BMJ Open Quality最新文献

Background: Healthcare-associated infections remain a major concern in critical care environments. Hand hygiene (HH) compliance is a key preventive measure, yet maintaining consistent adherence remains challenging. A quality improvement (QI) initiative was undertaken to enhance HH practices among healthcare providers in a tertiary hospital in South India.

Methods: From August to December 2023, a QI project was implemented in Coronary Care Units (CCU) at KLE's Dr. Prabhakar Kore Hospital. Using the Point of Care Quality Improvement (PoCQI) methodology, a multidisciplinary team applied WHO's multimodal HH strategy through iterative Plan-Do-Study-Act (PDSA) cycles. Interventions included: (1) installation of centralised scrub stations with sterile footwear, (2) bedside multilingual posters, (3) structured staff training with night-shift monitoring and (4) real-time observation with feedback supported by leadership engagement. Weekly HH compliance and infection outcomes were tracked.

Results: Five PDSA cycles were conducted. Mean HH compliance improved from a baseline of 63.8% to 80.5% by week 20, reflecting a 26.7% relative increase and remained above 78% through week 30, confirming sustained gains postintervention. No methicillin-resistant Staphylococcus aureus, Pseudomonas or Klebsiella infections were reported during the intervention period. Blood culture positivity after 48 hours of CCU stay remained at 0%. Mortality trends varied and showed no consistent pattern attributable to the intervention.

Conclusions: Integrating WHO's multimodal strategy with PoCQI led to a significant, low-cost improvement in HH compliance in a high-risk setting. This team-led approach demonstrated the impact of QI strategies in implementing cost-effective infection prevention practices in critical care settings.

Uncontrolled hypertension remains a leading contributor to morbidity and mortality, particularly among underserved populations. To address care variability and disparities in treatment, the University of California Health system developed and implemented the UC Way Hypertension Medication Algorithm across six academic health centres. This standardised, evidence-based protocol was co-developed by a team of multidisciplinary experts in pharmacy, cardiology, primary care and data science, with an emphasis on medication affordability and the use of two-drug fixed dose combinations as first-line therapy. Implementation strategies included stakeholder engagement, clinician education and integration into electronic health records and routine workflows. The algorithm now informs treatment decisions for over 90000 patients with hypertension and has been associated with improvements in hypertension control. The manuscript focuses on the process of algorithm development, adaptation within a complex multi-payer environment and lessons learned in promoting standardisation, clinician uptake and health equity at scale. This model may inform similar efforts across other decentralised health systems seeking to optimise chronic disease management.

Objectives: To evaluate whether QR (Quick Response) code-linked digital patient information leaflets (PILs) improve documentation of shared decision making (SDM) and patient experience in elective hip and knee replacement clinics.

Design: A two-cycle quality improvement project (completed audit loop) comparing preintervention and postintervention outcomes.

Setting: Elective orthopaedic clinics in a UK district general hospital (secondary care).

Participants: Patients listed for elective hip or knee replacement during two 6-week periods (25 in cycle 1; 43 in cycle 2). Patients with incomplete records or not assessed face-to-face were excluded.

Interventions: Introduction of QR code-linked digital PILs between audit cycles, provided at clinic appointments. The resource included procedure information, anaesthetic options, recovery expectations and links to translation services.

Primary and secondary outcome measures: Primary outcomes were documentation rates of PIL provision and key SDM domains in line with NICE NG157 (National Institute for Health and Care Excellence Guidance) and GIRFT (Getting it Right First Time) standards. Secondary outcomes were patient-reported measures of clarity, usability, accessibility and preference, obtained through an anonymous Likert-scale survey.

Results: Documentation that a PIL had been offered increased from 7% (hip) and 9% (knee) in cycle 1 to 24% and 36% in cycle 2. Documentation of patient understanding rose from 79% to 90%, and recovery expectations from ≤9% to 36%. Survey results showed 100% of respondents found the digital information clear, 86% preferred it over paper and 71% reported greater engagement with the digital format.

Conclusions: QR code-linked digital PILs improved documentation, engagement and accessibility in elective orthopaedic clinics. This low-cost, scalable intervention supports national guidance on SDM, aligns with NHS (National Health Service) Green Plan sustainability goals and has potential for spread to other surgical pathways.

During 2018-2020, data from the Norwegian Tonsil Surgery Register (NTSR) showed large differences in recontact rates due to postoperative pain in the participating ear, nose and throat (ENT) units. On average, 27% (range 12-39%) of the patients had contacted the healthcare system due to problems with postoperative pain after tonsil surgery. Because of these high rates and large variations, we conducted a quality improvement project introducing a standardised pain management programme for adult patients. The goal was to reduce the pain-related recontact rate to below 15% in the participating ENT units.Five ENT units with an average recontact rate of 33.6% (range 29.0-38.1%) participated in this project. In a workshop, the units agreed on a standardised pain management programme consisting of a patient information brochure and a prescription including multimodal analgesics with paracetamol and COX-2 inhibitor (etoricoxib) with supplementary analgesic (tramadol). The units introduced the programme in their daily practice from June 2022 to July 2024. At follow-up in 2024, the recontact rate had decreased from 33.6% to 15.5% in the participating units.Introducing a standardised pain management programme, including a standard prescription of analgesics and a standard patient information brochure, seems to improve the patients' pain management after tonsil surgery. This study shows that data from the NTSR can identify areas requiring improvement, initiate improvement projects and evaluate the changes in clinical practice.

Background: Failure of situational awareness (SA) has been identified as a common theme in potentially avoidable maternal and infant deaths, although the empirical basis for this attribution is unclear. Situation awareness is arguably a contentious issue which needs to be studied methodically to ascertain the theoretical and practical relevance to midwifery to better inform the application of this concept to the clinical context-rather than seemingly and uncritically import the construct from other healthcare areas and safety-critical sectors unrelated to midwifery practice.

Objectives: To identify how situation awareness is defined, understood, measured and interpreted within the midwifery care safety context as a precursor to further research which may contribute to improvements in safety of maternity care.

Methods: A scoping review was conducted using a well-established methodological framework. A comprehensive literature search yielded 259 articles, of which 11 were included in the final review. Data from each article were extracted, charted and subjected to a thematic analysis.

Findings: All primary research papers applied Endsley's original definition of situation awareness, either explicitly or implicitly. Team SA was viewed as an aggregate of individual clinicians' SA. Only two of the studies attempted to measure SA; others made inferences about levels of SA based on observable features of teamwork.

Conclusions: Endsley's model of SA has been applied to midwifery without full consideration of whether this theoretical construct is appropriate for this clinical context. Other extended SA models exist which could arguably provide a more informed systems-theoretic approach to maternity care safety, consistent with the current drive towards embedding systems thinking and creating a Just Culture in healthcare organisations.

Purpose: Using quality improvement (QI) processes, we sought to safely achieve >80% efficiency in same-day discharge (SDD) of eligible primary total hip arthroplasty (THA) patients.

Methods: A "Plan-Do-Study-Act" approach was used. QI elements included: research of prior relevant publications, clinical audit for data-driven evaluation, service evaluation assessments and clinical transformation on a small scale for piloting change. Care interventions were introduced within an already established highly iterative and enhanced recovery after surgery-based programme. Intervention 1 established patient eligibility. Those eligible could be SDD once discharge criteria were met (the "Standard" cohort). Intervention 2 implemented "Enhanced Recovery Canada" (ERC) recommendations for pre-emptive nausea and pain management, and lidocaine-based regional surgical anaesthesia (the "ERC" cohort). Intervention 3 changed from epidural to spinal lidocaine for surgical anaesthesia. This cohort was evaluated as part of the ERC cohort, as well as a stand-alone Lidocaine Spinal cohort. Clinical audits were the main comparative benchmarks. Improved rates of SDD were the primary measure of success. Safety was based on rates of unscheduled hospital encounters within 30-days of surgery. Data was collected prospectively and analysed using logistic regression, adjusting for age and gender. Patient satisfaction was also surveyed.

Results: The ERC cohort had significantly greater odds of successful SDD compared to the standard group (74.4% vs 54.3%, OR 2.51, p=0.0015). Odds were even higher for Lidocaine Spinal (80.6% vs 54.3%, OR 3.4, 95% CI (1.34 to 8.66), p=0.0102). There was no significant difference in the rates of unscheduled 30-day hospital encounters. The ERC group experienced fewer complications that prevented SDD (25.6% vs 45.7%, OR 0.41, p=0.0015). Patient satisfaction scores were high in the Spinal Lidocaine group.

Conclusion: Implementing ERC recommendations significantly improved SDD rates for THA without increasing postoperative complication rates. This suggests that targeted interventions can enhance the efficiency of SDD THA programmes without compromising patient safety.

Introduction: In 2005, Oman ratified the WHO Framework Convention on Tobacco Control (WHO FCTC), committing to reduce tobacco use through best-practice cessation services, including access to counselling, pharmacotherapy and a toll-free Quitline. However, Oman currently lacks a national cessation programme that fully meets WHO FCTC standards. This study evaluated the impact of implementing a best-practice tobacco cessation service at North Al-Khuwair Health Center (NKHC) on quit attempts among tobacco users.

Methods: A quality improvement initiative was implemented at NKHC using a Plan-Do-Study-Act approach to establish a best-practice cessation service. The study included all tobacco users attending NKHC from July 2024 to March 2025. Very brief advice was provided at each clinical encounter, and those expressing readiness to quit were enrolled in the specialised cessation clinic, where they received free behavioural and pharmacological support. All participants were followed according to the clinic protocol. The primary outcome was a quit attempt.

Results: Before July 2024, NKHC had no operational cessation service. Between July 2024 and March 2025, 30 tobacco users attended the clinic. Over half (n=17, 56.7%) were over 40 years of age, while 16.7% were younger than 18. Most participants were male (n=29, 96.7%), married (n=23, 76.7%), employed (n=23, 76.7%) and used smoked tobacco products (n=24, 80.0%). Tobacco use frequently occurred at home (n=12, 40.0%) or with friends (n=15, 30.0%). Nearly two-thirds of tobacco users (n=19, 63.3%) were exposed to secondhand smoke. Mental health conditions were reported among 13.3% of users. Nearly half had attempted to quit previously, mostly using the cold turkey method. All participants were asked and advised to quit; 80.0% were ready to quit, and most (88.9%) made a quit attempt.

Conclusion: Establishing best-practice tobacco cessation services in primary healthcare can increase readiness to quit and promote quit attempts. Further studies are required to assess quit rates.

Background: Improving patient safety in healthcare settings requires a culture of shared values, beliefs, attitudes, perceptions and knowledge. Despite the fact that medical errors are inevitable, patient safety culture (PSC) initiatives may be able to lessen their frequency and effects. To improve patient safety, it is essential to investigate how healthcare professionals see hospital PSC. In Ethiopia, no evidence has been studied nationally. In order to assess the pooled status of PSC and its associated factors at Ethiopian public hospitals, a systematic review and meta-analysis was conducted.

Methods: The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines were followed throughout our study. Pub-Med, CINAHL, Web of Sciences, Google Scholar and repository databases were used for the search. Stata V.17 was used to analyse the data using the random-effects model. Forest plots were used to present the pooled results.

Results: A total of 6583 participants were involved in 16 studies that were included in this systematic review and meta-analysis. The overall PSC for healthcare professionals working in Ethiopian public hospitals was found to be 47.78% (95% CI 44.72 to 50.84; I²=84.56%). 'Teamwork within units' was the only PSC dimension with a satisfactory percentage of positive responses (75.53%; 95% CI 73.57 to 77.49). Compared with other hospital settings (48.77%), PSC at referral hospitals was lower (43.49%). A positive response rate to overall PSC was significantly predicted by being a nurse or midwife (OR=3.06; 95% CI 1.27 to 7.41), participating in patient safety training (OR=3.23; 95% CI 2.33 to 4.48), having a BSc degree or higher (OR=2.62; 95% CI 1.56 to 4.38), working in medical-surgical units (OR=4.32; 95% CI 2.71 to 6.90) and having more work experience (OR=5.69; 95% CI 2.52 to 12.87).

Conclusion: The pooled status of PSC among healthcare professionals in Ethiopia is low. Compared with other hospital settings, the PSC was lower in referral hospitals. A higher positive response rate to the overall PSC was predicted by professional type, educational attainment, patient safety training, working units and longer work experiences. In order to promote patient safety, the Ministry of Health, hospital managers and policymakers must work collaboratively by launching initiatives to strengthen a positive PSC.

Aim: To identify health economic evaluation competencies to guide quality improvement (QI) practice and education in Ireland.

Methods: A parallel mixed-methods design was used. A rapid review profiled the focus (cost containment, efficiency and/or equity) and purpose (education, assessment, health system improvement) of health economic evaluation competencies used in healthcare education and management. In parallel, surveys were sent to senior healthcare leaders (N=528) and quality and healthcare management scholars (N=286) in Ireland. These examined knowledge, skills and experiences of using health economics in managing quality and safety, and the perceived usefulness of proposed competencies. Descriptive statistics were generated. Literature and survey findings were integrated to refine the competencies.

Results: Of the few competencies available from the literature, most had a multiple focus and purpose. Yet, none were focused on equity and few were used to assess competence. Of 189 survey respondents, few had received training in health economics (25%) or been involved in measurement of healthcare costs (34%), value for money (29%) or budget impact (23%). Barriers were terminology and inadequate infrastructure for linking clinical and financial data. Most (90-95%) endorsed the usefulness of proposed competencies. These were refined to form four major competencies: (1) understand the relationship between cost and quality in healthcare, (2) assess the basic costs and outcomes of a QI initiative, (3) understand and apply cost-effectiveness analysis to QI initiatives and (4) advance capacity for improvement by applying cost-effectiveness analysis to decision-making. Each major competency had four to six sub-competencies.

Conclusion: Health economic competencies should be integral to healthcare professionals' and managers' education and professional development.

Background: In critical fields such as anaesthesiology, maintaining uninterrupted focus during key procedures, particularly during critical phases of anaesthesia care, such as induction and extubation, is crucial for patient safety. Multitasking and interruptions in healthcare settings have been linked to increased error rates and reduced efficiency. This study comprises two parts: (1) an objective observational analysis of multitasking and interruptions and (2) an exploratory examination of their relationship to perceived work-related stress, perceived error risk and job satisfaction.

Methods: In this prospective observational study, 19 anaesthesia nurses at the University Hospital in Würzburg were observed during 30 field sessions. The study used the Work Observation Method by Activity Timing application for real-time recording and classification of tasks into primary activities (core clinical tasks), secondary activities (parallel tasks, ie, multitasking) and interruptions (externally triggered interruptions leading to task cessation). Spearman's rank correlation coefficients were calculated to examine associations between observational data and subjective ratings.

Results: Interruptions accounted for 4% of the total observation time, with secondary activities being performed during 8.5% of the time. The average duration of interruptions was 36 s. Primary activities constituted 74.36% of all tasks, with communication-related interruptions being the most frequent. Preparatory work comprised more than half of the total duration of primary activities. Communication tasks were the dominant event during secondary activities, with a significant number of steps associated with them. On a subjective level, a strong positive correlation was found between perceived stress and error potential.

Conclusions: Interruptions and secondary activities were common in anaesthesia nursing workflows but accounted for only a small proportion of total working time. Most interruptions involved communication required for perioperative coordination. Step-based movement estimates showed substantial physical workload, with walking activity unevenly distributed across task categories and predominantly occurring during primary activities.