Continuous Quality Improvement Cycle Research Articles

Facilitating person‐centred care: integrating an electronic client feedback tool into continuous quality improvement processes to deliver client‐responsive HIV services in the Democratic Republic of Congo

AbstractIntroductionEngaging communities in the design, implementation and monitoring of health services is critical for delivering high‐quality, person‐centred services that keep people living with HIV engaged in care. The USAID‐funded Integrated HIV/AIDS Project in Haut‐Katanga (IHAP‐HK) integrated an electronic client feedback tool into continuous quality improvement (CQI) processes. We aimed to demonstrate this system's impact on identifying and improving critical quality‐of‐care gaps.MethodsThrough stakeholder and empathy mapping, IHAP‐HK co‐designed a service quality monitoring system—comprising anonymous exit interviews and ongoing monitoring through CQI cycles—with people living with HIV, facility‐based providers and other community stakeholders. IHAP‐HK trained 30 peer educators to administer oral, 10‐ to 15‐minute exit interviews with people living with HIV following clinic appointments, and record responses via the KoboToolbox application. IHAP‐HK shared client feedback with facility CQI teams and peer educators; identified quality‐of‐care gaps; discussed remediation steps for inclusion in facility‐level improvement plans; and monitored implementation of identified actions. IHAP‐HK tested this system at eight high‐volume facilities in Haut‐Katanga province from May 2021 through September 2022.ResultsFindings from 4917 interviews highlighted wait time, stigma, service confidentiality and viral load (VL) turnaround time as key issues. Solutions implemented included: (1) using peer educators to conduct preparatory tasks (pre‐packaging and distributing refills; pulling client files) or escort clients to consultation rooms; (2) limiting personnel in consultation rooms during client appointments; (3) improving facility access cards; and (4) informing clients of VL results via telephone or home visits. Due to these actions, between initial (May 2021) and final interviews (September 2022), client satisfaction with wait times improved (76% to 100% reporting excellent or acceptable wait times); reported cases of stigma decreased (5% to 0%); service confidentiality improved (71% to 99%); and VL turnaround time decreased (45% to 2% informed of VL results 3 months after sample collection).ConclusionsOur results showed the feasibility and effectiveness of using an electronic client feedback tool embedded in CQI processes to collect client perspectives to improve service quality and advance client‐responsive care in the Democratic Republic of Congo. IHAP‐HK recommends further testing and expansion of this system to advance person‐centred health services.

CO-Creation and Evaluation of Food Environments to Advance Community Health (COACH)

Food environments are a key determinant of food intake and diet-related health. This paper describes the development of an iterative, adaptive, context-specific framework for health-enabling food environments embedded in cocreation theory. A 3-stage multimethod framework for the coproduction and prototyping of public health interventions was followed in an iterative manner during the development of the framework. These 3 stages were (1) evidence review, including systematic review, consultation with experts, and observation of current work; (2) codesign of the framework prototype with multiple stakeholders; and (3) coproduction through refinement of the prototype through stakeholder workshops and expert reviews with incorporation of researcher notes and workshop evaluation. We use the term prototype during the development phase and the term framework to report on the final product. COACH (CO-creation and evaluation of food environments to Advance Community Health) is a process framework that describes what best practice application of cocreation in health-enabling food retail environments should involve. COACH consists of 10 interdependent factors within a 4-phase continuous quality improvement cycle. The 4 phases of the cycle are engagement and governance establishment, communication and policy alignment, codesign and implementation, and monitoring and evaluation. Utilizing cocreation theory represents an innovative step in research and practice to improve the healthiness of food retail environments. COACH provides a specific, unique, and comprehensive guide to the utilization of cocreation to improve the healthiness of food environments in practice.

Lessons from a cross-institutional online professional development pilot

PurposeTo reflect on a collaborative approach used by a group of faculty and administrators from historically Black colleges and universities (HBCU) and predominantly Black institution (PBI) pharmacy programs to provide high quality, multiple institution, faculty development programming in online environments. DescriptionA pilot for a shared online professional development initiative between pharmacy programs at five HBCUs and one PBI was implemented as a two-hour combined video conference and webinar, with structured networking, instructional programming, and breakout group sessions. Learning outcomes focused on increasing knowledge and awareness of mindsets in faculty and students with additional project goals of beta-testing interactive web conference formats, developing cross-institutional networking, and identifying avenues for sharing resources and expertise. Analysis/interpretationKolb's Cycle of Experiential Learning (Concrete Experience, Reflective Observation, Abstract Conceptualization, and Active Experimentation) was used to guide reflection on the joint workshop. The instructional design, delivery, and learning experiences of the program itself were analyzed using Garrison's Community of Inquiry Framework. ConclusionsAction research approaches can be applied to facilitate the continuous quality improvement cycle in multi-institution initiatives, such as joint faculty development programming. ImplicationsLessons related to cross-institutional collaboration, communities of practice development, networking, and communication can be used for future joint faculty development sessions and other shared initiatives for institutions serving minoritized students as well as other multiple institution consortiums.

Online simulation-based education in graduate education: Initial implementation and content revision description.

Treating those with mental illness frequently requires collaboration among health care providers from different disciplines as well as easy access to care. Neither interprofessional collaboration (IPC) nor accessible care can be assumed to automatically occur or be available in the busy health care environment. Early and deliberate exposure of graduate students in health care disciplines to interprofessional educational activities is imperative to strengthen IPC. Empirical evidence supports the linkage between interprofessional education (IPE) early-on in training and IPC. Additionally, early and focused training of graduate students in health care disciplines to telebehavioral health (TBH) can help promote care access. The current literature supports TBH as an effective treatment approach that enhances access to care. Thus, the creation of educational activities for graduate students in health care disciplines that use early exposure and training in both: IPE and TBH approaches to enhance IPC can position future providers to provide quality patient care, especially given the COVID-19 pandemic implications on health care and education. This article describes the authors' experience in implementing and evaluating an interprofessional, simulation-based educational activity in psychopharmacology using a TBH approach in graduate nursing and psychology students. This quality improvement process used the plan-do-study-act cycle of continuous quality improvement to establish the initial implementation and the 11 steps of the International Nursing Association for Clinical Simulation and Learning standards of best practice to then refine this educational activity. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Identifying requisite learning health system competencies: a scoping review

ObjectivesLearning health systems (LHS) integrate knowledge and practice through cycles of continuous quality improvement and learning to increase healthcare quality. LHS have been conceptualised through multiple frameworks and models. Our...

Brief behaviour change counselling in non-communicable diseases in Mangochi, Southern Malawi: a hypothetical acceptability study

IntroductionBrief behaviour change counselling (BBCC) approaches have shown some potential in reversing and/or decreasing the effects of behavioural risk factors (harmful alcohol, smoking, physical inactivity and unhealthy diets). However, BBCC is new in Malawi. Thus, we explored the acceptability of brief behaviour change counselling using 5 As and a guiding style from motivational interviewing (BBCC + 5 As + GS) among health providers, policy-makers and patients living with noncommunicable diseases (NCDs) in the Mangochi district located in Malawi.MethodsAn exploratory qualitative cross-sectional study used purposive sampling to select 44 respondents. We conducted group discussions with five focus groups that included patients. We also carried out nine key-informant interviews with healthcare providers and policy-makers. Data were managed and organized with Atlas.ti. cloud and analysed using the thematic framework approach.FindingsSeveral themes, categories, and their subcategories emerged from the interviews. Participants perceived the introduction and delivery of BBCC + 5As + GS in Mangochi as smooth. However, they predicted a few challenges such as time and space to conduct the intervention, cultural bottlenecks caused by low education level, age differences between healthcare providers and patients, low provider- to- patient ratio and high provider turnover. For this method to be adopted, a simplified format is deemed necessary to improve effectiveness with patients. This technique can only be sustained if training opportunities are provided and if positive testimonies are given by beneficiaries. Incorporation of a continuous quality improvement cycle targeting challenges must be part of the intervention. Participants perceived that BBCC will contribute to developing the listening ability of healthcare providers. This would help in providing personalized and cost-effective care relevant to Mangochi. The participants also perceived that BBCC + 5As + GS will be affordable, credible and useful.ConclusionWe found a high acceptability rate of BBCC among stakeholders in NCDs clinics in Mangochi. There are a number of areas where BBCC + 5As + GS could be improved to increase the acceptability. Accordingly, a study of feasibility and preliminary efficacy is warranted to determine other prerequisites for the implementation of a large-scale trial using this BBCC+ 5 As + GS, and to fully understand the implementation requirements of a full trial in Mangochi.

Auditing integrated stroke care to support quality improvement activities: development of a peer-to-peer audit framework

PurposeTo organize stroke care, multiple stakeholders work closely together in integrated stroke care services (ISCS). However, even a well-developed integrated care program needs a continuous quality improvement (CQI) cycle. The current paper aims to describe the development of a unique peer-to-peer audit framework, the development model for integrated care (DMIC), the Dutch stroke care standard and benchmark indicators for stroke.Design/methodology/approachA group of experts was brought together in 2016 to discuss the aims and principles of a national audit framework. The steering group quality assurance (SGQA) consisted of representatives of a diversity of professions in the field of stroke care in the Netherlands, including managers, nurses, medical specialists and paramedics.FindingsAuditors, coordinators and professionals evaluated the framework, agreed on that the framework was easy to use and valued the interesting and enjoyable audits, the compliments, feedback and fruitful insights. Participants consider that a quality label may help to overcome necessity issues and have health care insurers on board. Finally, a structured improvement plan after the audit is needed.Originality/valueAn audit offers fruitful insights into the functioning of an ISCS and the collaboration therein. Best practices and points of improvement are revealed and can fuel collaboration and the development of partnerships. Innovative cure and care may lead to an increasing area of support among professionals in the ISCS and consequently lead to improved quality of delivered stroke care.

Surviving Sepsis Campaign: Strategies to Implement in Cardiogenic Shock Management

The Surviving Sepsis Guidelines can serve as a structure to help educate and create a set of recommendations on how to care for patients through this complicated pathway of shock. Designing a cardiogenic shock bundle could reduce the variability of care and possibly improve survival. Also, a more standard protocol would allow a review of the outcomes and a system to change practice nationally when new data or technology becomes available. This could create a continuous quality improvement cycle. Creating a “Surviving Cardiogenic Shock” system could help provide awareness for recognition of cardiogenic shock and advanced management alternatives needed at level one and two hospitals. The creation of cardiogenic shock systems of care would support smaller hospitals with a Hub and Spoke structure. Cardiogenic shock is not septic shock, but those in cardiology and cardiac critical care can and should take lessons from the Surviving Sepsis Campaign.

Risk Reduction of Healthcare Workers’ Exposure to COVID-19 using Failure Mode and Effect Analysis

Background: The exposure to COVID-19 by staff has a major impact on healthcare system. Objective: identify potential failures related to the exposure of HCWs to COVID-19, evaluate the potential causes and effects, and the actions to mitigate the risk of exposure. Methods: Members of the infection control department, quality department, nursing department, and medical administration were selected as team members to conduct the Failure Mode and Effect Analysis (FMEA). The identification of potential failure modes, causes and effects was conducted in consecutive meetings. Accordingly, were identified actions to reduce the staff exposure to COVID-19. Results: The description of the complex process was conducted including the potential in-hospital and hospital-community interaction for transmission of infection to staff. In eight areas were identified 20 potential failure modes: Hand hygiene, personal protective equipment, detection of sick staff, exposure in common areas, hiring new staff, staff living conditions, and staff knowledge, skill, and perceptions about all other infection control practices. The highest ranked priorities were identified including improper PPE use (556 points), late detection of sick staff (520 points), and poor compliance with infection control practices in common areas (436 points) respectively. The mitigation strategies focused on a wide range of actions to improve the staff education, improve practices and procedures, monitor practices and feedback to staff in a continuous quality improvement cycle. Conclusion: Data presented provides a comprehensive evaluation of the risks and mitigation measures to prevent the staff exposure to COVID-19 conducted in a high-risk environment by a qualified FMEA team. Keywords: failure modes and effect analysis; quality management; risk mitigation; staff exposure; COVID-19; Qatar;

The Store-and-Forward Telemedicine Service User-satisfaction Questionnaire: Development and validation of a questionnaire to monitor and assess health care providers' experiences

Introduction With wider adoption of store-and-forward telemedicine accelerating, particularly post-coronavirus disease 2019, it is essential to understand health care providers’ (HCPs) satisfaction with digital solutions offered by telemedicine organizations to (continuously) guarantee service quality. We developed the Store-and-Forward Telemedicine Service User-satisfaction Questionnaire to monitor and assess HCPs’ experiences with contracted telemedicine organizations. Methods Questionnaire construction (phase 1) consisted of exploratory literature search on validated telemedicine satisfaction questionnaires, a telemedicine domain and human factors expert focus group, stakeholder focus group (customer service employee and telemedicine account managers), and two pre-testing rounds among 18 HCPs. The pilot questionnaire (phase 2) was sent to 2179 HCPs for validity and reliability assessment. Results Phase 1: Two validated questionnaires (73 items overall) were used as input for Store-and-Forward Telemedicine Service User-satisfaction Questionnaire. Revisions resulted in 61 items. Phase 2: the pilot 61-item Store-and-Forward Telemedicine Service User-satisfaction Questionnaire instrument was completed by 181 of 2179 invited HCPs. Forty-one mandatory items of the pilot Store-and-Forward Telemedicine Service User-satisfaction Questionnaire rated on a 5-point Likert scale were included in psychometric analyses and resulted in six reliable scales: training, communication, organization policy and strategy, interaction platform, usage platform, and working conditions. Discussion The Store-and-Forward Telemedicine Service User-satisfaction Questionnaire is a reliable and valid questionnaire for measuring HCPs’ satisfaction with store-and-forward telemedicine services as part of a continuous quality improvement cycle. Reimbursement questions were excluded due to low response. As adoption of telemedicine may be impeded by financial compensation issues, this requires consideration in future telemedicine questionnaires. Store-and-Forward Telemedicine Service User-satisfaction Questionnaire including video consultation items is needed to monitor also synchronous services as these expanded in the coronavirus disease 2019 pandemic.

Implementation of the Internal Quality Assurance System at UIN Malang Indonesia

This study aims to examine the implementation of the internal quality assurance system (IQAS) at the State Islamic University of Maulana Malik Ibrahim Malang Indonesia (called UIN Malang). This research uses qualitative methods, data obtained through interviews, document review and observation, and data analysis techniques using interactive analysis models. The results of the research can be concluded as follows: 1) The University established a Quality Assurance Institute (QAI) at the university level, the Quality Assurance Unit (QAU) at the Faculty level, Postgraduate Program, Language Development Center, and Ma’had (campus dormitories) and Quality Control Groups (QCG) at the Department/Study Program level. 2) Compiling quality assurance system planning in documents: quality policy, quality manual, quality standards, quality forms, monitoring, measurement and self-evaluation, internal quality audits, and Management Review Meetings (MRM). 3) Applying the PDCA (Plan, Do, Check, Action) model which is the application of Total Quality Management (TQM) to produce a cycle of continuous quality improvement. 4) Establish idealized academic service quality standards based on benchmarking results. 5) Ensure the stages of implementation, evaluate and revise quality standards according to benchmarking on an ongoing basis. 6) Establish quality indicators to achieve stakeholder satisfaction, productivity, and efficiency. 7) Internalizing the values ​​and quality culture in the entire campus community. This research produces a strategy for implementing a comprehensive quality assurance system to build UIN Malang as the Center of Excellence and the Center for Islamic Civilization.

Alliances to disseminate addiction prevention and treatment (ADAPT): A statewide learning health system to reduce substance use among justice-involved youth in rural communities

BackgroundYouth in the justice system (YJS) are more likely than youth who have never been arrested to have mental health and substance use problems. However, a low percentage of YJS receive SUD services during their justice system involvement. The SUD care cascade can identify potential missed opportunities for treatment for YJS. Steps along the continuum of the cascade include identification of treatment need, referral to services, and treatment engagement. To address gaps in care for YJS, we will (1) implement a learning health system (LHS) to develop, or improve upon, alliances between juvenile justice (JJ) agencies and community mental health centers (CMHC) and (2) present local cascade data during continuous quality improvement cycles within the LHS alliances. Methods/designADAPT is a hybrid Type II effectiveness implementation trial. We will collaborate with JJ and CMHCs in eight Indiana counties. Application of the EPIS (exploration, preparation, implementation, and sustainment) framework will guide the implementation of the LHS alliances. The study team will review local cascade data quarterly with the alliances to identify gaps along the continuum. The study will collect self-report survey measures longitudinally at each site regarding readiness for change, implementation climate, organizational leadership, and program sustainability. The study will use the Stages of Implementation Completion (SIC) tool to assess the process of implementation across interventions. Additionally, the study team will conduct focus groups and qualitative interviews with JJ and CMHC personnel across the intervention period to assess for impact. DiscussionFindings have the potential to increase SUD need identification, referral to services, and treatment for YJS.

Adolescent transition to adult care for HIV-infected adolescents in Kenya (ATTACH): study protocol for a hybrid effectiveness-implementation cluster randomised trial

IntroductionSuccessfully transitioning adolescents to adult HIV care is critical for optimising outcomes. Disclosure of HIV status, a prerequisite to transition, remains suboptimal in sub-Saharan Africa. Few interventions have addressed both...

Curriculum Changes and Trends 2010-2020: A Focused National Review Using the AAMC Curriculum Inventory and the LCME Annual Medical School Questionnaire Part II.

Medical school curricula have evolved from 2010 to 2020. Numerous pressures and influences affect medical school curricula, including those from external sources, academic medical institutions, clinical teaching faculty, and undergraduate medical students. Using data from the AAMC Curriculum Inventory and the LCME Annual Medical School Questionnaire Part II, the nature of curriculum change is illuminated. Most medical schools are undertaking curriculum change, both in small cycles of continuous quality improvement and through significant change to curricular structure and content. Four topic areas are explored: cost consciousness, guns and firearms, nutrition, and opioids and addiction medicine. The authors examine how these topic areas are taught and assessed, where in the curriculum they are located, and how much time is dedicated to them in relation to the curriculum as a whole. When examining instructional methods overall, notable findings include (1) the decrease of lecture, although lecture remains the most used instructional method, (2) the increase of collaborative instructional methods, (3) the decrease of laboratory, and (4) the prevalence of clinical instructional methods in academic levels 3 and 4. Regarding assessment methods overall, notable findings include (1) the recent change of the USMLE Step 1 examination to a pass/fail reporting system, (2) a modest increase in narrative assessment, (3) the decline of practical labs, and (4) the predominance of institutionally developed written/computer-based examinations and participation. Among instructional and assessment methods, the most used methods tend to cluster by academic level. It is critical that faculty development evolves alongside curricula. Continued diversity in the use of instructional and assessment methods is necessary to adequately prepare tomorrow's physicians. Future research into the life cycle of a curriculum, as well optional curriculum content, is warranted.

Syphilis testing performance in Aboriginal primary health care: exploring impact of continuous quality improvement over time.

Data from 110 primary healthcare clinics participating in two or more continuous quality improvement (CQI) cycles in preventive care, which included syphilis testing performance (STP) for Aboriginal and Torres Strait Islander people aged between 15 and 54 years, were used to examine whether the number of audit cycles including syphilis testing was associated over time with STP improvement at clinic level in this specific measure of public health importance. The number of cycles per clinic ranged from two to nine (mode 3). As shown by medical record audit at entry to CQI, only 42 (38%) clinics had tested or approached 50% or more of their eligible clients for syphilis in the prior 24 months. Using mixed effects logistic regression, it was found that the odds of a clinic's STP relative to its first cycle increased only modestly. Counterintuitively, clinics undertaking the most preventive health CQI cycles tended to have the lowest STP throughout. Participation in a general preventive care CQI tool was insufficient to achieve and sustain high rates of STP for Aboriginal and Torres Strait Islander people required for public health benefit. Improving STP requires dedicated effort and greater understanding of barriers to effective CQI within and beyond clinic control.

A hybrid software processes management support model

Abstract The growing trend in agile approach to software development today shows a tendency towards combining practices from different approaches and methodologies. This trend can be explained by the difficulties in managing agile processes. A potential solution to these challenges could be a multi-agent model of software development process of supporting management in the cycle of continuous product quality improvement. The AGent-Object MOdel (AGOMO) was constructed to investigate this idea and an experiment was carried out in which a typical medium-sized project developed using hybrid methodology was reproduced. This article describes the first phase of research, in which replicative adequacy of this model was demonstrated, thus opening avenues for further research related to project management support.

Toward a Person-Centred Learning Health System: Understanding Value from the Perspectives of Patients and Caregivers.

What matters most to people who use healthcare? What matters to their caregivers? How do we use this information to support ongoing quality improvement in the healthcare system? In this paper, we explore three concepts from the current healthcare discourse, intended to drive health system improvements: person-centred care, value-based healthcare and learning health systems. We propose that key tenets from each of these concepts should be combined to create a person-centred learning health system (PC-LHS). We highlight two key points: First, in achieving a PC-LHS, the experiences, priorities and values of patients and their caregivers should be continually collected and fed into data systems to monitor ongoing quality improvement and performance benchmarking. Second, the information collected in determining value must include important contextual factors - including the social determinants of health - as patient health and well-being outcomes will ultimately be shaped by these factors, in addition to health system and disease factors. In summary, improving value for patients and caregivers, by capturing the things that matter most to them, within their life contexts, needs to be part of the continuous quality improvement cycle that lies at the heart of a learning health system.

Mergers of primary care organizations: a systematic review of the literature

Abstract Background Mergers as large-scale collaborations in primary care organizations have become a commonplace in developed countries to offer economies of scale and more efficient delivery of care to population. The aim of this systematic review is to summarize the scientific evidence on the relationship between the increase in the size of organizations providing primary care services and their performance. Methods The PICO model was adopted and three electronic databases (Medline, Scopus, ISI Web of Knowledge) were searched using appropriate keywords. Screening by title and abstract and data extraction were performed by two independent investigators. Articles, written in English, evaluating the performance after increasing the size of an organization were included. Selected articles were assessed for quality and risk of bias using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Process and outcome quality indicators were used for evaluation. Results From a total of 1337, 12 studies met the inclusion criteria and 103 indicators were identified: 59.2% did not show any variation, 33.9% improved significantly after the merger, 6.9% worsened after the merger. In particular, diabetes care did not show any statistically significant variation in 40.0 % of the indicators, while 10.0 % showed an improvement and 10.0% a worsening in clinical outcomes. A significant negative association was found between practice list size and reported non-urgent or urgent doctors’ availability (P < 0.05, both). The process of merging also created perceptions of takeover and had a negative effect on staff. Conclusions The effects of mergers are conflicting and there is little evidence that the performance is associated with the size of the structures involved. Assessment on the impact of primary care mergers should to be related to the population needs and the context where these processes are carried out. Key messages Merging processes may lead to contrasting results. To assess periodically and systematically the impact of mergers in a continuous quality improvement cycle.

Gregory A. Adams, MHA

Gregory A. Adams is executive vice president and group president for Kaiser Permanente, reporting to the chairman and CEO. He has direct responsibility for all 8 Kaiser Permanente Regions, serving more than 12.3 million members and operating 39 hospitals and 701 medical office facilities. In addition to his group president responsibilities, he serves on the organization's national executive team and executive committee. Adams started his career with Kaiser Permanente in 1999 and has held a number of executive leadership positions within the organization, including president of the Northern California Region. Prior to joining Kaiser Permanente, Adams held several executive roles in the health care industry, providing strategic and operational leadership for hospitals, health systems, and medical groups throughout the country.

Using quality improvement tools in the investigation of prolonged turn around time and improving the efficiency in the core laboratory

We developed an evidence-based continuous quality improvement (CQI) cycle for laboratory safety as a method of utilizing survey data to improve safety in a public health laboratory setting.•Expert Opinion: The CQI cycle begins with the solicitation of laboratory staff input via an annual survey addressing potential chemical, physical and radiological hazards associated with multiple laboratory activities. The survey collects frequency, severity and exposure data related to these activities in the context of the most pathogenic organisms handled at least weekly.•Gap Analysis: Step 2 of the CQI cycle used survey data to identify areas needing improvement. Typically, the traditional two-dimensional risk assessment matrix is used to prioritize mitigations. However, we added an additional dimension – frequency of exposure – to create three-dimensional risk maps to better inform and communicate risk priorities.•Mitigation Measures: Step 3 of the CQI cycle was to use these results to develop mitigations. This included evaluating the identified risks to determine what risk control measures (elimination, substitution, engineering, administrative or PPE) were needed. In the 2016 iteration of the CQI cycle described here, all mitigations were based on administrative controls.•Evaluation and Feedback: The last step of the CQI cycle was to evaluate the inferred effects of interventions through subsequent surveys, allowing for qualitative assessment of intervention effectiveness while simultaneously restarting the cycle by identifying new hazards.Here we describe the tools used to drive this CQI cycle, including the survey tool, risk analysis method, design of interventions and inference of mitigation effectiveness.