BMJ Open Quality最新文献

Background: Quality improvement strategies are used in healthcare to enhance the quality, safety and efficiency of service delivery. While the involvement of managers is considered critical, their roles remain underdocumented. This study examines the roles of managers in COMPAS+, a quality improvement collaborative conceived to enhance chronic disease care in Quebec, Canada. It explores managers' specific contributions to quality improvement projects to deepen understanding of effective managerial engagement.

Methods: This qualitative case study compares the roles played by managers (health network directors, division managers and local service network and family medicine group directors) within four regional health networks that participated in COMPAS+ from 2016 to 2019. Deductive and inductive thematic analysis of workshop reports, action plans and interviews with 24 key actors was performed, informed by a recent scoping review of decision-makers' roles in quality improvement projects and project management literature.

Results: The study revealed variability in project management across cases, particularly in the distribution of responsibility among upper, middle and lower management. Upper management provided strategic direction, middle management oversaw project execution and bridged organisational tiers, while lower management coordinated local change efforts. Middle managers were tasked with project management but often lacked role clarity and training. A significant gap was found in methodological guidance, typically provided by a quality improvement facilitator. This gap hindered projects' potential and, in some cases, led to deviations from the intended quality improvement model.

Conclusions: Effective quality improvement project management requires well-defined managerial roles, training and communication between management levels. Our findings highlight the importance of integrating a facilitator role to provide methodological expertise and ensure adherence to quality improvement processes. Contextual expertise and local change leadership may be complemented by external quality improvement expertise. These insights lay the groundwork for future research on evidence-based strategies for effective project management.

Background: Enhanced recovery after caesarean delivery (ERAC) is gaining popularity and has been shown to improve maternal and neonatal outcomes. We aimed to identify the presence and type of quality improvement (QI) methodology used in ERAC studies through an exploratory analysis, including author surveys and literature review.

Methods: We performed a literature search using four databases (MEDLINE through PubMed, Cumulative Index of Nursing and Allied Health Literature, Web of Science and Embase) to identify ERAC studies. Studies were considered if they compared an 'enhanced' or 'fast track' protocol to a control group and evaluated more than one system or outcome. The adopted QI methodology was evaluated through a standardised questionnaire developed by the authors which was sent to the authors of included studies.

Results: We identified 29 studies. A standardised questionnaire was applied to all included papers to evaluate the presence and type of QI methodology, and 24 authors were approached to complete the survey. We received results from 15 authors, yielding a response rate of 63%. 40% of authors reported use of defined QI methodology, the majority using the Model for Improvement. The QI components most used by those not reporting use of a defined methodology were engagement with multidisciplinary key stakeholders (80%), use of key drivers (87%) and process mapping (60%). Most authors reported use of traditional statistical methodology when analysing results (73%), and 60% reported use of Standards for Quality Improvement Reporting Excellence guidelines. The mean duration of baseline data collection by non-randomised controlled trial studies was 11 months and 9.9 months after implementation.

Conclusion: There is a large variation in the QI practices used in protocol implementation and publication of ERAC studies. The minority of authors report the use of a defined QI methodology and very few report the use of standardised tools in their published works.

Prospero registration number: CRD42023399418.

Introduction: Sudden unexpected infant death (SUID) remains a leading cause of infant mortality in the USA, disproportionately affecting Black/African American infants. In Cook County, Illinois, Black/African American infants had SUID rates 14 times higher than non-Hispanic white infants between 2020 and 2021. Despite widespread safe sleep education, racial disparities persist. Our Specific, Measurable, Acheivable, Relevant, and Time-Bound (SMART) aim was to increase safe sleep compliance among mothers of Black/African American infants discharged from our neonatal intensive care unit (NICU) by 5% over 12 months by providing targeted, equitable and culturally sensitive education, measured using an adapted validated safe sleep survey.

Methods: This project, conducted in a level III NICU at the University of Illinois Hospital in Chicago began planning in May 2023. Baseline data were collected (November 2023-February 2024) via caregiver surveys and chart reviews. Plan-Do-Study-Act (PDSA) cycles (March-November 2024) introduced interventions like the 'Alone-Back-Crib' (ABC) Safe Sleep handouts on SUID disparities, staff education, and short videos. Compliance was assessed postdischarge through surveys and clinic questionnaires, with preintervention and postintervention data analysed using χ² and t-tests. A control chart (p-chart) tracked process changes.

Results: Among 248 infants (70 baseline, 178 intervention), mean safe sleep compliance increased from 96% to 97% (p=0.26). Reports of infants 'never' sleeping alone in a crib declined from 11.4% to 3.9% (p=0.01). Caregivers valued enhanced messaging on SUID disparities.

Conclusions: Despite high baseline compliance, culturally tailored education reinforced safe sleep practices. While overall adherence changed minimally, increased awareness and behavioural shifts highlight the need for sustained interventions, community engagement, implicit bias training and systemic strategies to reduce racial disparities in SUID.

Engaging caregivers as active partners in care is a cornerstone of Strategic Objective 4 in the WHO's Global Patient Safety Action Plan 2021-2030. Despite its recognised importance, caregiver integration in acute care remains inconsistent, with significant gaps in registration processes, role clarity and institutional support. At Singapore General Hospital (SGH), a 1900-bed academic medical centre, caregiver involvement was previously informal and varied across clinical settings. This hospital-wide quality improvement initiative aimed to improve the caregiver-to-admission ratio from 1:6 to 1:4 within 6 months. Caregiver was defined as a family member formally registered through the hospital's Automated Visitor Management System (AVMS) and oriented to participate in basic patient care. A multidisciplinary team co-designed a scalable intervention through staff engagement and collaboration with the SingHealth Patient Advocacy Network (SPAN). Key strategies included simplified electronic registration, admission-based caregiver orientation, policy revisions to enable overnight stays, bedside education and flexible learning tools. These changes were embedded into clinical workflows and supported by infrastructure enhancements. Between April 2024 and March 2025, admission-to-caregiver ratio improved from 1:6 in the pre-implementation period to 1:4 post-implementation (5512 caregivers across 33 191 admissions pre-implementation vs 9592 caregivers across 38 874 admissions post-implementation). In addition, hospital-wide patient experience indicator from the Service Level Tracking (SLT) dashboard was included as a balancing measure. The percentage of patients and families who responded 'Definitely yes' to recommending SGH to family and friends improved from 81.9% pre-implementation to 85.2% post-implementation. The initiative reflects not only SGH's operational readiness and leadership commitment but also a broader paradigm shift: the healthcare team's growing recognition of the value of partnering with families, and the public's increasing willingness to participate in care even within high-acuity hospital environments. This project exemplifies how aligning systems, mindsets and partnerships can bring the WHO's patient safety goals into practical, sustainable action.

Background: Patients with limited English proficiency (LEP) face significant language barriers in healthcare, leading to poorer clinical outcomes. Professional medical interpreters are essential for equitable, high-quality care. While their use is widely recommended, there is limited understanding of the optimal objective outcome measures to best evaluate interpreter effectiveness in secondary and tertiary care settings.

Methods: A scoping review was conducted which was prospectively registered on the Open Science Framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Four databases (MEDLINE, PubMed, Embase and CINAHL) were searched without date or language limits. We included comparative studies assessing professional medical interpreting services for adult patients with LEP in secondary or tertiary care using objective outcome measures related to clinical outcomes and/or healthcare utilisation. Data extraction included study design, interpreter modalities, outcome measures and adjustments for confounders.

Results: Eleven studies met the inclusion criteria. Most were cohort or cross-sectional studies, predominantly conducted in the USA. The most common outcome measures were clinical, including length of stay (n=8), readmission (n=5) and return emergency visits (n=3). Four studies assessed healthcare utilisation, including outpatient appointment adherence. Results varied: some studies showed reduced length of stay and readmissions with interpreter use, while others found longer stays or no effect. Disease-specific outcomes (e.g., stroke care quality and obstetric indicators) consistently favoured interpreter or health advocate use. Adjustment for confounders was inconsistent with few studies accounting for illness severity.

Conclusion: This review highlights the heterogeneity and limitations in existing outcome measures for evaluating interpreter services. Length of stay and readmission are commonly used but prone to confounding. Disease-specific outcomes may offer greater sensitivity and relevance, especially when adjusted for clinical severity. Future research should prioritise the development of validated, standardised outcome sets that reflect both patient priorities and clinical relevance. These are essential for guiding service improvement and equitable healthcare delivery for LEP populations.

Background: Recruiting participants for injury and violence-related studies can be challenging, and online data collection opportunities can expand reach, offer convenience and extend a sense of safety to potential participants who may be in unsafe situations or do not want to travel to a location due to safety concerns. While increasing accessibility for some participants, online primary data collection presents challenges around potential fraudulent participants. This methodological paper highlights the strategies for preventing and mitigating fraudulent participants in online qualitative data collection, using a recent firearm violence study in a Northeast city as an example.

Purpose: Using a recent data collection effort related to firearm injury as a case study, the purpose of the current methodology paper is to highlight concerns and challenges with online qualitative data collection and provide strategies for preventing, detecting and removing fraudulent participants in qualitative injury and violence prevention research.

Results: Various predata collection activities can promote a study design that deters fraudulent participants, and additional 'in-the-moment' data collection activities can flag potential suspicious participants. Strategies include prescreening participants, requiring video and answers to basic questions relevant to the study topic and confirming certain pieces of information.

Conclusion: Online primary data collection can increase accessibility and support the safety of participants in injury and violence research, and there are considerations around detecting and removing fraudulent participants that researchers should note. Like all methods, a balance exists between study access, aims and resources. Researchers new to online qualitative data collection can use the strategies outlined here.

Background: Increase in life expectancy in Ireland and social isolation has led to an increasing number of people living in residential care facilities (RCFs). Residents are frequently transferred to emergency departments (ED) for a variety of reasons. Studies found that up to 40% of these hospital admissions were deemed inappropriate. An inappropriate admission in previous studies has been defined as a situation in which care in lower cost settings would be as safe and less disruptive than care in higher cost hospital settings.

Methods: A review of a convenience sample of ED attendances to University Hospital Kerry (UHK) found that 50% were inappropriate. A SMART aim in a quality improvement project (QIP) is an aim which is Specific, Measurable, Achievable, Relevant and Time based. The SMART aim of this QIP was to reduce the number of persons residing in RCFs, being inappropriately referred to UHK, from 50% to 30% from March 2024 to May 2025.Quality improvement (QI) measures included the standardisation of terminology through the workings of the palliative frailty multidisciplinary team, development of a communication document on resuscitation status and treatment escalation preferences, and the implementation of an advanced nurse practitioner (ANP) palliative care service for RCFs supported by a palliative medicine physician. Education was integral in this QIP.

Results: QI measures resulted in a reduction in monthly ED attendances of RCF residents from a median of 82 to 50. Inappropriate attendances reduced from 50% to 31%. Stakeholders' feedback on the new service was overwhelmingly positive. The project resulted in financial savings for the health service.

Conclusion: Integration of the geriatric and palliative medicine services with staff of RCFs allowed for sharing of knowledge, standardisation of terminology and development of alternative models of care and pathways to access specialties. The introduction of a designated ANP palliative care service for RCFs has been essential in helping residents to receive the right care, in the right place, at the right time.

Advanced chronic kidney disease (CKD) is commonly associated with disturbances in acid-base balance. Studies have shown that correcting metabolic acidosis in CKD offers several clinical benefits, including slower disease progression and reduced mortality. Acidosis can be addressed with oral sodium bicarbonate, an easy-to-administer and relatively inexpensive treatment compared with novel drugs such as sodium-glucose co-transporter-2 -(SGLT-2) inhibitors. Although sodium bicarbonate is frequently prescribed in CKD, less attention is paid as to whether serum bicarbonate levels are adequately optimised. This project aimed to increase the proportion of advanced CKD patients with serum bicarbonate levels within the normal range.Retrospective data collection was conducted at our tertiary renal centre to establish baseline bicarbonate levels and assess prescribing practices for sodium bicarbonate. Quality improvement (QI) methodology was then applied to implement a series of interventions designed to increase awareness of acidosis and to promote the appropriate use of oral sodium bicarbonate.Results from baseline data collection showed that 94% of patients had a serum bicarbonate level checked within the previous 6 months. However, only 46% of patients had levels within the optimal range. Although initial improvement was noted following our first intervention, this was not sustained through subsequent QI cycles, and the proportion of patients with optimal bicarbonate levels remained largely unchanged by the end of the project.Optimising serum bicarbonate is an important component of the management of advanced CKD. While this project led to increased awareness and short-term gains, further work is required to achieve lasting improvements and embed change into routine practice.

Introduction: Diagnostic errors significantly contribute to adverse events, patient harm and malpractice claims. While most research focuses on physicians, allied health professionals (AHPs) also play a critical role in diagnostic processes. Existing studies, primarily based on medical-record reviews, often overlook communication gaps and team dynamics affecting diagnostic accuracy. This study aims to (1) describe the overall characteristics and patterns of diagnostic errors reported in the national adverse-event database and (2) compare the clinical features, diagnostic processes and contributing factors between cases involving physicians and those involving AHPs.

Methods: We examined diagnostic-error reports from 1631 hospitals in the Japan Council for Quality Healthcare database (2010-2023). Cases were identified using predefined keywords, and two independent physicians assessed them using the Revised Safer Dx Instrument and Diagnostic Error Evaluation and Research (DEER) taxonomy. Contributing factors were analysed, and statistical methods explored error patterns and stakeholder comparisons.

Results: Among 147 654 event reports, 445 cases involved diagnostic errors. The most common errors occurred in diagnostic testing, assessment and follow-up, particularly misinterpretation of pathological or radiological reports on new injuries during hospitalisation. Physicians were the primary responsible providers (79.3%), while nurses were involved in 19.3% of cases. DEER taxonomy analysis revealed that nurses were more associated with errors in presentation, history-taking and physical examination (p<0.001). Additionally, patient-related factors, observation, reporting and training played a significantly greater role in errors involving nurses than physicians (p<0.001).

Discussion: By leveraging expert-assessed unstructured data, this study provides a broader perspective on diagnostic safety. Findings highlight the critical role of AHPs in diagnostic errors. Our study underscores the need for targeted, profession-specific interventions embedded within broader interprofessional initiatives to effectively reduce diagnostic errors and enhance patient safety.