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Background: Integrating behavioral health services in primary care is challenging; a toolkit approach to practice implementation can help. A recent comparative effectiveness randomized clinical trial examined the impact of a toolkit for improving integration on outcomes for patients with multiple chronic conditions. Some aspects of behavioral health integration improved; patient-reported outcomes did not. This report evaluates the implementation strategy (Toolkit) using Proctor's (2011) implementation outcomes model., Methods: Using data from the 20 practices randomized to the active (toolkit strategy) arm (education, redesign workbooks, online learning community, remote coaching), we identified 23 measures from practice member surveys, coach interviews, reports, and field logs to assess Toolkit acceptability, appropriateness, feasibility, and fidelity. A practice survey score was high (met expectations) if its average was ≥ 4 on a scale 1-5; all other data were coded dichotomously, with high = 1., Results: Regarding acceptability, 74% (14) of practices had high scores for willingness of providers and staff to use the Toolkit and 68% (13) for quality improvement teams liking the Toolkit. For appropriateness, 95% (19) of practices had high scores for the structured process being a good match and 63% (12) for the Toolkit being a good match. Feasibility, measured by Toolkit prerequisites, was scored lower by site members at project end (e.g., provider leader available as champion: 53% of practices) compared to remote coaches observing practice teams (74%). For "do-ability," coaches rated feasibility lower for practices (e.g., completion of workbook activities: 32%) than the practice teams (68%). Fidelity was low as assessed across seven measures, with 50% to 78% of practices having high scores across the seven measures., Conclusions: Existing data from large trials can be used to describe implementation outcomes. The Toolkit was not implemented with fidelity in at least one quarter of the sites, despite being acceptable and appropriate, possibly due to low feasibility in the form of unmet prerequisites and Toolkit complexity. Variability in fidelity reflects the importance of implementation strategies that fit each organization, suggesting that further study on contextual factors and use of the Toolkit, as well as the relationship of Toolkit use and study outcomes, is needed., Trial Registration: ClinicalTrials.gov NCT02868983; date of registration: 08/15/2016., (© 2024. The Author(s).)

Background: Adverse events occur frequently at emergency departments (ED) because of several risk factors related to varying conditions. It is still unclear, which factors lead to patient safety incident reports. The aim of this study was to explore the root causes behind ED-associated patient safety incidents reported by personnel, and based on the findings, to suggest learning objectives for improving patient safety., Methods: The study material included incident reports (n = 340) which concerned the ED of a teaching hospital over one year. We used a mixed method combining quantitative descriptive statistics and qualitative research by inductive content analysis and deductive Ishikawa root cause analysis., Results: Most (76.5%) incidents were reported after patient transfer from the ED. Nurses reported 70% of incidents and physicians 7.4%. Of the reports, 40% were related to information flow or management. Incidents were evaluated as no harm (29.4%), mild (46%), moderate (19.7%), and severe (1.2%) harm to the patient. The main consequences for the organization were reputation loss (44.1%) and extra work (38.9%). In the qualitative analysis, nine specific problem groups were found: insufficient introduction, adherence to guidelines and protocols, insufficient human resources, deficient professional skills, medication management deficiencies, incomplete information transfer from the ED, language proficiency, unprofessional behaviour, identification error, and patient-dependent problems. Six organizational themes were identified: medical staff orientation, onboarding and competence requirements; human resources; electronic medical records and information transfer; medication documentation system; interprofessional collaboration; resources for specific patient groups such as geriatric, mental health, and patients with substance abuse disorder. Entirely human factor-related themes could not be defined because their associations with system factors were complex and multifaceted. Individual and organizational learning objectives were addressed, such as adherence to the proper use of instructions and adequate onboarding., Conclusions: System factors caused most of the patient safety incidents reported concerning ED. The introduction and training of ED -processes is elementary, as is multiprofessional collaboration. More research is needed about teamwork skills, patients with special needs and non-critical patients, and the reporting of severe incidents., (© 2024. The Author(s).)

Objective: To reduce the rate of central line-associated bloodstream infections (CLABSI) in the M Health Fairview Neonatal Intensive Care Unit (NICU) from 2.15 infections per 1,000 central line days to less than one per 1,000 line days using process evaluation., Methods: An interdisciplinary team used process mapping and Failure Modes and Effects Analysis (FMEA) to identify root causes and improvement opportunities in central line maintenance. The focus was on neonates born at <32 weeks of gestational age and weighing less than 750 g. Interventions included standardized clean space, algorithms to reduce line access, and standardized kits for line maintenance., Results: Over 4 years, the project achieved an 86.6% reduction in CLABSI events, decreasing from 15 events in 2019 to two in 2023. The CLABSI rate dropped by 85%, from 2.15 to 0.32 per 1,000 line days. Statistical analysis indicated a significant reduction in FMEA risk scores for the identified failure modes, with an average reduction of 33%., Conclusion: The process-focused approach and interdisciplinary collaboration significantly reduced CLABSI rates in the NICU. Future efforts should aim to maintain these improvements and achieve a target of zero CLABSI events., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 National Association for Healthcare Quality.)

Background: The Institute for Safe Medication Practices and The Joint Commission recommend the implementation of bidirectional smart infusion pump interoperability with the electronic health record (EHR) to improve medication safety. However, there are barriers associated with implementation of this process., Purpose: The purpose of this process improvement project was to identify, evaluate, and implement improvements in pump integration with the EHR to decrease manual programming and increase the use of the smart pump functions (the dose error reduction system or infusion guardrails)., Methods: A medication safety task force was formed, and end users were surveyed for barriers. The task force found and implemented solutions to improve the process., Results: Infusion pump integration rates for seven hospitals improved from 79.4% to 91.8% ( p < .001), and the use of smart pump programming increased from 84.7% to 93.6%., Conclusions: Including all stakeholders in the project allowed barriers to be identified and solutions to be implemented. As more healthcare systems implement technology-related processes to improve patient safety, this work can guide medication safety teams on how to optimize technology use by removing barriers to the use of pump integration with the EHR., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 National Association for Healthcare Quality.)

Background: Inpatient serum phosphate replacement is common, but there is great variability in replacement practice, which leads to overuse. Electronic health record (EHR) interventions with clinical decision support (CDS) can be effective tools to guide clinicians toward best clinical practices. The authors' objective was to use CDS tools to reduce overuse of hypophosphatemia corrections at a large safety-net health care system., Methods: The first intervention involved enhancing an existing order set for phosphate repletion by incorporating CDS to guide appropriate repletion orders based on deficit severity and simplifying ordering. The second intervention was a Best Practice Advisory (BPA) that triggered when an intravenous (IV) phosphate repletion was ordered for a patient with mild to moderate phosphate deficiency without an existing nil per os (NPO) order. The primary outcome measure was the number of patients with mild and moderate hypophosphatemia receiving IV replacement without NPO orders per 1,000 patient-days., Results: Across all hospitals, rate of IV replacement in patients with mild to moderate hypophosphatemia (1.0 to 1.9 mg/dL) without NPO orders decreased from 7.22 to 3.40 per 1,000 patient-days (53.0% reduction, p < 0.001), while the oral replacements in this population increased from 6.39 to 8.87 (38.8% increase, p < 0.001). For patients with phosphate levels ≥ 2.0, IV replacements decreased from 10.66 to 5.36 (49.8% reduction, p < 0.001), and oral replacements from decreased 19.78 to 16.69 (15.6% reduction, p < 0.01)., Conclusion: This intervention successfully reduced inpatient IV phosphate replacements by 53.0% in patients with mild to moderate hypophosphatemia using a two-pronged EHR intervention across a large safety-net setting., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Mucosal barrier injury central line-associated bloodstream infections (MBI-CLABSIs) remain a challenge among the pediatric cancer population. These infections commonly occur by oral or gastrointestinal (GI) bacteria translocating through impaired gut or oral mucosa. Although strategies to prevent gut MBI-CLABSIs are well characterized, oral pathogen prevention strategies are lacking., Methods: The authors' oncodental collaboration quality improvement project, which included two Plan-Do-Study-Act (PDSA) cycles, aimed to improve MBI-CLABSI rates and oral care adherence on a pediatric hematopoietic stem cell transplant (HSCT) unit. PDSA cycle 1 integrated dental residents into existing rounds every third week to screen for dental, gum, and mucosal disease and provide targeted education to patients and families. PDSA cycle 2 implemented a novel oral health educator (OHE) role in which a trained dental hygienist rounded four days per week. Monthly MBI-CLABSI rates and oral care adherence were followed from December 2020 to May 2021 (baseline), June 2021 to March 2022 (PDSA cycle 1), and April 2022 to December 2022 (PDSA cycle 2). Qualitative surveys captured patient and family perception, and a cost savings analysis was completed., Results: A 58.8% reduction in MBI-CLABSI rate (events per 1,000 central venous line days) was detected (baseline: 5.1; PDSA cycle 2: 2.1), oral care adherence improved 41.7% (baseline: 60.9%; PDSA cycle 2: 86.3%), 100% of patients found it beneficial to receive oral care demonstrations, and an annual cost savings of $541,000 was estimated., Conclusion: Direct patient outcomes have measurably improved. This project suggests the implementation of an OHE in pediatric HSCT inpatient units may be valuable to patients and families and may be a cost-effective way to reduce MBI-CLABSIs resulting from oral pathogens., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Congestive heart failure (HF) is a leading cause of hospitalization and readmission, leading to increased health care utilization and cost. This is complicated by high incidence, prevalence, and hospitalization rates among racial and ethnic minorities, with a widening in the mortality disparity gap. Remote patient monitoring (RPM) has the potential to proactively engage patients after discharge to optimize medication management and intervene to avoid rehospitalization. However, it also may widen the equity gap due to technological barriers and bias., Methods: A prospective, observational quality improvement (QI) initiative leveraging an amended tool from the Institute for Healthcare Improvement Model for Improvement was incorporated with an equity lens and five Plan-Do-Study-Act (PDSA) cycles at a single site. The intervention used an HF bundle that included RPM, clinical telepharmacy, remote therapeutic monitoring, and community paramedicine., Results: Between May 2022 and March 2023, five PDSA cycles were run involving 90 enrolled patients. In total, 38 (42.2%) patients received the complete HF bundle, 42 (46.7%) a partial bundle, and 10 (11.1%) only RPM. The patients with the complete bundle had a readmission rate of 2.6% compared to 14.3% in the partial bundle and 20.0% in RPM alone. The biggest impact of this program was the incorporation of community paramedicine. The program also noted an improvement in equitable enrollment after adjusting mid-program by avoiding cellular phone-enabled devices and transitioning to a hub-based model., Conclusion: This single-site QI-based initiative implemented an HF-based RPM program that leveraged clinical telepharmacy and community paramedicine. This program identified a disparity of care gap regarding the equitable distribution of services and made mid-study adjustments to improve the disparity gap. The program found that use of the HF bundle resulted in a decreased hospital readmission rate., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Sepsis is a life-threatening emergency, and early recognition and treatment in the emergency department (ED) is critical to improving outcomes., Methods: The authors implemented an interdisciplinary quality improvement (QI) project to standardize sepsis screening workflow across an academic health system consisting of a large tertiary care urban hospital, one freestanding ED, and two small rural affiliate hospitals (RA-1 and RA-2). The research team used the Institute for Healthcare Improvement Model for Improvement framework, consisting of iterative Plan-Do-Study-Act (PDSA) cycles. The primary outcome was rates of screening for sepsis at each site. Secondary outcomes included sepsis mortality and Centers for Medicare & Medicaid Services (CMS) sepsis bundle (SEP-1) compliance at our main medical center. Primary outcome was assessed using electronic dashboards extracting the ratio of ED encounters with electronic health record (EHR)-documented sepsis screening per total ED encounters. The SEP-1 bundle was assessed as percent compliance, and mortality was calculated as average observed to expected (O:E). Averages were compared from preintervention to after initiating improvements using two-tailed t-tests., Results: This QI project took place from December 2022 to December 2023 across four EDs that experience around 138,000 visits annually. A standardized workflow was established at ED triage with an EHR-based question and an associated nurse and physician defined response. Preintervention (October 2022 to November 2022) triage rates for sepsis were 1.7% (163/9,560), 25.3% (523/2,068), 11.0% (360/3,272), and 36.5% (915/2,506) at our main hospital, freestanding ED, RA-1, and RA-2, respectively. After four PDSA cycles, triage rates rose to 91.9% (4,927/5,360), 97.5% (1,032/1,059), 99.0% (1,845/1,863), and 97.4% (1,328/1,363), respectively (p < 0.005). Sepsis triage rates rose most slowly at the large academic medical center, where progressive PDSA cycles were needed to achieve > 90% screening for sepsis. Mean O:E mortality was 0.99 for the 9 months of available data preintervention and 0.83 in the 17 months postintervention (p = 0.07). CMS sepsis bundle compliance was 28.4% for the 15 months preintervention and 40.5% in the 17 months postintervention, (p = 0.14)., Conclusion: An interdisciplinary QI project leveraged EHR optimization to integrate with human workflows over four PDSA cycles to achieve standardized and improved screening for sepsis in the ED. This resulted in lower sepsis mortality and increased sepsis bundle compliance, though results were not statistically significant., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Women Veterans with co-morbid medical and mental health conditions face persistent barriers accessing high-quality health care. Evidence-based quality improvement (EBQI) offers a systematic approach to implementing new care models that can address care gaps for women Veterans., Objective: This study examines factors associated with the successful deployment of EBQI within integrated health systems to improve primary care for women Veterans with complex mental health needs., Design: Following a 12-site (8 EBQI, 4 control) cluster randomized study to evaluate EBQI effectiveness, we conducted an in-depth case study analysis of one women's health clinic that used EBQI to improve integrated primary care-mental health services for women Veterans., Participants: Our study sample included providers, program managers, and clinic staff at a women Veteran's health clinic that, at the time of the study, had one Primary Care and Mental Health Integration team and one women's health primary care provider serving 800 women. We analyzed interviews conducted 12 months, 24 months, and 4 years post-implementation and call summaries between the clinic and support team., Main Measures: We conducted qualitative thematic analysis of interview and call summary data to identify EBQI elements, clinic characteristics, and reported challenges and successes within project development and execution., Key Results: The clinic harnessed core EBQI elements (multi-level stakeholder engagement, data-driven progress-monitoring, PDSA cycles, sharing results) to accomplish pre-defined project goals, strengthen inter-disciplinary partnerships, and bolster team confidence. Clinic characteristics that facilitated implementation success included prior QI experience and an organizational culture responsive to innovation, while lack of pre-existing guidelines and limited access to centralized databases posed implementation challenges., Conclusions: Successful practice transformation emerges through the interaction of evidence-based methods and site-specific characteristics. Examining how clinic characteristics support or impede EBQI adaptation can facilitate efforts to improve care within integrated health systems., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: Since the health information system (HIS) in public health care services in Serbia was introduced in 2009, it has gradually expanded. However, it is unclear how well the HIS components have developed and the whole system's stage of maturity., Method: In June-September 2021, a maturity assessment of the Serbian HIS was conducted for the first time using the HIS Stages of Continuous Improvement (SOCI) toolkit. The toolkit measures HIS status across 5 HIS domains: leadership and governance, management and workforce, information and communication technology (ICT), standards and interoperability, and data quality and use. The domains were further divided into 13 components and 39 subcomponents whose maturity stage was assessed on a 5-point Likert scale, indicating the level of development: (1) emerging/ad hoc; (2) repeatable; (3) defined; (4) managed; and (5) optimized. The toolkit was applied in a working group of 32 professionals and experts who were engaged in developing the new national eHealth strategy and action plan., Results: The overall maturity score of the Serbian HIS was 1.6, which indicates a low level. The highest baseline score (2) was given to the standards and interoperability domain, and the lowest (1.1) was given to ICT infrastructure. The remaining 3 domains (leadership and governance, Management and Workforce, and Data Quality and Use) were similarly rated (1.7, 1.7, and 1.6, respectively)., Conclusion: A baseline assessment of the maturity level of Serbian HIS indicates that the majority of components are between the emerging/ad hoc stage and repeatable, which represent isolated, ad hoc efforts, with some basic processes in place and existing and accessible policies. This exercise provided an opportunity to address identified weaknesses in the upcoming national eHealth strategy., (© Ollis et al.)

Stroke registries are tools for improving care and advancing research. We aim to describe the methodology and resourcing of existing national stroke registries. We conducted a systematic search of the published, peer-reviewed literature and grey literature examining descriptions of data collection methods and resourcing of national stroke registries published from 2012 to 2023. The systematic review was registered in PROSPERO (CRD42023393841). 101 records relating to 21 registries in 19 countries were identified. They universally employed web-based platforms for data collection. The principal profession of data collectors was nursing. All included the acute phase of care, 28% (6) registered the pre-hospital (ambulance) phase and 14% (3) included rehabilitation. 80% (17) collected outcome data. The registries varied in their approach to outcome data collection; in 9 registries it was collected by hospitals, in 2 it was collected by the registry, and 7 had linkage to national administrative databases allowing follow-up of a limited number of end points. Coverage of the total number of strokes varies from 6 to 95%. Despite widespread use of Electronic Health Records (EHRs) the ability to automatically populate variables remained limited. Governance and management structures are diverse, making it challenging to compare their resourcing. Data collection for clinical registries requires time and necessary skills and imposes a significant administrative burden on the professionals entering data. We highlight the role of clinical registries as powerful instruments for quality improvement. Future work should involve creating a central repository of stroke registries to enable the development of new registries and facilitate international collaboration., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear., Aim: To identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010-2023, and to conduct a structured quality assessment., Methods: We drew on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance to inform the design and reporting of our study. We identified relevant programmes using multiple search strategies of grey literature, research databases and other sources. Programmes that met a prespecified definition of improvement programme, that focused on intrapartum care and that had a retrievable evaluation report were subject to structured assessment using selected features of programme quality., Results: We identified 1434 records via databases and other sources. 14 major initiatives in English maternity services could not be quality assessed due to lack of a retrievable evaluation report. Quality assessment of the 15 improvement programmes meeting our criteria for assessment found highly variable quality and reporting. Programme specification was variable and mostly low quality. Only eight reported the evidence base for their interventions. Description of implementation support was poor and none reported customisation for challenged services. None reported reduction of inequalities as an explicit goal. Only seven made use of explicit patient and public involvement practices, and only six explicitly used published theories/models/frameworks to guide implementation. Programmes varied in their reporting of the planning, scope and design of evaluation, with weak designs evident., Conclusions: Poor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes., Competing Interests: Competing interests: TJD: Research and Innovation lead for PROMPT Maternity Foundation and has a part-time appointment at NHS Resolution where he leads on a Safety Action within the Maternity Incentive Scheme., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Type 2 diabetes (T2D) is one of the most prevalent chronic diseases worldwide and a leading cause of cardiorenal disease and mortality. Only one-third of individuals with T2D receive care as recommended by the American Diabetes Association's clinical practice guidelines. Effective strategies are needed to accelerate the implementation of guideline concordant T2D care., Methods: The Michigan Collaborative for Type 2 Diabetes (MCT2D) is a statewide population health collaborative quality initiative (CQI) developed to improve the care of all people with T2D in Michigan. MCT2D has developed a learning health system with physician organizations and their constituent practices to support quality improvement initiatives focused on (1) improving use of guideline-directed pharmacotherapy to improve cardiorenal outcomes, (2) increasing evidence-based use of continuous glucose monitoring, and (3) supporting use of lower carbohydrate eating patterns., Results: Between 2021 and 2022, MCT2D recruited 28 of the 40 Michigan-based physician organizations participating in Blue Cross' Physician Group Incentive Program with 336 constituent practices and 1357 physicians in primary care (304), endocrinology (21) and nephrology (11). In January 2022, baseline data included a sample of 96,140 unique individuals with T2D. The baseline HbA1c was ≤ 7.0% for 66.3% of patients (n = 32,787), while 14.9% of patients had a most recent HbA1c ≥ 8.0% (n = 7,393). The most recent body mass index (BMI) was ≥ 30.0 for 64.8% of patients (n = 38,516)., Discussion: MCT2D has organized a statewide collaborative to recruit and engage a diverse and large set of physician organizations and their constituent practices. This is a promising opportunity to accelerate adoption of guideline-concordant care for people with T2D and may be a model for other state or regional collaboratives. Future directions include specific evidence-based interventions targeted at reducing diabetes-linked comorbidities and associated healthcare costs as well as strategies focused on T2D prevention among at-risk populations., (© 2024. The Author(s).)

Background: The use of rapid qualitative methods has increased substantially over the past decade in quality improvement and health services research. These methods have gained traction in implementation research and practice, wherein real-time adjustments are often made to optimize processes and outcomes. This brisk increase begs the questions: what does rigor entail in projects that use rapid qualitative analysis (RQA)? How do we define a pragmatic framework to help research teams design and conduct rigorous and valid rapid qualitative projects? How can authors articulate rigor in their methods descriptions? Lastly, how can reviewers evaluate the rigor of rapid qualitative projects?., Methods: A team of seven interdisciplinary qualitative methods experts developed a framework for ensuring rigor and validity in RQA and methods suitable for this analytic approach. We conducted a qualitative evidence synthesis to identify gaps in the literature and then drew upon literature, standard procedures within our teams, and a repository of rapid qualitative training materials to create a planning and reporting framework. We iteratively refined this framework through 11 group working meetings (60-90 minutes each) over the course of one year and invited feedback on items to ensure their completeness, clarity, and comprehensibility., Results: The Planning for and Assessing Rigor in Rapid Qualitative Analysis (PARRQA) framework is organized progressively across phases from design to dissemination, as follows: 1) rigorous design (rationale and staffing), 2) semi-structured data collection (pilot and planning), 3) RQA: summary template development (accuracy and calibration), 4) RQA: matrix analysis (matrices), and 5) rapid qualitative data synthesis. Eighteen recommendations across these sections specify best practices for rigor and validity., Conclusions: Rapid qualitative methods play a central role in implementation evaluations, with the potential to yield prompt information and insights about context, processes, and relationships. However, guidance on how to assess rigor is nascent. The PARRQA framework enhances the literature by offering criteria to ensure appropriate planning for and assessment of rigor in projects that involve RQA. This framework provides a consensus-based resource to support high-level qualitative methodological rigor in implementation science., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Global health care quality improvement efforts have focussed on management practices. However, knowledge in primary care settings, especially in developing countries, such as China, is lacking., Objective: To examine the organizational and physician features associated with health care quality in China's community health centres (CHCs)., Methods: We conducted a cross-sectional survey of 224 primary care physicians (PCPs) in 38 CHCs in Jinan, Tianjin, Shenzhen, and Shanghai. Clinical and prevention care quality with a 5-level scale (1 = never, 5 = always) reported by the PCPs were used to measure the quality of care. Two-level hierarchical linear models were estimated to examine the organization and physician-level variables associated with primary care quality., Results: The average clinical care quality score was 4.08 and 3.59 for preventative care out of 5. At the organizational level, organizational culture and organizational support were the strongest predictors of physician-reported quality of care. At the physician level, professional fulfilment, psychological safety, and organizational citizenship behaviour were positively associated with care quality., Conclusions: Chinese CHCs clinical quality ranked high by PCPs, but the quality of preventative care provision required improvement. To improve primary care quality, managers of CHCs should implement optimal organizational structures, supportive organizational cultures, and strong organizational support at the organization level and cultivate high professional fulfilment, safe, and trustful relationships with colleagues at the physician level., (© The Author(s) 2024. Published by Oxford University Press. 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.)

Summary Statement: Simulation is underutilized as a tool to improve healthcare quality and safety despite many examples of its effectiveness to identify and remedy quality and safety problems, improve teamwork, and improve various measures of quality and safety that are important to healthcare organizations, eg, patient safety indicators. We urge quality and safety and simulation professionals to collaborate with their counterparts in their organizations to employ simulation in ways that improve the quality and safety of care of their patients. These collaborations could begin through initiating conversations among the quality and safety and simulation professionals, perhaps using this article as a prompt for discussion, identifying one area in need of quality and safety improvement for which simulation can be helpful, and beginning that work., Competing Interests: J.F.C. receives an honorarium for serving as an associate editor of Simulation in Healthcare; J.F.C., S.F., and R.H.S. received travel support from the American Society of Anesthesiologists; D.P.S. is an advisor and receives payment or stock options as compensation for the following companies: Provation, SenSIght.AI, Kela Health, and Vox Telehealth. He is a senior partner for healthcare at A.I. MIR. The other authors declare no conflict of interest., (Copyright © 2024 Society for Simulation in Healthcare.)

Background: A complete transthoracic echocardiogram takes approximately 45 minutes to complete, including time for image acquisition and preliminary reporting by the sonographer. The process can take substantially longer if there are technical difficulties or if contrast must be administered due to suboptimal imaging windows. This can create a considerable echocardiogram backlog at high-volume institutions. At the authors' institution, there was a concern that ordering providers were inappropriately designating studies as stat to get their patients to the front of the bottleneck. On review, the quality improvement team found that 19.9% of all echocardiograms ordered during June 2021 were designated stat, of which 44.0% contained indications that the team determined were rarely appropriate for a stat priority designation., Methods: The team located a flaw in the electronic health record interface that encouraged overuse of the stat designation, so an interface change was designed and implemented to create a hard stop requiring the selection of predetermined indications for any stat order. We also reduced the number of steps required to select the less-urgent ASAP priority to encourage its use over stat priority., Results: Within one month postintervention, there was a statistically significant 36.3% reduction in the order of stat echocardiograms, with a concurrent 173.9% rise in ASAP orders over the same time frame. These numbers remained steady at one-year and two-year follow-up analyses., Conclusion: A quick and simple modification to the echocardiogram order user interface can lead to a considerable reduction in the number of stat orders., (Published by Elsevier Inc.)

Introduction: Birth asphyxia-related deaths is a major global concern. Rapid initiation of ventilation within the "Golden Minute" is important for intact survival but reported to be challenging, especially in low-/middle-income countries. Helping Babies Breathe (HBB) is a simulation-based training program for newborn resuscitation. The aim of this HBB quality improvement (QI) intervention was to decrease time from birth to ventilation and document potential changes in perinatal outcomes., Method: Prospective observational QI study in a rural Tanzanian hospital, October 1, 2017, to August 31, 2021, first-year baseline, second-year QI/simulation intervention, and 2-year postintervention. Trained research assistants observed wide-ranging information from all births (N = 12,938). The intervention included monthly targeted HBB simulation training addressing documented gaps in clinical care, clinical debriefings, and feedback meetings., Results: During the QI/simulation intervention, 68.5% nonbreathing newborns were ventilated within 60 seconds after birth compared with 15.8% during baseline and 42.2% and 28.9% during the 2 postintervention years ( P < 0.001). Time to first ventilation decreased from median 101 (quartiles 72-150) to 55 (45-67) seconds ( P < 0.001), before increasing to 67 (49-97) and 85 (57-133) seconds after intervention. More nonbreathing newborns were ventilated in the intervention period (12.9%) compared with baseline (8.5%) and the postintervention years (10.6% and 9.4%) ( P < 0.001). Assumed fresh stillborns decreased significantly from baseline to intervention (3.2%-0.7%) ( P = 0.013)., Conclusions: This QI study demonstrates an increase in nonbreathing newborns being ventilated within the Golden Minute and a significant reduction in fresh stillborns after introduction of an HBB QI/simulation intervention. Improvements are partially reversed after intervention, highlighting the need for continuous simulation-based training and research into QI efforts essential for sustainable changes., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society for Simulation in Healthcare.)

Objectives : This quality improvement (QI) project was to lean the process for managing critical high and low glucose levels in the hospice unit and to simplify the pharmacologic options for hypoglycemic management for nursing staff. Methods : The process for developing and refining the recommendations involved a modified Delphi approach with a team of key stakeholders with overlapping expertise in hospice care practice. Recommendations were based on literature review, judgement of experts, and clinical experience. Stakeholders ranked six potential solutions and two were prioritized within the scope of this project. Results : From 1/1/21 - 12/31/21, there were 48 veterans with insulin sliding scale orders in the hospice unit, of which there were six critical values acted on. A standard operating procedure (SOP) for the management of critical glucose values in hospice was developed based on updated processes. In addition, hospice patient specific insulin sliding scale order sets were created and endorsed for utilization and dissemination. Following implementation on 3/1/22, no critical values were found in the hospice unit from 3/1/22 - 6/1/22 during the sustainment period. Conclusions : The implementation of hospice insulin sliding scale order sets and SOP on the management of critical glucose values in hospice reduced the number of critical glucose values., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Health care delivery contributes a significant carbon footprint in the United Kingdom, and paradoxically climate change is linked to poorer human health outcomes. New General Medical Council (GMC) requirements mandate medical graduates must be able to apply sustainable care to their practice. Implementation of sustainable health care (SHC) teaching is a new challenge for medical schools, and there are several identified barriers including an overcrowded curriculum, lack of expertise within faculties, lack of institutional support and inadequate assessment techniques., Approach: We established a new SHC curriculum spiralling throughout the overall medical curriculum, and as part of this introduced a sustainable quality improvement (susQI) project to our final year cohort. SusQI considers the environmental, social and financial impacts as well as patient and population outcomes. Our students undertook this in their final year GP assistantships., Evaluation: We sought multi-sourced data through focus groups, formal end of placement feedback, informal feedback and external feedback. We applied thematic analysis to focus group transcriptions and triangulated with the other data sources. We identified some common themes: First, susQI was enjoyed and valuable; second, it allowed meaningful participation; third, it created a co-learning environment; and fourth, timing and curriculum placement are important when integrating susQI., Implications: SusQI can implement SHC into the overcrowded medical curriculum in a low cost, low resource manner without the need for experienced faculty. SusQI is empowering for students and grants them an active team role. Expansion into secondary and tertiary care is feasible, and we contend that susQI can be placed in other health care curricula., (© 2024 The Authors. The Clinical Teacher published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Introduction: Culturally and linguistically diverse (CALD) patients should but do not routinely receive professional interpretation. The authors examined provider perceptions of barriers and solutions to interpreter services (IS) in a safety-net hospital to inform quality improvement (QI)., Methods: A 13-item survey was distributed to 750 clinicians representing 10 services across professional roles, including social workers. Closed- and open-ended questions addressed accessing IS, IS value, and care for CALD patients. Respondents ranked eight barriers to routine IS use and provided ideas for improvement. Descriptive statistics characterized survey results in aggregate and by professional role and care team. Quantitative and qualitative results were triangulated for agreement between survey domains and coded free-text response themes., Results: A total of 221 responses were analyzed (29.5% response rate). Cost was the lowest-ranked barrier across roles. Leading barriers were efficiency pressures and cumbersome access. Free-text responses agreed with these findings. CALD patients were perceived to have higher complication risk by 87.5% of social workers but by 56.8% of other roles. Recommendations to increase IS varied by team: streamlined access process (46.2% emergency, 37.8% inpatient respondents), expanded in-person interpretation (55.6% inpatient, 45.8% perioperative respondents), and better equipment (44.4% outpatient, 35.9% emergency, 25.0% perioperative respondents)., Conclusion: Provider experiences vary by care team and interpretation modality. Interpretation services are cumbersome to access and compete with efficiency pressures, leading to shortcuts that fail to provide adequate language access. Three initial QI efforts resulted: increased video interpretation equipment, a new language access committee, and a new language access leadership role., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Care transitions among high-intensity units caring for patients with complex needs are a critical yet undeveloped area of patient safety research. In addition, effective communication and coordination across disciplines remain elusive. This study introduces and tests the Multi-Team Shared Expectations Tool (MT-SET), an exercise that aims to engage health care teams in eliciting needs and establishing agreed-upon expectations teams and individuals within a multi-team system have of one another. We piloted the exercise within hospital-based workflows for oncology inpatients and later adopted it to elicit data on mutual needs and expectations of teams across units involved in patient transitions in two patient safety projects. Our studies demonstrated that the exercise identified common cross-unit coordination problems of delays in care, unwanted variations in care, and lack of standardized communication among units. It also revealed mismatched prioritization of each of these problems between specific unit types. The participants reported that the MT-SET helped establish positive relationships for building better cross-unit and cross-disciplinary teamwork and coordination. There is a need for systematic approaches to understand and facilitate cross-unit communication and coordination in care delivery and transitions. Future studies should broaden the application of the exercise to additional types of multi-unit and multidisciplinary teams and observe intervention ideas generated from the exercise, as well as their implementation., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: During the COVID-19 pandemic in the United Kingdom, multiple aspects of everyday human existence were disrupted. In contrast, almost all levels of educational learning continued, albeit with modifications, including adaptation to virtual-or online-classroom experiences. This pedagogic transition also occurred in the National Institute of Health and Care Research Applied Research Collaboration Northwest London's (NIHR ARC NWL) Improvement Leader Fellowship, an annual programme focusing on quality improvement (QI). This qualitative study aimed to understand how these changes impacted the Fellows' learning experience., Methods: We explored the experiences of two cohorts of programme Fellows (n = 18, 2020-2021 and n = 15, 2021-2022) with focus groups, analysed under a constructivist qualitative research paradigm., Results: The two primary and four sub-themes that emerged were: Online QI learning experience (benefits and challenges) and Implementing online QI learning (facilitators and barriers). While benefits had three further sub-themes (i.e., digital flexibility, connection between learners, and respite from impact of COVID-19), challenges had four (i.e., lack of interaction, technological challenges and digital exclusion, human dimension, and digital fatigue). While the facilitators had three sub-themes (i.e., mutual and programmatic support, online resource access, and personal resilience), barriers had one (i.e., preventing implementation and lack of protected time)., Conclusion: Despite challenges to in-person ways of working, online learning generally worked for action-orientated QI learning, but changes are needed to ensure the effectiveness of future use of virtual learning for QI. Understanding the challenges of the translation of learning into action is crucial for implementation learning, gaining insight into how improvement Fellows navigated this translation when learning remotely and implementing directly in their workplace is key to understanding the evolving nature of implementation over the pandemic years and beyond., (© 2024. The Author(s).)

Background: Communication breakdowns among healthcare providers have been identified as a significant cause of preventable adverse events, including harm to patients. A large proportion of studies investigating communication in healthcare organizations lack the necessary understanding of social networks to make meaningful improvements. Process Improvement in healthcare (systematic approach of identifying, analyzing, and enhancing workflows) is needed to improve quality and patient safety. This review aimed to characterize the use of SNA methods in Process Improvement within healthcare organizations., Methods: Relevant studies were identified through a systematic search of seven databases from inception - October 2022. No limits were placed on study design or language. The reviewers independently charted data from eligible full-text studies using a standardized data abstraction form and resolved discrepancies by consensus. The abstracted information was synthesized quantitatively and narratively., Results: Upon full-text review, 38 unique articles were included. Most studies were published between 2015 and 2021 (26, 68%). Studies focused primarily on physicians and nursing staff. The majority of identified studies were descriptive and cross-sectional, with 5 studies using longitudinal experimental study designs. SNA studies in healthcare focusing on process improvement spanned three themes: Organizational structure (e.g., hierarchical structures, professional boundaries, geographical dispersion, technology limitations that impact communication and collaboration), team performance (e.g., communication patterns and information flow among providers., and influential actors (e.g., key individuals or roles within healthcare teams who serve as central connectors or influencers in communication and decision-making processes)., Conclusions: SNA methods can characterize Process Improvement through mapping, quantifying, and visualizing social relations, revealing inefficiencies, which can then be targeted to develop interventions to enhance communication, foster collaboration, and improve patient safety., (© 2024. The Author(s).)

Introduction Best-practice guidelines recommend that patients are followed-up to check if they have recovered following a mild traumatic brain injury (mTBI) and to refer to concussion services, if needed. However, in New Zealand, rates of follow-up are low and access to concussion services can be delayed. Aim We aimed to improve rates of follow-up and access to concussion services for mTBI patients aged ≥8 years by the implementation of a supported health pathway and test its success. Methods The pathway included a decision support tool, funded follow-up appointments, clinician training and a patient education resource. Sociodemographics, injury details and proportions of patients receiving a follow-up by type and time were extracted from the Accident Compensation Corporation (ACC) database between 18 May 22 and 30 June 23 and compared to national ACC data prior to implementation. Results Data were extracted for 220 patients, with a mean age of 31.5 years, 51.4% female and 21.4% Māori and Pacific. There was an increase in the proportion of patients receiving a follow-up from 36% pre-implementation to 56.8% post-implementation. Sixty-three patients (28.6%) accessed a concussion service post-implementation compared to 10% pre-implementation. Time to concussion service reduced from an average of 55 (s.d. = 65.4) to 37 days (29.5). Discussion Risk factor criteria within the decision support tool need to be weighted to improve specificity of referrals. Timing from injury to medical review in primary care needs to be considered. This quality improvement project provides preliminary evidence for implementation of a supported health care pathway for mTBI.

Handoffs involve the transfer of patient information and responsibility for care between health care professionals. The purpose of the current scoping review was (1) to describe handoff studies with education as part of the intervention and (2) to explore the role of handoff educational interventions in sustaining handoff improvements. This scoping review utilized previously published systematic reviews and a structured, systematic search of 5 databases (January 2006-June 2020). Articles were identified, and data were extracted by pairs of trained, independent reviewers. The search identified 74 relevant articles, most published after 2015 (70%) and conducted in the United States (76%). Almost all of the studies (99%) utilized instruction, 66% utilized skills practice, 89% utilized a memory aid, and 43% utilized reinforcement. However, few studies reported using education theory or followed accepted tenets of curriculum development. There has been a substantial increase over time in reporting actual handoff behavior change (17%-68%) and a smaller but important increase in reporting patient outcomes (11%-18%). Thirty-five percent of studies (26/74) had follow-up for 6 months or more. Twelve studies met the criteria for sustained change, which were follow-up for 6 months or more and achieving statistically significant improvements in either handoff skills/processes or patient outcomes at the conclusion of the study. All 12 studies with sustained change used multi-modal educational interventions, and reinforcement was more likely to be used in these studies than all others (75%, 9/12) versus (37%, 23/62), P = 0.015. Future handoff intervention efforts that include education should use education theory to guide development and include needs assessment and goals and measurable objectives. Educational interventions should be multi-modal and include reinforcement. Future research studies should measure actual handoff behavior change (skills/process) and patient outcomes, include follow-up for more than 6 months, and use education reporting guidelines., (Copyright © 2024 the American College of Medical Quality.)

The application of technology in precision medicine (i.e., using data to tailor care for specific groups) and machine learning (modeling data to develop new ways to meet particular needs) plays a vital role in population health. And yet, technology alone cannot resolve the challenges presented by the underlying social determinants of health (SDOH) and the structure of healthcare institutions. Progress requires a partnership of stakeholders to build holistic solutions. Typically, a rigid institutional reliance on a sequential process of hypothesis, study, experimentation, and evaluation drives the development of health programs and policies. While this process works in many cases, the results are not always long-lasting. The roots of many health problems persist in their communities, despite expanded funding and advanced resources. In light of this reality, should healthcare leaders do more of what has been done in the past, or should they explore another way-a new way of thinking-to design collaborative, people-driven programs and policies that can improve and sustain the health of their communities? The response presented here and detailed in our book, Public Health and Health Systems Management: A Population Health Perspective (scheduled for publication in 2025 by Health Administration Press), considers healthcare's complex structure and SDOH and promotes the value of design thinking to address those factors., Competing Interests: The authors declare no conflicts of interest.

Background: Medicines are the cornerstone of healthcare. Lean methodology approach such as Value Stream Mapping (VSM) is being used in healthcare to manage resources wisely to ensure sustainability of medicines and resources. The aim of this quality improvement study was to evaluate and improve the medication management and hospital imprest supply processes in Australia's first dedicated cardiology hospital using VSM., Method: We conducted a review of our medicine supply processes at a 180-bed cardiology hospital in Australia. We followed a lean methodology approach over a 4-month period from February to May 2023 and evaluated the outcome of our improvements for another 4 months from July to October 2023. We used VSM to identify non-value adding activities. Cost of medicines holding was calculated, as well as time taken to complete supply processes, pre and post., Results: Pharmacy department stockholdings reduced by 51%; p = 0.000121 (from $539,662 to $275,406). Time taken to manage the inventory system also reduced by 42%; p = 0.025762 (from 148 h/month to 62 h/month). Lean methodology such as VSM can facilitate cost-effective and sustainable system improvements for pharmacy procurement systems., (© 2024 The Author(s). The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Background: Human immunodeficiency virus (HIV) and hepatitis C (HCV) screening and human papillomavirus (HPV) vaccine uptake remain suboptimal. To improve HIV and HCV screening and HPV vaccination, the authors implemented a quality improvement project in three southwestern Pennsylvania family medicine residency practices., Methods: From June 1 to November 30, 2021, participating practices used universal screening and vaccination guidelines and chose from multiple strategies at the office (for example, standing orders), provider (for example, multiple forms of provider reminders), and patient (for example, incentives) levels derived from published literature and tailored to local context. Age-eligible patients for each recommendation with at least one in-person office visit during the intervention period were included. To assess the interventions' effect, the authors obtained testing and vaccination data from the electronic health record for the intervention period, contrasted it with identical data from June 1 to November 30, 2020, and used logistic regression controlling for patient age, sex, and race to determine differences in screening and vaccination between intervention and baseline periods., Results: A total of 14,920 and 15,523 patients were eligible in the baseline and intervention periods, respectively. Following the intervention, HIV lifetime screening but not first-time screening for patients 13-64 years old was significantly higher (78.9% vs. 76.1%, p = 0.004, and 39.6% vs. 36.6%, p = 0.152, respectively, adjusted odds ratio [aOR] 1.21, 95% confidence interval [CI] 1.06-1.38). HCV lifetime screening for patients 18-79 years old was significantly higher postintervention (62.5% vs. 53.5%, p < 0.001, aOR 1.51, 95% CI 1.4-1.64). For patients 9-26 years old, no change in HPV initiation was observed, but the percentage of patients who completed their HPV vaccinations in the observed period was significantly higher postintervention (7.0% vs 4.6%, p = 0.006, aOR 1.58, 95% CI 1.14-2.2). During the postintervention period, the researchers identified 0 new HIV diagnoses and 48 HCV diagnoses (19 eligible for treatment)., Conclusion: Family medicine residency office-based multistrategy efforts appear to successfully increase patient uptake of HIV and HCV screenings and maintain HPV vaccination rates., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

The protracted form of COVID-19 known as 'long covid' was first described in 2020. Its symptoms, course and prognosis vary widely; some patients have a multi-system, disabling and prolonged illness. In 2021, ring-fenced funding was provided to establish 90 long covid clinics in England; some clinics were also established in Scotland and Wales. The NIHR-funded LOCOMOTION project implemented a UK-wide quality improvement collaborative involving ten of these clinics, which ran from 2021 to 2023. At regular online meetings held approximately 8-weekly, participants prioritised topics, discussed research evidence and guidelines, and presented exemplar case histories and clinic audits. A patient advisory group also held a priority-setting exercise, participated in quality meetings and undertook a service evaluation audit. The goal of successive quality improvement cycles aimed at changing practice to align with evidence was sometimes hard to achieve because definitive evidence did not yet exist in this new condition; many patients had comorbidities; and clinics were practically constrained in various ways. Nevertheless, much progress was made and a series of 'best practice' guides was produced, covering general assessment and management; breathing difficulties; orthostatic tachycardia and other autonomic symptoms; fatigue and cognitive impairment; and vocational rehabilitation. This paper summarises key findings with the frontline clinician in mind., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Trisha Greenhalgh reports financial support was provided by National Institute for Health and Care Research. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Cardiovascular disease (CVD) is the primary cause of premature morbidity and mortality in the United States and Tennessee ranks among the highest in CVD events. While patient-centered outcomes research (PCOR) evidence-based approaches that reach beyond the traditional doctor-patient visit hold promise to improve CVD care and prevent serious complications, most primary care providers lack time, knowledge, and infrastructure to implement these proven approaches. Statewide primary care quality improvement (QI) collaboratives hold potential to help address primary care needs, however, little is known regarding their effectiveness in improving uptake of PCOR evidence-based population health approaches and improving CVD outcomes. This study describes the design and implementation of a stepped-wedge cluster randomized controlled trial to assess the effectiveness of participation in a statewide quality improvement cooperative (The Tennessee Heart Health Network [TN-HHN]) on cardiovascular outcomes., Methods/design: The TN-HHN Effectiveness Study randomized 77 practices to 4 waves (i.e., clusters), with each wave beginning three months after the start of the prior wave and lasting for 18 months. All practice clusters received one of three Network interventions, and outcomes are measured for each three months both in the control phase and the intervention phase. Primary outcomes include Center for Medicare and Medicaid Services measures for aspirin use, blood pressure control, cholesterol control, and smoking cessation (ABCS)., Conclusions: This trial, upon its conclusion, will allow us to assess the effect of participation in a statewide quality improvement cooperative on cardiovascular outcomes as well as key contributors to successful practice transformation., Competing Interests: Declaration of competing interest Susan Butterworth provides consulting and training in motivational interviewing-based health coaching for organizations. All other authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: We declare no competing interests.

Purpose: To innovatively use the FOCUS-PDCA quality improvement strategy to establish an external quality assessment (EQA) working group to continuously improve EQA performance, an important indicator of the national tertiary public hospital performance appraisal., Methods: The project was carried out at the National Center for Clinical Laboratories. Using FOCUS-PDCA, which combines problem-focused steps (FOCUS) and improvement steps (PDCA), a project team was established to carry out improvement work. Root cause analysis was carried out to analyze the problems in quality control from EQA project application to results analysis and an improvement plan was implemented according to the steps of FOCUS-PDCA. The project was executed in three cycles from 2019 to 2021 to obtain more satisfactory results., Results: After implementing three cycles of FOCUS-PDCA, the EQA participation rate increased from 66.5% in 2018 to 100% in 2021, and the EQA pass rate increased from 94.9% in 2018 to 99.3% in 2021. Consequently, the hospital moved into the top 50 in performance assessment for the first time in 2020 and ranked 27th in 2021., Conclusion: The use of the FOCUS-PDCA quality improvement strategy can improve the EQA performance of national tertiary public hospitals and help them achieve satisfactory results in the national examination., (© 2024 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Background: Communication failures contribute to quality gaps and may lead to serious safety events (SSEs) in the operating room (OR). Our perioperative services team experienced an increased rate of SSEs in 2020. Event analysis revealed clustered causes: communication failures and lack of timely information to prepare for cases. Consequently, the team implemented a daily morning OR safety huddle conducted before bringing patients into the OR to reduce quality gaps and improve communication., Methods: The attending surgeon and anesthesiologist, circulating nurse, and scrub staff are required to be present. Cases are discussed using a standard format designed by the OR team with built-in time for questions and clarifications. The surgeon initiates the huddle; the circulating nurse leads and records the discussion. OR leadership initially performed daily audits but gradually reduced them when huddles became standard operating procedure (SOP). SSEs were recorded from December 2015 to September 2020 preintervention and October 2020 to July 2023 postintervention., Results: Following the implementation of huddles, there were no SSEs for more than 900 days (2.0 SSEs/year preintervention vs. 0.0 SSEs/year postintervention). The first SSE during the postintervention period occurred in March 2023. Huddle compliance was consistently > 95%. No delays were observed in first-case on-time starts postintervention. The huddle is now SOP for all general OR teams and interventional radiology., Conclusion: Implementing the morning safety huddle contributed to a reduction in the rate of SSEs without introducing delays to first-case start-times., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Abstract: Functional neurological disorder (FND) sits at the intersection of neurology and psychology and has a variety of presentations, severity, and symptomatology. It affects a considerable number of pediatric patients and overwhelmingly influences healthcare spending. Diagnosis, treatment, and outcomes are varied, challenging, and lack standardization, often leading to frustration from patients, caregivers, and providers. Multidisciplinary care is essential though communication is often complex and disjunct. Using quality improvement tools and experiences from one institution, a team was established to ameliorate these concerns. A clinical care pathway was designed for the diagnosis and treatment of FND in the pediatric inpatient setting. This pathway was the result of the multidisciplinary team effort and an outcome, highlighting the need for early and intentional diagnosis with diagnosing provider specified, provider education and consistent language, patient and caregiver education, and clear and thorough discharge planning. Through the implementation of this pathway, it is anticipated that patient and provider satisfaction will improve as will the outcomes and care given to affected individuals. This work can be applied to the global treatment of FND and raise awareness to effectively managed care as well as the opportunity for clinicians to drive institutional change., Competing Interests: L. Brown has received personal compensation as a speaker for Biogen and Sarepta unrelated to this study. M. Norwood and L. Thompson have no conflicts of interest to disclose., (Copyright © 2024 National Association for Healthcare Quality.)

Against the background of the discussion about a comprehensive regional mental health care service, the essay discusses the possibility of a comprehensive, transparent and meaningful evaluation. Proposals for how structures, processes, and outcomes may be assessed are presented. We argue for collecting data that are transparent and actionable on all levels of care organisations. The suggested evaluation would be innovative, meaningful for individual patients, services, health care organisations and whole regions, and thus a way for a data-driven ongoing quality improvement., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: China is transforming its hospital-centric service delivery system into a people-centered integrated care model, with service delivery organized around the health needs and expectations of people., Objective: To guide reforms and align with public expectations, this study profiles successful integration in primary health care from the public perspective., Methods: Guided by the rainbow model of integrated care, semi-structured interviews were conducted in six provinces in China. A total of 58 interviewees completed the interviews. Tape-based analysis was used to produce narrative summaries. Researchers listened to the recordings and summarized by 30-s segments. Thematic analysis was performed on summaries to identify thematic families., Results: Five themes and 16 sub-themes were generated. Respondents' expectations were primarily on three themes: clinical integration (such as interaction between professional and client, continuity, and empowering and engaging individuals), functional integration (such as resources management, quality improvement, and reforming payment systems), and system integration (such as institutional distribution and supervision). Yet a few interviewees mentioned professional integration (multi-disciplinary collaboration) and organizational integration (inter-organizational strategy)., Conclusions: Qualitative data were used to reveal public perceptions of successful primary health care integration. Service processes, institutional distribution, regulation, resource management, and quality improvement are more visible to the public and will be priorities for future efforts. Whereas inter-organizational strategies and multi-disciplinary collaboration have been shown to facilitate service improvements. Future efforts could consider how policy efforts can be grounded in visible service delivery through management practices.

Background: The Transformative Care Continuum (TCC) emerged in 2018 at Ohio University's Heritage College of Osteopathic Medicine, combining a three-year medical education track with a three-year family medicine residency. TCC aligns evolving family physician roles through the Kern model, AMA's Master Adaptive Learner model, Health Systems Science Training, and Kirkpatrick's evaluation model., Methods: The TCC curriculum emphasizes intensive coaching, clinical encounter video evaluation, reflection, and case-log review. It fosters longitudinal clinical integration, community engagement, and a dynamic learning atmosphere. Students receive rigorous patient-centered communication training and engage in residency-based quality improvement projects, targeting care gap closure and community health in an accelerated 3-year program., Outcomes: Assessment of TCC graduates demonstrates advanced team communication, leadership, and project management skills, with entrustable professional activities (EPA) scores meeting or surpassing those of traditional program graduates. Projects led by students have yielded notable clinical enhancements, national recognition, and significant philanthropic funding for non-medical determinants of health. Finally, there is an overall increase in scholarly activity and leadership roles within the residency programs that have engaged these students., Discussion: Lessons reveal intrinsic challenges and heightened academic demands for students and residency programs. Additional educational support for students may be necessary, though costly. Limitations in residency slots and faculty availability as student educators potentially hinder scalability. Ongoing faculty training, cultural support, and early integration of digital systems for curriculum management and evaluation are vital for success. Obtaining patient satisfaction, health outcomes, and program measures remains challenging due to privacy concerns and approval processes between institutions., Conclusion: Programs like TCC effectively prepare students for family physician leadership and change management roles through tailored learning, longitudinal experiences, health systems training, and addressing critiques of traditional medical education. Continuous feedback and robust communication strategies are essential for program improvement, fostering well-prepared family physicians committed to health system enhancement.

Background: Quality healthcare is a global priority, reliant on robust health systems for evidence-based medicine. Clinical laboratories are the backbone of quality healthcare facilitating diagnostics, treatment, patient monitoring, and disease surveillance. Their effectiveness depends on sustainable delivery of accurate test results. Although the Strengthening Laboratory Management Towards Accreditation (SLMTA) programme has enhanced laboratory quality in low-income countries, the long-term sustainability of this improvement remains uncertain., Objective: To explore the sustainability of quality performance in clinical laboratories in Rwanda following the conclusion of SLMTA., Methods: A quasi-experimental design was adopted, involving 47 laboratories divided into three groups with distinct interventions. While one group received continuous mentorship and annual assessments (group two), interventions for the other groups (groups one and three) ceased following the conclusion of SLMTA. SLMTA experts collected data for 10 years through assessments using WHO's StepwiseLaboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. Descriptive and t-test analyses were conducted for statistical evaluation., Results: Improvements in quality were noted between baseline and exit assessments across all laboratory groups (mean baseline: 35.3%, exit: 65.8%, p  < 0.001). However, groups one and three experienced performance declines following SLMTA phase-out (mean group one: 64.6% in reference to 85.8%, p  = 0.01; mean group three: 57.3% in reference to 64.7%, p  < 0.001). In contrast, group two continued to enhance performance even years later (mean: 86.6%compared to 70.6%, p  = 0.03)., Conclusion: A coordinated implementation of quality improvement plan that enables regular laboratory assessments to pinpoint and address the quality gaps is essential for sustaining quality services in clinical laboratories.

Objective: To assess the effectiveness of evidence-based quality improvement (EBQI) as an implementation strategy to expand the use of medications for opioid use disorder (MOUD) within nonspecialty settings., Data Sources and Study Setting: We studied eight facilities in one Veteran Health Administration (VHA) region from October 2015 to September 2022 using administrative data., Study Design: Initially a pilot, we sequentially engaged seven of eight facilities from April 2018 to September 2022 using EBQI, consisting of multilevel stakeholder engagement, technical support, practice facilitation, and data feedback. We established facility-level interdisciplinary quality improvement (QI) teams and a regional-level cross-facility collaborative. We used a nonrandomized stepped wedge design with repeated cross sections to accommodate the phased implementation. Using aggregate facility-level data from October 2015 to September 2022, we analyzed changes in patients receiving MOUD using hierarchical multiple logistic regression., Data Collection/extraction Methods: Eligible patients had an opioid use disorder (OUD) diagnosis from an outpatient or inpatient visit in the previous year. Receiving MOUD was defined as having been prescribed an opioid agonist or antagonist treatment or a visit to an opioid substitution clinic., Principal Findings: The probability of patients with OUD receiving MOUD improved significantly over time for all eight facilities (average marginal effect [AME]: 0.0057, 95% CI: 0.0044, 0.0070) due to ongoing VHA initiatives, with the probability of receiving MOUD increasing by 0.577 percentage points, on average, each quarter, totaling 16 percentage points during the evaluation period. The seven facilities engaging in EBQI experienced, on average, an additional 5.25 percentage point increase in the probability of receiving MOUD (AME: 0.0525, 95%CI: 0.0280, 0.0769). EBQI duration was not associated with changes., Conclusions: EBQI was effective for expanding access to MOUD in nonspecialty settings, resulting in increases in patients receiving MOUD exceeding those associated with temporal trends. Additional research is needed due to recent MOUD expansion legislation., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: To test effectiveness of the LEAP (Learn Engage Act Process) Program on engaging frontline Veteran Health Administration (VHA) medical center teams in continuous quality improvement (QI), a core capability for learning health systems., Data Sources and Study Setting: Data sources included VHA electronic health record (EHR) data, surveys, and LEAP coaching field notes., Study Design: A staggered difference-in-differences study was conducted. Fifty-five facilities participated in LEAP across eight randomly assigned clusters of 6-8 facilities per cluster over 2 years. Non-participating facilities were used as controls. A MOVE! weight management program team completed a Plan-Do-Study-Act cycle of change supported by learning curriculum, coaching, and virtual collaboratives in LEAP facilities. Primary outcome was program reach to Veterans. A mixed-effects model compared pre- versus post-LEAP periods for LEAP versus control facilities. LEAP adherence, satisfaction, and cost to deliver LEAP were evaluated., Data Collection/extraction Methods: Thirty months of facility-level EHR MOVE! enrollment data were included in analyses. LEAP Satisfaction and QI skills were elicited via surveys at baseline and 6-month post-LEAP., Principal Findings: Fifty-five facilities were randomly assigned to eight time-period-based clusters to receive LEAP (71% completed LEAP) and 82 non-participating facilities were randomly assigned as controls. Reach in LEAP and control facilities was comparable in the 12-month pre-LEAP period (p = 0.07). Though LEAP facilities experienced slower decline in reach in the 12-month post-LEAP period compared with controls (p < 0.001), this is likely due to unexplained fluctuations in controls. For LEAP facilities, satisfaction was high (all mean ratings >4 on a 5-point scale), self-reported use of QI methods increased significantly (p-values <0.05) 6 months post-LEAP, and delivery cost was $4024 per facility-based team., Conclusion: Control facilities experienced declining reach in the 12-month post-LEAP period, but LEAP facilities did not, plus they reported higher engagement in QI, an essential capability for learning health systems., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: To describe a process model for assisting partners in addressing requirements of legislation and review policy analysis, planning, and evaluation design processes and tools. Throughout its 25-year history, the United States Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) program has been a forerunner in partnering with organizational leaders to improve health care. The Foundations of Evidence-based Policymaking Act of 2018 provided new opportunities for QUERI and other implementation scientists to support federal agency leaders in implementing, evaluating, and reporting on congressionally mandated programs. Although implementation scientists have the skills to support partnered implementation and evaluation, these skills must be adapted for congressionally mandated projects as many scientists have limited experience in policy analysis and the intersection of data informing organizational policy, programs, and practices (i.e., evidence-based policy)., Data Sources and Study Setting: During the conduct of four congressionally mandated projects, our national VA QUERI team developed processes and tools to achieve the goals and aims of our VHA partners and to ensure our collective work and reporting met legislative requirements., Study Design: Our process model, program planning, and analysis tools were informed by an iterative process of refining and adapting the tools over a period of six years, spanning the years 2017 to 2023., Principal Findings: Work to support our partners was conducted across three phases: preparation and planning, conducting implementation and evaluation, and developing the congressionally mandated report. The processes and tools we developed within the context of mutually respectful and honest partnerships have been critical to our QUERI center's success in this area., Conclusions: Lessons we learned may help other scientists partnering in VA or other federal agencies to plan, conduct, and report on congressionally mandated projects., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Nearly 60% of people with HIV in New York State are over 50 years of age. After town halls and a statewide survey of long-term survivors, older people living with HIV, and their providers, the Quality of Care Program of the AIDS Institute in the New York State Department of Health developed a statewide quality improvement project that aimed to improve screening for functional impairments among people aging with HIV. Thirteen sites reported outcomes of a pilot project using a modification of the World Health Organization's Integrated Care of Older People (ICOPE) intrinsic capacity screen in small scale, short cycle tests of change. A total of 1,629 people were found to be eligible for screening, and of these, 638 people were screened. Both clinical and non-clinical sites were able to identify significant areas of need. Positive screens ranged from a low of 17% for the identification of hearing issues to 49% for vision concerns. Only 11% of people with memory or nutritional concerns were referred for services; hearing loss was the domain with the largest number of referrals, at 27%. Although in many cases, when referrals were not made, patients/clients were already under care for the identified functional deficit, in other cases no services were available for referral or patients/clients declined to use the offered service. Sites also responded to the findings of the screen by initiating process changes, and many reported continuing to screen for functional impairments after the close of the pilot. The modified ICOPE screen is still in use in sites throughout the state. This pilot demonstrated that a collaboration between people with lived HIV experience, the New York State Department of Health, clinicians, and service providers could result in improved quality of care for people aging with HIV., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To evaluate nationwide implementation of a Guidebook designed to standardize safety practices across VA-delivered and VA-purchased care (i.e., Community Care) and identify lessons learned and strategies to improve them., Data Sources and Study Setting: Qualitative data collected from key informants at 18 geographically diverse VA facilities across 17 Veterans Integrated Services Networks (VISNs)., Study Design: We conducted semi-structured interviews from 2019 to 2022 with VISN Patient Safety Officers (PSOs) and VA facility patient safety and quality managers (PSMs and QMs) and VA Facility Community Care (CC) staff to assess lessons learned by examining organizational contextual factors affecting Guidebook implementation based on the Consolidated Framework for Implementation Research (CFIR)., Data Collection/extraction Methods: Interviews were conducted virtually with 45 facility staff and 10 VISN PSOs. Using directed content analysis, we identified CFIR factors affecting implementation. These factors were mapped to the Expert Recommendations for Implementing Change (ERIC) strategy compilation to identify lessons learned that could be useful to our operational partners in improving implementation processes. We met frequently with our partners to discuss findings and plan next steps., Principal Findings: Six CFIR constructs were identified as both facilitators and barriers to Guidebook implementation: (1) planning for implementation; (2) engaging key knowledge holders; (3) available resources; (4) networks and communications; (5) culture; and (6) external policies. The two CFIR constructs that were only barriers included: (1) cosmopolitanism and (2) executing implementation., Conclusions: Our findings suggest several important lessons: (1) engage all collaborators involved in implementation; (2) ensure end-users have opportunities to provide feedback; (3) describe collaborators' purpose and roles/responsibilities clearly at the start; (4) communicate information widely and repeatedly; and (5) identify how multiple high priorities can be synergistic. This evaluation will help our partners and key VA leadership to determine next steps and future strategies for improving Guidebook implementation through collaboration with VA staff., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objectives: To describe the impacts of four Veterans Health Administration (VA) Quality Enhancement Research Initiative (QUERI) projects implementing an evidence-based lifestyle intervention known as the Diabetes Prevention Program (DPP)., Data Sources and Study Setting: 2012-2024 VA administrative and survey data., Study Design: This is a summary of findings and impacts from four effectiveness-implementation projects focused on in-person and/or online DPP across VA sites., Data Collection/extraction Methods: Patient demographics, participation data, and key findings and impacts were summarized across reports from the VA Diabetes-Mellitus Quality Enhancement Research Initiative (QUERI-DM) Diabetes Prevention Program (VA DPP) Trial, QUERI-DM Online DPP Trial, the Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) QUERI DPP Project, and EMPOWER 2.0 QUERI Program., Principal Findings: Between 2012 and 2024, four VA QUERI studies enrolled 963 Veterans in DPP across 16 VA sites. All participants had overweight/obesity with one additional risk factor for type 2 diabetes (i.e., prediabetes, elevated risk score, or history of gestational diabetes) and 56% (N = 536) were women. In addition to enhancing the reach of and engagement in diabetes prevention services among Veterans, these projects resulted in three key impacts as follows: (1) informing the national redesign of VA MOVE! including recommendations to increase the number of MOVE! sessions and revise guidelines across 150+ VA sites, (2) enhancing the national evidence base to support online DPP delivery options with citations in national care guidelines outside VA, and (3) demonstrating the importance of gender-tailoring of preventive care services by and for women Veterans to enhance engagement in preventive services., Conclusions: Over the past decade, the evolution of VA QUERI DPP projects increased the reach of and engagement in diabetes prevention services among Veterans, including women Veterans who have been harder to engage in lifestyle change programs in VA, and resulted in three key impacts informing type 2 diabetes and obesity prevention efforts within and outside of VA., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA. Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)