which could cause them to question why they became involved in the first place. The paper ends with practical recommendations about working together, covering things such as helping lay people with the emotional impact of involvement from the beginning to the end of projects; finding ways to ensure everybody is treated in the same way and solving practical problems; and tips on leading and supporting groups of this kind, especially with personal issues like trusting each other.

Abstract 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.

Background: National audits aim to reduce variations in quality by stimulating quality improvement. However, varying provider engagement with audit data means that this is not being realised. Aim: The aim of the study was to develop and evaluate a quality dashboard (i.e. QualDash) to support clinical teams’ and managers’ use of national audit data. Design: The study was a realist evaluation and biography of artefacts study. Setting: The study involved five NHS acute trusts. Methods and results: In phase 1, we developed a theory of national audits through interviews. Data use was supported by data access, audit staff skilled to produce data visualisations, data timeliness and quality, and the importance of perceived metrics. Data were mainly used by clinical teams. Organisational-level staff questioned the legitimacy of national audits. In phase 2, QualDash was co-designed and the QualDash theory was developed. QualDash provides interactive customisable visualisations to enable the exploration of relationships between variables. Locating QualDash on site servers gave users control of data upload frequency. In phase 3, we developed an adoption strategy through focus groups. ‘Champions’, awareness-raising through e-bulletins and demonstrations, and quick reference tools were agreed. In phase 4, we tested the QualDash theory using a mixed-methods evaluation. Constraints on use were metric configurations that did not match users’ expectations, affecting champions’ willingness to promote QualDash, and limited computing resources. Easy customisability supported use. The greatest use was where data use was previously constrained. In these contexts, report preparation time was reduced and efforts to improve data quality were supported, although the interrupted time series analysis did not show improved data quality. Twenty-three questionnaires were returned, revealing positive perceptions of ease of use and usefulness. In phase 5, the feasibility of conducting a cluster randomised controlled trial of QualDash was assessed. Interviews were undertaken to understand how QualDash could be revised to support a region-wide Gold Command. Requirements included multiple real-time data sources and functionality to help to identify priorities. Conclusions: Audits seeking to widen engagement may find the following strategies beneficial: involving a range of professional groups in choosing metrics; real-time reporting; presenting ‘headline’ metrics important to organisational-level staff; using routinely collected clinical data to populate data fields; and dashboards that help staff to explore and report audit data. Those designing dashboards may find it beneficial to include the following: ‘at a glance’ visualisation of key metrics; visualisations configured in line with existing visualisations that teams use, with clear labelling; functionality that supports the creation of reports and presentations; the ability to explore relationships between variables and drill down to look at subgroups; and low requirements for computing resources. Organisations introducing a dashboard may find the following strategies beneficial: clinical champion to promote use; testing with real data by audit staff; establishing routines for integrating use into work practices; involving audit staff in adoption activities; and allowing customisation. Limitations: The COVID-19 pandemic stopped phase 4 data collection, limiting our ability to further test and refine the QualDash theory. Questionnaire results should be treated with caution because of the small, possibly biased, sample. Control sites for the interrupted time series analysis were not possible because of research and development delays. One intervention site did not submit data. Limited uptake meant that assessing the impact on more measures was not appropriate. Future work: The extent to which national audit dashboards are used and the strategies national audits use to encourage uptake, a realist review of the impact of dashboards, and rigorous evaluations of the impact of dashboards and the effectiveness of adoption strategies should be explored. Study registration: This study is registered as ISRCTN18289782. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 12. See the NIHR Journals Library website for further project information.

Abstract 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.

BackgroundDashboards 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. ObjectiveThis 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. MethodsQualDash 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. ResultsThe 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. ConclusionsWeb-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

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.

IntroductionNational 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 analysisRealist 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 disseminationThe 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.