To evaluate the effectiveness of a theory-informed, iterative implementation strategy (IS) to improve point-of-care ultrasound (POCUS) documentation compliance among emergency medicine (EM) residents according to American College of Emergency Physicians (ACEP) guidelines in a high-volume emergency department (ED).
We conducted a 19-month (December 2023–June 2025) mixed-methods implementation study at a tertiary academic ED in India. The Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change guided six iterative IS phases, including education, co-design, workflow optimisation and audit/feedback. Participants were EM residents. The primary outcome was the proportion of POCUS examinations achieving ≥80% compliance with ACEP documentation standards. Compliance trends were analysed across phases and summarised using proportions and medians with IQRs. Qualitative data from five focus group discussions were analysed using CFIR to identify barriers, facilitators and mechanisms of change. Quantitative and qualitative findings were integrated using a joint display.
We assessed 3074 POCUS examinations. The proportion of scans achieving ≥80% compliance increased from 0% at baseline to 35.1% postimplementation. Median compliance rose from 24% (IQR 17–34) to 69% (IQR 54–84). Compliance followed a nonlinear trajectory. Initial phases showed minimal gains (0%–8.7%) due to workflow barriers. A marked acceleration occurred during IS-5 (22.5%) following the introduction of a user-designed, single multimodal form and gamification. Qualitative analysis demonstrated a shift from initial resistance (CFIR: compatibility, complexity) to normalisation (implementation climate), although technical challenges with image archiving persisted.
User-centred co-design and peer engagement were key to the improvement, although persistent infrastructure challenges limited further gains and highlighted the need for informatics-enabled solutions. This study demonstrates that low-cost, context-sensitive strategies can enhance POCUS documentation effectively in high-volume, resource-constrained EDs.
A multifaceted, iterative IS guided by theoretical frameworks significantly improved POCUS documentation compliance. User-centred design and participatory engagement were critical mechanisms for sustainable practice change in a resource-variable EM setting.
CTRI/2024/03/063671.
Evidence on the nature and scale of risk and safety concerns in optometry practice is very limited, especially compared with other primary care professions. In Scotland, many changes occurred in the profession during and because of the COVID-19 pandemic. The theme of risk and patient safety was, therefore, chosen as the priority focus for the 2022 mandatory national training programme, which optometrists providing General Ophthalmic Services in Scotland are required to undertake.
To explore and identify perceived current and future safety risks and how these might be mitigated in relation to professional optometry practice in Scotland.
Study participants were all registered General Optical Council members from nine of the 14 regional health boards in Scotland. Data were collected via three online focus groups over a 2-month period during 2021 with each comprising six to eight participants. Data were transcribed with permission and then subjected to a basic thematic analysis.
16 optometrists participated in the study. Six principal themes were generated from the data analysis: (1) current overview and context (eg, perceived increased risk); (2) competency risks (eg, skills and knowledge to manage disease); (3) conduct risks (eg, behaviours of practitioners); (4) contextual risks (eg, environmental issues); (5) future risks (eg, technology) and (6) risk mitigations (eg, education and training).
Optometrists participating in this study expressed concerns that the level of perceived clinical risk in the Optometry profession is increasing, mainly related to technology, scope of practice, role development and changes in consumer demand. Multiple recommendations are made to minimise reported risks including education for new roles; increased focus on improving care quality; support to those involved in safety incidents and complaints; taking a systems approach to areas of high risk and sharing good practices.
Wrong-side diagnostic imaging order errors are preventable errors that can delay diagnosis and cause patient harm yet remain underdetected due to limitations in existing reporting systems.
To develop and validate an automated electronic health record (EHR)-based method for detecting potential wrong-side diagnostic imaging order errors using an adapted Retract-and-Reorder (RAR) approach and to identify associated risk factors.
Retrospective cohort study.
Six-facility health system comprising inpatient, outpatient and emergency room sites.
We screened 355 000 imaging orders with side specified, placed during 2021 across our healthcare system. We adapted the RAR methodology, originally developed to detect near-miss medication errors, by extending detection windows to 24 hours and identifying any orders switching from one side to the contralateral side, accounting for multiprovider workflows inherent in imaging. We validated the method through chart review of 100 randomly selected RAR events, then applied the query across all imaging orders. Multivariate logistic regression was used to identify risk factors associated with RAR events.
We identified 1667 RAR events (4.70 per 1000 orders). Validation yielded a positive predictive value of 87% (95% CI 79.0% to 92.2%), estimating 4.09 confirmed wrong-side errors per 1000 orders. The odds of an RAR event were significantly higher in outpatient settings compared with inpatient settings (OR 4.53; 95% CI 3.80 to 5.42) and among administrative staff compared with attending physicians (OR 2.08; 95% CI 1.73 to 2.49). CT scans showed 79% higher odds of an RAR event compared with X-rays (OR 1.79; 95% CI 1.34 to 2.39).
This validated approach offers a scalable solution for automated detection of potential wrong-side diagnostic imaging order errors. The methodology leverages commonly available EHR data to support continuous surveillance and intervention evaluation for improved diagnostic safety.
Ultrasound examination turnaround time refers to the duration from when a clinician orders the test to when results are reported. In many public hospitals, limited workforce capacity, inefficient workflows and unstructured scheduling contribute to prolonged waiting times for diagnostic imaging. Timely ultrasound diagnosis is essential for appropriate clinical decision-making and patient flow. This project aimed to reduce excessive waiting times for ultrasound appointments in a high-volume public hospital
A Quality Improvement (QI) project was conducted in the Radiology Department of Saint Peter Specialized Hospital between August and November 2022. The aim was to reduce the median waiting time for ultrasound appointments from 28 days to less than 5 days. A root cause analysis (RCA) identified key contributors, including delayed start times, absence of structured scheduling, workflow interruptions and limited machine availability. Driver diagrams and prioritisation matrices informed intervention selection and tested through sequential Plan–Do–Study–Act (PDSA) cycles. Interventions included workflow optimisation, extended effective working hours, productivity enhancement, structured appointment scheduling and deployment of point-of-care ultrasound for emergency cases.
The maximum waiting time for senior radiologist ultrasound appointments decreased from 28 days to ≤5 working days. The backlog for technologist-led examinations was eliminated. Daily productivity increased from 10 to 48 scans per radiologist and from 18 to 65 scans per technologist. Run charts demonstrated progressive and sustained improvement across four PDSA cycles.
The QI project achieved significant reductions in ultrasound waiting times through organisational and workflow redesign without additional funding. Sustainability relied on staff engagement, leadership support and embedding new practices into routine operations. These low-cost, context-appropriate strategies may be applicable to other resource-constrained hospitals facing similar challenges.
Healthcare systems struggle to balance the need for frontline problem-solving with the requirement for theory-driven strategies that ensure sustainable system-wide improvement. Implementation science, improvement science and quality improvement have emerged as complementary approaches to bridge gaps between evidence and practice, yet their integration remains limited. This scoping review examines how these disciplines intersect and can be applied to enhance HIV care delivery.
We conducted a scoping review of peer-reviewed articles published between 2016 and 2025. From an initial identification of 244 articles, 18 core studies were selected for snowball sampling, resulting in a pool of 113. After screening for accessibility and relevance, 30 studies were included in the final review that explicitly addressed overlaps between implementation science, improvement science and quality improvement. Data were charted on study objectives, methodologies, frameworks and relevance to healthcare improvement, and synthesised to identify common themes, models and barriers to integration.
The integration of these three disciplines creates a robust framework for health system change: implementation science emphasises fidelity and evidence-based uptake, improvement science prioritises generalisable knowledge and quality improvement enables rapid, local problem-solving. Their combined application can enhance the scalability, sustainability and efficiency of interventions. Models such as the HIV/AIDS Bureau Implementation Science Model, Reach-Effectiveness-Adoption-Implementation-Maintenance and the Learning Evaluation framework illustrate practical integration, showing how iterative quality improvement efforts can inform broader implementation strategies. Barriers include siloed approaches, variable terminology and limited organisational capacity, highlighting the need for cross-disciplinary collaboration, training and infrastructure support.
Integrating implementation science, improvement science and quality improvement provides a pathway to accelerate evidence translation, strengthen system-wide healthcare quality and improve patient-centred outcomes in HIV care. Synthesising shared principles and alignment opportunities offers actionable guidance for healthcare systems seeking to leverage the strengths of each discipline for more effective, scalable and sustainable care delivery.
Timely and coordinated care transitions from hospital to home are vital to ensuring patient safety and satisfaction, especially among chronically ill and high-risk patients.
At Armed Forces Hospitals–Taif Region (Kingdom of Saudi Arabia), delays in referral to assessment by home healthcare (HHC) services led to delay in the initiation of HHC falling short of global standards.
This quality improvement project aimed to enhance the transition pathway from hospital to home care and to assess the effect of the intervention on the 30-day readmission rate and patient satisfaction among chronic patients requiring HHC follow-up.
This initiative, implemented between September 2024 and June 2025, used the Lean Six Sigma methodology (Define, Measure, Analyse, Improve and Control), the 4P patient experience model and the strength-based clinical case management model to design and implement a structured care transition pathway that included early electronic referral alerts, standardised discharge workflows, predischarge HHC assessments, individualised care plans, transition navigators, centralised coordination, virtual follow-up clinics and weekly multidisciplinary rounds.
The timely initiation of HHC improved from 51% to 89.4% for high-priority patients and 71% to 92% for low-priority patients through improving referral to HHC initiation prior to discharge, and patient satisfaction increased from 46% to 91%. The average 30-day readmission rate declined from 35.8% to 7.7%. This translated into estimated cost savings of SAR4 960 536–4 982 136 (US$1 322 809–1 328 569), attributed primarily to avoided bed-days for preventable readmissions. There was a decrease in emergency department visits with the monthly average decreasing from 2.2 visits to 1.0 visits, representing a 54.5% reduction.
Embedding structured transition workflows and leveraging multidisciplinary collaboration significantly improved care continuity, safety and outcomes for chronic patients transitioning from hospital to home.
Falls can present a significant cost to individuals, their loved ones and the healthcare system. People with dementia on inpatient wards are at increased risk of falls, making this an important patient safety issue.
The aim of the project was to reduce falls rate on an older adult mental health ward by 30% (from an average of 5.4 to 3.7 per 1000 occupied bed days) by September 2024.
Using quality improvement methodology, a multidisciplinary team tested interventions to enhance therapeutic engagement, strengthen supportive nursing observations, mitigate medication-related risks and improve the ward environment.
The project surpassed its aim, reducing falls rate by 74% to 1.4 falls per 1000 occupied bed days.
This project demonstrated the importance of a multidisciplinary approach to falls reduction, as well as the value of employing Plan-Do-Study-Act methodology for rapid testing and learning.
A lack of transparent reporting of race and ethnicity in clinical research limits the ability to identify health inequities and evaluate to what extent clinical research includes diverse populations. Our objectives are: (1) to identify study characteristics associated with reporting race and ethnicity of clinical study participants and (2) to document temporal trends in race and ethnicity reporting on ClinicalTrials.gov.
Cross-sectional analysis of interventional trials and observational studies from 2009 to 2024; multivariable logistic regression assessed study-level factors associated with reporting race and ethnicity.
Global registry of clinical studies (ClinicalTrials.gov).
58 163 studies with posted results and without early termination.
Study characteristics: sponsor trial phase, study type and country.
Reporting of race, reporting of ethnicity, reporting of both.
Among 58163 studies (mean enrolment=1215 participants), 44.8% did not report race or ethnicity to the repository (mean enrolment=1481 participants). The proportion of studies reporting both race and ethnicity rose from 7.4% in 2013 to 54.6% in 2024. In multivariable models, observational studies had lower odds of reporting race and ethnicity (OR 0.55, 95% CI 0.49 to 0.61) compared with interventional trials. Phase 4 trials were least likely phase to report race and ethnicity (OR=0.32; 95% CI 0.29 to 0.35), and studies with only National Institute of Health funding were more likely to report race and ethnicity compared with studies with any industry funding or sponsorship (OR=1.70, 95% CI 1.61 to 1.79). For studies that reported race, White participants comprised ≥50% each year based on study-level percentages; proportions of Asian participants declined, and Black participants fluctuated. ‘Not Hispanic or Latino’ remained ≥80% of reported ethnicity annually.
Race and ethnicity reporting on ClinicalTrials.gov has improved markedly yet remains incomplete, with shortfalls in late-phase and observational studies.
Quality improvement reports (QIRs) are important for disseminating real-world interventions in healthcare. However, as a relatively new genre of scholarly writing, QIRs vary widely in clarity, methodological rigour and scholarly contribution. Despite the availability of reporting frameworks such as Standards for Quality Improvement Reporting Excellence (SQUIRE) V.2.0, key elements—such as methodological rigour, contextual detail and rationale for interventions—are often under-reported or poorly articulated. This study aimed to (1) identify best practices in publishing QIRs and (2) examine common methodological strengths and weaknesses in project design and execution.
We conducted a scoping review using the six-stage framework by Arksey and O’Malley. A purposeful sample of 71 QIRs published in 2019 across three leading quality improvement (QI) journals—BMJ Quality & Safety, BMJ Open Quality and Joint Commission Journal on Quality and Patient Safety—was analysed. Data extraction was guided by SQUIRE V.2.0 and supplemented by additional best practices. Return-of-findings sessions with QI scholars, journal editors, frontline practitioners and an international QI conference audience refined the findings and ensured practical relevance.
Most QIRs described a local problem and intervention but only 22% articulated strong aim statements with measurable targets. Two-thirds referenced a QI methodology but many descriptions of common QI tools lacked rigour. Process and balancing measures were often missing or inadequately justified. While Plan-Do-Study-Act cycles were commonly reported, few met criteria for ‘authenticity’. Data analysis and display methods varied, with several common weaknesses. Discussion sections frequently lacked depth and contextual factors—critical for reproducibility—were inconsistently described. Eight core lessons emerged to support more rigorous, transparent and impactful reporting.
As an emerging genre of scholarly communication, many QIRs still fall short in conveying methodological rigour and transferable insights. This review provides practical recommendations, illustrated by strong examples, to help authors and educators improve the clarity and impact of QIRs across healthcare settings.
To carry out a qualitative evaluation of personalised, multimodal prehabilitation for patients with advanced ovarian cancer in the UK, to inform the design and implementation of future programmes worldwide.
A multicentre, qualitative exploration of patients with advanced (stage III–IV) ovarian cancer with a surgical intent to treatment, who had been referred to a UK National Health Service prehabilitation programme. Using a purposive, maximum variation sampling approach, patients were invited to complete a semi-structured interview about their views and experiences of multimodal prehabilitation (exercise, nutritional, psychological and medical optimisation interventions). The interview focused on acceptability, perceived usefulness of the service and barriers and facilitators to engagement and adherence. Interviews were conducted virtually. Audio recordings of interviews were transcribed verbatim. Data were analysed thematically.
Interviews were completed with 21 patients, with a median age of 56.5 years (range 37–89 years). Four main themes were identified with associated subthemes as follows: (1) introduction to the programme (timing, volume and content of information), (2) perceived need (support system and mindset, psychological and physical health), (3) delivery of the programme (convenience of appointments, accessibility of staff, family involvement, individual components of the intervention; ie, physical, psychological, nutritional interventions and group work) and (4) future engagement (addressing postsurgical gynaecological health and closure).
Overall, prehabilitation was acceptable to patients with advanced ovarian cancer who had been referred to a multimodal prehabilitation programme. Perceived accessibility of staff and inclusion of patients’ social network facilitated engagement. Lack of perceived need for prehabilitation was a barrier to participation, particularly for those with a strong support system or self-confessed strong physical and psychological baseline fitness. Effective patient-centred communication about prehabilitation could support patients with making informed choices about engagement in prehabilitation as part of their care plan.
The comprehensive root cause analysis identified three critical barriers to physiotherapy utilisation within our department—inadequate screening procedures, insufficient staff and patient education and poorly defined referral processes. A pre–post intervention design was implemented across outpatient, inpatient and postnatal care settings. Interventions included structured patient education through pamphlets, digital media and discharge materials, systematic PFD screening and strengthened referral pathways. Nursing staff received targeted training and physician engagement was integrated in later cycles to improve patient receptivity. Outcomes were assessed through referral rates, completed physiotherapy appointments and pre/post education surveys with nursing staff.
Baseline data revealed inconsistent referrals and low health literacy as key barriers. During the first cycle, many antenatal patients deferred physiotherapy until postpartum, highlighting the need for stronger physician involvement. Adjustments in the second cycle, particularly routine counselling by obstetrics doctors, improved patient acceptance and referral compliance. As a result, physiotherapy uptake increased significantly, reaching the target of 50% within 2 months. Nursing staff also demonstrated improved confidence and knowledge in PFD education.
This initiative successfully embedded pelvic floor health into standard maternal care, underscoring the importance of education, multidisciplinary collaboration and physician advocacy in overcoming stigma and systemic gaps. It also establishes a sustainable framework for integrating pelvic floor health into maternity care and improving long-term outcomes for women.
]]>Early respiratory sampling in mechanically ventilated patients with suspected community-acquired pneumonia (CAP) is essential for guiding antimicrobial therapy, but endotracheal aspirate (ETA) is frequently contaminated with upper airway flora and bronchoscopic bronchoalveolar lavage (BAL) is invasive. Non-directed BAL (ND-BAL) can be performed at the bedside without bronchoscopy and has comparable diagnostic accuracy to bronchoscopic BAL.
To implement ND-BAL as a bedside procedure for mechanically ventilated intensive care unit (ICU) patients admitted within 48 hours of hospital admission with suspected CAP, increasing the proportion receiving a respiratory sample within 6 hours of ICU admission from 38% to ≥70% over 12 months and to compare oral flora contamination between ETA and ND-BAL.
A multidisciplinary team introduced a standardised ND-BAL protocol in a tertiary ICU. Baseline audit (January–December 2023) was compared with postimplementation data (March 2024–February 2025).
The proportion of eligible patients with a respiratory sample collected within 6 hours increased from 14/40 (35%) to 34/44 (77%). ND-BAL samples demonstrated lower oral flora contamination than ETA (50% vs 90.9%). Legionella culture testing increased from 15% to 56.8%, while empiric methicillin-resistant Staphylococcus aureus and Legionella antimicrobial coverage remained similar. No ND-BAL-related adverse events were identified.
ND-BAL was feasibly integrated as a joint nursing–medical bedside procedure and improved the timeliness and quality of respiratory sampling in mechanically ventilated patients with suspected CAP. This provides a platform for future rapid molecular diagnostics and antimicrobial stewardship.
This programme aimed to integrate specialised mental health services through the introduction of routine screening, internal referral pathways, on-site psychiatric assessment, treatment and external referral pathways and determine the spectrum of mental health disorders among individuals with HIV at the Infectious Diseases Institute, Uganda.
The psychiatric health services were set up in collaboration with health experts from the institute who facilitated the screening and treatment protocols for mental illnesses in HIV care. Patients were screened for mental illnesses; those who screened positive were further assessed by a psychiatrist and treated and others were referred for further treatment as needed at Mulago National Referral Hospital. We conducted a chart review in 2016 of all cases that had registered since 2013. Statistical analysis was conducted using STATA V.13.0 to generate descriptive statistics.
A specialised mental health clinic was successfully incorporated into Infectious Disease Institute, Makerere. The protocols for screening, treatment, long-term management and follow-up were established. Among the 211 retrieved cases, there were more females (66.5%), and nearly a quarter of the individuals (22.4%) had a history of prior mental illness. Predominant diagnoses included depression (27%), adjustment disorder (16.1%) and HIV-related psychosis (10%).
Our findings underscore the viability of integrating specialised mental health services into routine HIV differentiated care through this model. Mental disorders, notably depression, were prevalent within this clinic. Based on these insights, we advocate for enhanced mental healthcare delivery for the HIV populations.
]]>Workflow data were collected from 55 patients treated between January 2022 and June 2024 to establish a baseline. Quality improvement methods using the Lean Six Sigma (Define, Measure, Analyse, Improve, Control) framework were applied to identify inefficiencies and implement changes through two sequential improvement cycles focused on standardising processes governing patient arrival, predosing and discharge. Wrapping workflow interventions simplified material use and standardised the wrapping order.
After the first improvement cycle, average OPT decreased from 156.3 min to 114.2 min (26.9% reduction from baseline). The proportion of patients with an OPT under 2 hours increased from 9.1% to 61.9%. After the second improvement cycle, OPT further decreased to 103.0 min (34.1% reduction from baseline), and 73.3% of patients were discharged within 2 hours. Material costs per treatment decreased from $35.80 to $19.00 (46.9% reduction), with additional unquantified cost and time savings from procedure scheduling changes.
The sequential application of Lean Six Sigma strategies significantly reduced process time and material costs in outpatient ¹3¹I therapy without compromising radiation safety standards. These interventions demonstrate how structured quality improvement can enhance staff efficiency and resource use, providing a replicable model for other complex clinical workflows.
]]>This study was conducted at Hamad General Hospital’s Acute Medical Assessment Unit to enhance the informed consent process for routine medical procedures, including thoracocentesis, paracentesis, lumbar puncture and blood transfusions. Prefilled consent forms were developed for each bedside procedure, detailing both common and uncommon complications with estimated prevalence. Multilingual patient information templates and pictorial aids were produced to address the needs of patients from diverse language and literacy backgrounds. The intervention was implemented over 10 sequential Plan–Do–Study–Act cycles, each lasting 4 weeks, targeting barriers such as workflow integration, accessibility of forms and staff engagement.
Patient satisfaction with the informed consent process increased from 64% to 94% over the course of the project. Patients reported improved understanding of procedure risks, benefits and alternatives and nursing staff described greater confidence and proactive participation in the process.
This outcome supports a structured, standardised consent process supported by multilingual written materials and visual aids, which can substantially improve patient understanding and satisfaction for bedside procedures. Embedding these tools into routine workflows, supported by multidisciplinary engagement, can deliver more equitable and consistent patient-centred care.
]]>To develop and implement a closed-loop full-process management system for body fluid specimens in hospitalised patients, with the aim of improving submission timeliness and specimen quality.
A multidisciplinary inpatient specimen management team was established to analyse the causes of inefficiencies in the collection-to-submission process of body fluid specimens. Based on these findings, targeted interventions were formulated and implemented in February 2025. The preanalytical turnaround times and unqualified specimen rate before and after implementation were compared.
After implementing the closed-loop management system, the delayed submission rate of body fluid specimens decreased from 15.62% to 5.8% and the unqualified specimen rate decreased from 0.70% to 0.39%. The improvement in submission timeliness and specimen quality was statistically significant (p<0.05). All indicators showed significant differences at 3 and 6 months after intervention compared with before intervention (p<0.05).
The implementation of a closed-loop full-process management system for body fluid specimens effectively improved the timeliness of specimen submission, reduced delays and decreased the occurrence of unqualified specimens, thereby enhancing patient safety.
Quality improvement collaboratives (QICs) are a common strategy to improve healthcare in low-resource settings. However, their success is highly variable. The Model for Understanding Success in Quality (MUSIQ) posits that contextual factors at multiple levels determine outcomes. We used MUSIQ to investigate why a well-supported perinatal QIC in Ethiopia had mixed results, testing the hypothesis that internal organisational factors rather than external support would be the primary differentiator of success.
A cross-sectional study was conducted with all quality improvement (QI) team members across six public hospitals in Addis Ababa participating in a perinatal QIC. Contextual factors were assessed using the validated MUSIQ tool. The primary outcome was binary QI success (met/not met a predefined target for reducing perinatal mortality/morbidity). MUSIQ scores were compared between successful and non-successful hospitals using Mann-Whitney U tests. A multivariable logistic regression model was built to identify factors independently associated with success.
Sixty-seven QI team members participated (95.7% response rate). The overall mean MUSIQ score was 121.2±15.6, indicating a ‘reasonable chance of success’. However, scores were significantly higher in successful hospitals (median 129.9 vs 118.8, p=0.002). While external support scores were uniformly high, successful hospitals demonstrated significantly stronger scores in the organisation (p=0.045) and QI team (p=0.005) domains. Regression analysis confirmed that factors within the QI team (leadership, physician involvement) and organisation (senior leadership engagement) domains were independently associated with success, after accounting for other variables.
The success of this QIC was predominantly determined by internal organisational and team factors, not by the strong external support common to many global health initiatives. This highlights a critical implementation gap: top-down QICs often fail to catalyse the necessary internal leadership and team dynamics for success. Future initiatives must invest in building internal organisational context alongside providing external technical support.
This scoping review documents participatory system dynamics (PSD) applications in implementation science (IS) studies following a recent, increased integration of the two fields in the USA. It aims to illustrate ‘how’ and ‘why’ PSD modelling improves understanding of determinants of implementation outcomes for quality improvement.
We queried PubMed and PsycInfo for PSD, IS and their synonyms (community-based system dynamics or group model building, dissemination, quality improvement, translational research or knowledge translation). USA-based empirical studies were included when they described synchronous participatory activities to define a modelling problem over time. Studies were included when PSD was used as an implementation research method or implementation practice strategy. Fifty-eight studies on concept mapping were excluded, as were 65 intervention mapping studies. Nine articles remained after full-text review.
Most studies (n=7) investigated PSD itself as the intervention for understanding an implementation problem or use it as a tool to understand how to implement an evidence-based practice (n=4) or select an IS strategy (n=3). Most articles were case studies, investigating feasibility and knowledge translation during the preparation phase.
We recommend that implementation research and practice clarify whether PSD is used as a method to uncover contextual determinants or strategy to do so. PSD has strong potential to use enhanced participant buy-in and problem definition to understand ‘how’ implementation strategies account for cyclical and temporal determinants. Greater alignment between PSD activities, participatory theory, implementation phases and outcomes is needed to strengthen evaluation of PSD’s applications in IS.
The protocol for this paper is listed in the UNC Libraries repository (https://cdr.lib.unc.edu/concern/scholarly_works/6682xg09r).
Implementing guideline-based diabetes prevention programs (DPPs) for women with recent gestational diabetes mellitus (GDM) is critical, given the global rise in type 2 diabetes (T2D) and the established association between GDM and subsequent diabetes risk. Implementing new healthcare programs, however, is inherently challenging, as success depends on the engagement and commitment of frontline providers. Determining stakeholders' readiness for change was therefore critical before implementing a postpartum DPP for patients with recent GDM.
We conducted a cross-sectional survey of healthcare providers across three DPP implementation settings in Ontario, Canada. Survey measures included the Organizational Readiness for Implementing Change (ORIC) scale and a measure assessing constructs from the inner setting domain of the Consolidated Framework for Implementation Research (CFIR). Due to our low sample size, we analyzed results descriptively.
We surveyed 36 stakeholders across three implementation settings. The ORIC scale and CFIR-based measurement tool scores were relatively high (greater than 4.00 out of 5.00) across most participants. Scores were similar across service types and professional roles.
Stakeholders across three settings appear ready to implement a postpartum DPP for patients with GDM. Although those from an integrated care setting tended toward higher readiness based on change efficacy and commitment, the results of the CFIR-based measurement tool underscore the importance of using tailored approaches when implementing programs in community-based settings with lower resources.
Low-value care (LVC) research originates predominantly from Western healthcare systems. This narrative review offers the first synthesis of LVC patterns, determinants and reduction initiatives across six diverse Asian countries (Japan, Singapore, South Korea, China, Malaysia and India), comparing them with Western models to inform context-specific de-implementation strategies and identify key priorities for further research.
This is a narrative review of 132 English and non-English literature (2000–2025) from academic databases, grey literature, and policy documents across the six countries that was analysed using a novel framework examining LVC landscapes (healthcare challenges and measurement), determinants (structural, organisational, clinician, patient) and reduction initiatives.
Asian systems mirror Western pressures from demographic shifts, escalating costs and a growing burden of non-communicable diseases, underscoring the urgency of reducing LVC. Despite this, systematic measurement of LVC in Asia remains limited. Common LVC determinants include fee-for-service incentives, medicolegal concerns and a ‘more is better’ cultural perception, though further research, particularly on cross-country comparisons and from the patient’s perspective, is needed. LVC reduction initiatives are still emerging in Asia, with existing approaches shaped by local cultural norms and resource constraints, suggesting that Western strategies provide valuable insights but require adaptation for successful local de-implementation.
This multicountry review establishes a foundation for further collaborative LVC research in Asia via a holistic framework linking country-specific contexts to tailor de-implementation strategies. Key priorities for LVC research in Asia include systematic LVC quantification, development of contextualised evidence-based recommendations and implementation of contextualised multicomponent interventions, supported by further research and regional collaboration.
The application of intraoperative tourniquets is a fundamental component of distal radius fracture surgery, yet it carries a risk of significant complications. The British Orthopaedic Association (BOA) has published safety guidelines (BOA Standards for Trauma (BOAST)) to standardise practice, but adherence is often suboptimal. This quality improvement project aimed to evaluate and improve compliance with these guidelines in a real-world clinical setting.
A two-cycle retrospective audit was conducted at a major trauma centre in the UK. The first cycle (January to April 2023, n=34) established baseline compliance with seven key BOAST documentation standards. Following this, a multifaceted intervention was implemented, including staff education, the introduction of a standardised checklist and the placement of visual reminders in operating theatres. A re-audit was then conducted (May to June 2024, n=63) to measure the impact of these interventions.
Baseline documentation compliance was extremely low, with only tourniquet pressure recorded in 20.5% (7/34) and tourniquet time documented in 55.9% (19/34). Following the interventions, documentation of tourniquet pressure increased to 59.0% (37/63) and tourniquet site, padding, compressive exsanguination, skin condition, tourniquet size and tourniquet time showed modest improvements. Overall compliance, however, remained below optimal levels.
A targeted quality improvement initiative combining education and practical tools can lead to meaningful improvements in adherence to tourniquet safety guidelines. Despite these gains, persistent documentation gaps highlight the need for more robust, system-level solutions, such as integration into electronic health records, to ensure sustained compliance and enhance patient safety.
Antimicrobial resistance poses a significant threat to global health, exacerbated by the misuse of antibiotics. The aetiology examinations are crucial for rational antibiotic use but often inadequate in clinical practices. This study aimed to improve the aetiological submission rate before therapeutic antibiotic use (aetiological submission; AS rate) in a provincial psychiatric hospital in China using lean management to improve antimicrobial stewardship.
A quality improvement initiative was conducted from June 2021 to April 2022 by employing the Define, Measure, Analyze, Improve, Control (DMAIC) lean model. The effectiveness of the intervention was evaluated by comparing the aetiological submission status of 885 hospitalised patients receiving therapeutic antibiotics during the baseline period (June to October 2021) with that of 904 inpatients during the postintervention period (November 2021 to April 2022) and by evaluating whether there was a significant difference in the AS rates within the five targeting departments before and after the intervention.
The hospital-wide AS rate significantly increased from 12.43% (110/885) at baseline to 84.96% (768/904) after intervention (²=941.24, p<0.001), exceeding the target of 50%. Significant improvements (all p<0.001) were also observed in all targeting departments.
The application of lean management, specifically the DMAIC lean model, proved highly effective in enhancing the AS rate. This systematic approach provides an improvement model for antimicrobial stewardship and offers valuable experience and reference for other healthcare institutions in their antimicrobial stewardship practices.
Donor-funded health programmes strengthen national quality systems in low-income and middle-income countries, but abrupt withdrawal of external support can create institutional gaps and threaten service sustainability.
To analyse the impact of sudden donor funding cessation, using the experience of the Health Care Accreditation Council (HCAC) as an illustrative case, and to explore implications for quality infrastructure and health system resilience.
This structured case-based policy analysis draws on institutional documentation, administrative records and publicly available reports to examine the effects of funding withdrawal on quality programmes and organisational capacity.
Funding cessation led to contraction of technical workforce capacity, scaling back of quality improvement and professional development activities, and disruption of accreditation-related support. The case exposed vulnerabilities associated with donor dependency and insufficient transition planning.
Abrupt donor withdrawal can weaken quality systems and patient safety gains. Strengthening resilience requires diversified financing, structured transition frameworks and institutional strategies that embed quality governance within nationally owned systems.
Social determinants of health (SDoH) influence disease incidence, access to care, experiences, and outcomes. Recognising their importance, researchers and governments have emphasised the need to collect SDoH data in healthcare settings. However, gaps remain in understanding how to collect this information respectfully and equitably. To address these gaps, we aimed to understand local community perspectives on patient-centred SDoH data collection.
We held a community engagement session to gather input from equity-denied communities on SDoH questions, response options, preferred methods of answering and appropriate data use. Qualitative data were analysed using content analysis, guided by the Capability, Opportunity and Motivation-Behaviour (COM-B) model. We also collected patient feedback from the first six months of implementing patient-centred SDoH data collection in ambulatory services at a large academic health science centre. This feedback was collected through an anonymous Microsoft Forms survey on comfort, safety and ease of responding to the SDoH questions and was summarised using medians and frequencies.
The community engagement session included 22 participants, including eight patient advisors from diverse community organisations. Participants identified COM-B-related barriers to completing the questionnaire, such as unclear terminology, privacy concerns and mistrust of data use. Facilitators included inclusive language, multiple response methods, and transparency, particularly around data use. After integrating this feedback, the early implementation demonstrated high levels of comfort and safety. Additional feedback from the implementation highlighted opportunities to expand response methods, enhance staff engagement and education and establish ongoing partnerships with patients and communities to support the equitable use of SDoH data.
Collecting SDoH data in healthcare settings is essential for facilitating equity-informed quality improvement, research, and decision-making. Our project highlights opportunities to overcome barriers by expanding response methods, enhancing staff engagement and education and fostering ongoing partnerships with patients and communities to support equitable SDoH data use and reporting.
Robust evidence supports International Ovarian Tumour Analysis (IOTA)-Assessment of Different Neoplasias in the Adnexa (ADNEX) ultrasound triage at 10% threshold for ovarian cancer (OC) diagnosis to identify women for referral to tertiary gynaecological cancer centres for further management. The IOTA-ADNEX risk prediction model has superior sensitivity compared with the current standard of care triage, Risk of Malignancy Index (RMI-1), yet NHS adoption is limited. In our survey of British Gynaecological Cancer Society clinicians, only 30% (24/79) currently follow an IOTA model, despite 80% (63/79) supporting implementation. We evaluated IOTA-ADNEX implementation within two NHS one-stop clinics (OSC) for suspected OC, examining clinical outcomes alongside implementation barriers and facilitators.
Mixed-methods study conducted across two UK NHS hospitals between June 2023 and June 2025. Implementation outcomes were surgical intervention rates comparing IOTA-ADNEX-guided and retrospectively calculated RMI-based management using National Institute for Health and Care Excellence/Royal College of Obstetricians and Gynaecologists thresholds and patient process metrics. 11 qualitative semi-structured interviews were conducted with NHS staff involved in OSC implementation and thematic analysis performed.
Of 334 patients, 42% (139) underwent same-day discharge. Using IOTA-ADNEX at a 10% threshold, 10% (32/334) of patients underwent surgery under the general gynaecology and cancer unit team. In comparison, 30% (94/334) would have undergone surgery under the same teams if RMI-based triage had been used. Five themes identified from qualitative analysis: organisational infrastructure, clinical decision-making, communication and pathway definition, professional collaboration and training support, and patient experience. Key facilitators included dedicated clinical leadership, timely decision-making capabilities and quality assurance sessions. Barriers included lack of standardised post-clinic pathways and insufficient staff communication about pathway changes.
IOTA-ADNEX implementation in OSC offers high same-day discharge rates and reduction in surgical rates compared with RMI triage. To ensure success, implementation should be supported by adequate infrastructure, training and clear pathways. It requires leadership, comprehensive staff training and robust communication strategies. These findings provide practical guidance for healthcare systems for wider implementation of IOTA-ADNEX.
All patients and accompanying family members attending the MDT clinic at Sheffield Children’s Hospital between November 2023 and May 2024 (n=242 attendances) were invited to complete a 15-item feedback questionnaire covering access, consultation quality, communication, self-management confidence, psychosocial support and environmental factors. Responses were coded numerically (–2 to +2), summed and normalised to a percentage scale. Quality improvement methodology was applied to analyse results against a Trust-defined benchmark of 82.5% and identify SMART (Specific, Measurable, Achievable, Relevant, Time-bound) improvement targets.
49 questionnaires were returned (20.2% response rate). High satisfaction was reported for consultation time and clinician responsiveness (100%), staff professionalism (94%) and clarity of management instructions (90%). Domains falling below benchmark included appointment scheduling (77.6%), waiting times (81.6%), communication with primary care (78.6%), self-management confidence (80.6%) and transition planning (66%). Based on the baseline results, we subsequently implemented SMART-based interventions, including nurse-led triage, pharmacist-led medication reviews and structured transition pathways. Early feedback suggested improved coordination and reduced waiting times.
Families value MDT outpatient care in paediatric IBD, particularly in-clinic interactions and clarity of care. Persistent gaps in access, primary care coordination and transition planning highlight opportunities for targeted improvement. Integrating patient-reported experience with structured quality-improvement frameworks provides a pragmatic approach to enhancing service delivery and benchmarking outcomes.
]]>Wales currently has over 8000 PADs registered on a UK-wide defibrillator network—‘The Circuit’ supported by the British Heart Foundation. This enables emergency services to direct people to the nearest emergency-ready PAD when an OHCA occurs. However, not all PADs are on The Circuit as registration is not mandated, and maintaining PAD fleets in emergency-ready status represents a substantial challenge. Limited research exists regarding the veracity of operational status of PADs in real-world settings, or initiatives which increase numbers of available emergency-ready PADs.
This national quality improvement (QI) project assessed the introduction, spread and scale across Wales of an innovative role, Community Coordinators, funded by Welsh Government through the Save a Life Cymru programme. The project aimed to increase the emergency-ready status of the Welsh PAD fleet by 5% from a baseline of 89% by June 2024. Data from The Circuit supported establishment of baseline measures and ongoing data analytics during the study period (August 2022–July 2024).
The introduction of Community Coordinators increased the proportion of Wales’ emergency-ready PADs from 0.89 to 0.94. Process measures indicated firstly, an increase in registered PADs in Wales from 6415 to 8638. Secondly, the proportion of PADs registered with a PAD Guardian on The Circuit increased from 0.73 to 0.89.
This QI project demonstrated that the problem of PAD non-readiness is complex, multifactorial and dynamic. Networked Community Coordinators to support volunteer PAD Guardians increased the emergency-ready status of the all-Wales defibrillator fleet. This innovative Welsh model could benefit wider UK and international communities.
]]>Staffing shortages contribute to admission delays, fragmented care and hospitalist burnout. Although telemedicine has been widely adopted in critical care and subspecialties, its use in general inpatient admissions remains understudied. This study evaluated the feasibility, operational performance and early perceptions of a TeleHospitalist admissions programme designed to address nocturnal staffing shortages in a large academic health system.
In October 2024, Houston Methodist launched a nocturnal TeleHospitalist programme. The programme provided centralised coverage via audio-video technology, operating from 18:00 to 02:00 initially and expanding to 18:00–06:00. Adult patients admitted from the emergency department (ED) between October 2024 and August 2025 and clinical staff involved in admission workflows, were surveyed. Operational data on admission timeliness were extracted from the Epic electronic medical record, and patient and staff experiences were evaluated through structured surveys and qualitative feedback.
Over 10 months, 1575 TeleHospitalist encounters were completed (median age 65 years (IQR 49 to 75); 56% were ≥65 years). Median hospital length of stay was 38.5 hours (IQR 17.3 to 66.3), and median ED arrival-to-admission time was 7.3 hours (IQR 4.7 to 12.8). Among 311 patient respondents (19.7%; median age 66.5 years (IQR 52.3 to 75.6); 5% were ≥65 years), satisfaction scores were high (median 4 (IQR 3 to 5). Staff responses (n=29) demonstrated strong endorsement: 86% favoured continuation, 79% reported comfort with the technology and 75% rated admission processes as better than traditional workflows.
A system-wide TeleHospitalist admissions programme was feasible and well accepted by patients and staff. Older adults reported positive experiences, suggesting age is not a barrier to virtual inpatient care. Early findings indicate improved timeliness, communication and workflow efficiency while mitigating overnight staffing gaps. Future studies will evaluate long-term outcomes, cost-effectiveness and strategies to enhance privacy and patient engagement.
Perinatal Quality Collaboratives (PQCs) are state multidisciplinary teams working to improve maternal and infant healthcare by implementing quality improvement (QI) initiatives and other activities (initiatives/activities). This study aimed to improve understanding of the scope of PQCs and their work across the USA from 2022 to 2023.
The National Network of PQCs conducted an online assessment of PQCs representing all 50 US states and the District of Columbia during May–July 2023. While the assessment included some historical questions, most questions asked PQCs to report on work conducted from 1 April 2022 to 31 March 2023. Descriptive statistics of assessment data—including PQC characteristics, participation, community partner engagement, QI initiatives, and activities—were calculated.
The 45 responding PQCs were primarily housed in departments of health (35.6%), academic institutions (33.3%), or non-profit organisations (22.2%). Sixty-two percent of PQCs were established within the past 10 years (2014–2023). On average, 72.6% of birthing hospitals in each state participated in their PQC. Among the 26 PQCs with neonatal intensive care unit (NICU) participation, an average of 77.1% of NICUs in the state participated in their PQC. Thirty-two PQCs (71.1%) engaged with ≥1 patient/family member, and 30 PQCs (66.7%) engaged with ≥1 community-based organisation. PQCs reported on 195 initiatives/activities that they worked on during the reporting period. Twenty-six PQCs (57.8%) were working on 3–5 initiatives/activities. Most initiatives/activities were maternal-focused (n=105, 54.4%), followed by mother–infant–dyad-focused (n=53, 27.5%), and neonatal-focused (n=30, 15.5%). The most frequent initiative/activity topics were hypertensive disorders of pregnancy; substance use disorders among pregnant women; respectful care and non-medical factors that impact health; neonatal abstinence syndrome; and mental health among pregnant/postpartum women.
These findings illustrate the breadth of PQC work and how PQCs could contribute to national efforts to improve perinatal care.
Maternal mortality is an area of particular concern in public health, especially in Africa, maternal deaths are the highest in the world. Globally, 287 000 women died during and following pregnancy and childbirth, almost 95% of all maternal deaths occurred in low and lower middle-income countries. Ethiopia is one of the countries struggling to reduce high maternal mortality from 412 deaths per 100 000 live births to 70 deaths per 100 000 live births. Ethiopia has implemented various initiatives to handle delays related to maternal death and availing free transport and maternity service. Despite all this effort, however, the number of maternal deaths remains unacceptably high. However, none of the quality improvement (QI) projects tested and implemented to reduce maternal mortality at facility level. In response to this gap, this QI project is aimed at increasing days between maternal death at Dessie Comprehensive Specialized Hospital, Amhara region, Ethiopia.
Model for Improvement method was applied. As a baseline, we collected 1 year maternal mortality data, 6 months of chart review to assess the quality of care and 1 year’s data collected during implementation.
The T-chart shows the average days between maternal deaths at Dessie Comprehensive Specialized Hospital increased from 14 days to 39 days. When we compared the absolute numbers, there were 21 maternal deaths within 1 year after implementing the interventions, which was only nine maternal deaths compared with the same period in the previous year. When we calculated the maternal mortality ratio, we reduced it from 327 per 100 000 live births to 162 per 100 000 live births.
The project involved three successful interventions: conducting consultations within 20 min, using the E-MOTIVE bundle checklist and implementing the pre-eclampsia/eclampsia bundle checklist. Additionally, through our Plan-Do-Study-Act cycles, we learnt that a short consultation process, having one intensive care unit bed ready for mothers, ensuring the availability of essential medicines like tranexamic acid, using bundles, maintaining strong communication, engaging senior management in QI activities and holding frequent meetings of the QI committee were all helpful in improving our QI project.
We conducted a prospective observational controlled study (LEPED2) involving adult patients presenting to the ED with chest pain. 31 patients with LEP, identified as needing professional interpreter services, were compared with 43 patients with non-LEP. All patients with LEP received interpretation via a virtual video device. The primary outcome was triage time. Secondary outcomes included the utilisation of CT scans and hospital admission rates. Statistical analyses included one-tailed t-tests and 2 tests.
Patients with LEP required significantly more time for triage (mean 7.76 min) than patients with non-LEP (5.41 min), representing a 43% increase (p=0.0003). Although differences in CT utilisation and admission rates were not statistically significant, a trend towards increased diagnostic testing among patients with LEP was observed.
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