Collaborative Improvement Research Articles

The Duration of Symptoms Influences Outcomes After Lumbar Microdiscectomies: A Michigan Spine Surgery Improvement Collaborative.

Retrospective Cohort. We investigate whether duration of symptoms a patient experiences prior to lumbar microdiscectomy affects pain, lifestyle, and return to work metrics after surgery. A retrospective review of patients with a diagnosis of lumbar radiculopathy undergoing microdiscectomy was conducted using a statewide registry. Patients were grouped based on self-reported duration of symptoms prior to surgical intervention (Group 1: symptoms less than 3months; Group 2: symptoms between 3months and 1year; and Group 3: symptoms greater than 1year). Radicular pain scores, PROMIS PF Physical Function measure (PROMIS PF), EQ-5D scores, and return to work rates at 90days, 1year, and 2years after surgery were compared using univariate and multivariate analysis. There were 2408 patients who underwent microdiscectomy for lumbar disc herniation for radiculopathy with 532, 910, and 955 in Groups 1, 2, and 3, respectively. Postoperative leg pain was lower for Group 1 at 90days, 1year, and 2years compared to Groups 2 and 3 (P < .05). Postoperative PROMIS PF and EQ-5D scores were higher for Group 1 at 90days, 1year, and 2years compared to Groups 2 and 3 (P < .05). Patients with prolonged symptoms prior to surgical intervention experience smaller improvements in postoperative leg pain, PROMIS PF, and EQ-5D than those who undergo surgery earlier. Patients undergoing surgery within 3months of symptom onset have the highest rates of return to work at 1year after surgery.

Experiences and Challenges of Parents with Children Removed Through a Statutory Process

The South African Constitution grants children the right to protection, and in cases where their safety and development are compromised, prompt removal and placement into alternative care is mandated. However, statutory removals can lead to tension and challenges between parents and social workers, impacting the parent-social worker relationship and complicating the removal process. This study delved into the experiences and challenges faced by parents involved in such removal processes. A qualitative approach was adopted, utilising semi-structured interviews for data collection. Thematic analysis yielded two main themes and several related sub-themes. The study revealed that parents’ overall experience remained negative, with limited participation in the removal process and their expectations not being fully met. Findings underscore the significance of the social worker-parent relationship while acknowledging its inherent difficulties. Communication gaps were evident, with parents often left uninformed and unconsulted during the removal process. The research highlights the need for improved communication and collaboration between social workers and parents to ensure a more transparent and supportive removal process. Addressing these challenges can ultimately lead to better outcomes for both the children and their families involved in the child protection system.

Letter to the Editor Regarding “The Potential Negative Effects of Smoking on Cervical and Lumbar Surgery Beyond Pseudarthrosis: A Michigan Spine Surgery Improvement Collaborative Study”

Letter to the Editor Regarding “The Potential Negative Effects of Smoking on Cervical and Lumbar Surgery Beyond Pseudarthrosis: A Michigan Spine Surgery Improvement Collaborative Study”

Response to Letter to the Editor: The Potential Negative Effects of Smoking on Outcome After Elective Cervical and Lumbar Surgery: A Michigan Spine Surgery Improvement Collaborative Study

Response to Letter to the Editor: The Potential Negative Effects of Smoking on Outcome After Elective Cervical and Lumbar Surgery: A Michigan Spine Surgery Improvement Collaborative Study

Efforts to Improve Science Process and Collaboration Skills with the Implementation of the REACT Learning Model on Students

Education is an effort to improve the quality of individuals, directly or indirectly to become the basis and keep pace with the development of Science and Information Technology. Science process skills and collaboration skills are two of the few skills that can be mastered by students to keep up with the Times. However, this skill is still not fully mastered by all students. As the problem in this study is still low skills of science process and collaboration skills of Class XI students at SMAN 1 East Kampar. The purpose of this study was to determine the improvement of science process skills and collaboration skills of students through the application of the REACT learning model. The method used is Class Action Research (CAR) which is carried out as many as 2 cycles. Samples in this study were students of Class XI MIPA 4. Data collection was done through collaboration skills observation sheet and science process skills test assessment. The results of this study found that there was an increase in science process skills and collaboration skills of students of Class XI MIPA 4 SMAN 1 Kampar Timur after the application of the REACT learning model.

Feasibility testing of an interprofessional education intervention to support collaborative practice in home care for older stroke survivors with multiple chronic conditions

ABSTRACT This mixed-methods study examined the feasibility of implementing a new six-month, theory-based, interprofessional education intervention, and explored its effects and impact on collaborative practice among home care providers caring for older adult stroke survivors (≥65) with multiple chronic conditions. The evaluation utilized a qualitative descriptive and one group repeated measures design which included participant questionnaires, focus groups and field notes. Participants included 37 home care providers (registered nurses, physiotherapists, occupational therapists, personal support workers, care coordinators, and their supervisors) in Ontario, Canada. The intervention was feasible and acceptable to home care providers. Perceived benefits included improved communication and collaboration within teams, enhanced role understanding, increased learning with and from each other, and increased appreciation of all team members’ expertise. From 3 to 6 months post initial IPE training, there was a statistically significant improvement in three domains of collaborative practice as measured by the Collaborative Practice Assessment Tool (communication/information exchange; community linkage and coordination of care; decision-making and conflict management) and one domain of collaborative practice, as measured by the 19-item Team Climate Inventory (task orientation). Implications for implementing interprofessional education in home care practice settings are described. Further testing in other populations and settings is warranted.

A quality improvement initiative for patients with chronic kidney disease to promote their smoking cessation.

Cigarette smoking is a critical issue in caring for patients of chronic kidney disease (CKD). However, there is no routine care program designed for combining both smoking cessation and CKD care. The process of our quality improvement (QI) collaboration used data under our routine payment-for-performance for pre-end-stage renal disease (P4P Pre-ESRD) in Taichung Veterans General hospital from 2020 to 2022. We share our experience with a QI project that integrates the Ottawa model for smoking cessation (OMSC) with the Pre-ESRD care program as part of routine CKD care. The electronic health information systems were improved to reduce workload of medical staff. The number was more for both qualified CKD educators and nephrologists for smoking cessation. The access and availability for smoking cessation were immediate and convenient for patients. Specifically, all the actions were performed by CKD educators, with nephrologists overseeing the process in routine care. By combining OMSC with the Pre-ESRD program, we were able to provide smokers with satisfactory access and availability to smoking cessation services within our healthcare facility. The smoker cases found were more in number (206 in 2020, 344 in 2021, and 421 in 2022). Before the integrated OSTC-Pre-ESRD program (in 2020), the proportion of smokers was 3.88%. After implementing the integrated program, smokers increased significantly on a yearly basis (9.69% in 2021 and 9.82% in 2022). Finally, case numbers of on-site smoking cessations increased significantly after implementing the integrated system (0 in 2020, 17 in 2021, and 20 in 2022). All CKD patients for smoking cessation were also more (8 in 2020, 46 in 2021, and 38 in 2022). After implementing the QI program, focusing on the integrated OMSC-Pre-ESRD program, we found more smokers undergoing smoking cessation. This QI program highlighted the importance of better access and availability for smoking cessation.

ADT Use and Nodal Irradiation in Men Receiving Post-Prostatectomy Salvage Radiotherapy within a Statewide Radiation Oncology Quality Consortium.

For men with biochemical recurrence after radical prostatectomy, salvage radiotherapy (SRT) is a standard of care. Outcomes are improved when SRT is delivered at lower PSA levels, and there has been increased emphasis on more timely treatment. With early SRT, however, there remains uncertainty as to the optimal use and duration of androgen deprivation therapy (ADT) and pelvic lymph node radiation (PLNRT). Moreover, PET imaging and genomic classifiers have emerged as tools to guide treatment decisions, but their uptake in routine practice is unknown. To address these questions, we analyzed a contemporary cohort treated with SRT within the Michigan Radiation Oncology Quality Consortium (MROQC). We hypothesized that ADT and PLNRT practices would reflect recent trial results in this setting. Eligible patients receiving SRT at an MROQC center were enrolled from 06/09/20 to 11/04/22. Data was prospectively collected via patient-, physician-, and physicist-completed forms. Patients were matched to the Michigan Urological Surgery Improvement Collaborative (MUSIC) database for additional treatment- and patient-related data. Univariable (UVA) and multivariable analyses (MVA) were performed to test associations between patient/tumor factors and ADT or PLNRT use. A total of 191 patients across 26 centers were enrolled in the MROQC database. Of these, 116 were matched to the MUSIC database. Median time from RP to SRT was 17 months (IQR 8 - 33 months). The median post-RP PSA prior to SRT was 0.25 (IQR 0.16 - 0.60). Early SRT was defined as pre-SRT PSA ≤0.5, and 27% (n = 31/116) had a pre-SRT PSA >0.5. Twenty-eight were pT3b/T4, 97% were pN0/NX, and 51% had positive surgical margins. Fractionation was conventional (>28 fractions) in 58% and moderate hypofractionation (20-28 fractions) in 38%. Table 1 describes the patients receiving ADT and/or PLNRT. Median ADT duration was 6 mo (IQR 6 - 7 mo). MVA revealed pre-SRT PSA >0.5 (OR 5.05 [1.89 - 15.33]) and pT3b/T4 disease (OR 4.23 [1.40 - 14.56]) were significantly associated with ADT use (p <0.05), but not grade group (GG) or margin status. PLNRT was significantly associated with pre-SRT PSA >0.5 (OR 3.04 [1.21 - 8.42], p <0.05) but not pT stage, margin status, or GG. PET imaging was performed in 37% of men (52% negative, 21% prostate bed alone uptake, and 26% lymph node positivity) and genomic classifiers were performed in 24%. Nearly 75% of biochemically recurrent prostate cancer patients within MROQC received early SRT, and about half received ADT. A pre-SRT PSA >0.5 was strongly associated with ADT and PLNRT. With prostate bed SRT alone, very few received ADT. Given the considerable heterogeneity in treatment, additional studies may help identify patients who most benefit from ADT + PLNRT, and who may be spared potential added toxicity.

Sustainable groundwater management and its implications for agricultural land repurposing

In this paper, we examine the implications of groundwater sustainability policies on agricultural land retirement and how retired land can be repurposed to minimize social, economic, and environmental harms, while maximizing potential benefits. Globally, as water resources are strained by increasing agricultural demand and biophysical factors, policies are enacted to restrict groundwater pumping for irrigated agriculture in order to stem social, economic, and environmental harm. However, little is known about the implications of land retirement on ecosystems and people, and how this land can be best repurposed. Using Kern County, CA, as a case study, we draw from 23 qualitative interviews with stakeholders in the agricultural, water, and conservation sectors to understand the impacts of sustainable groundwater management policy and options for land repurposing. Stakeholders in our study outlined both positive and negative impacts of such policies across the region, including increased financial costs of agricultural production, crop type switches to perennial crops such as trees and vines, and improved communication and collaboration among stakeholders. Stakeholders discussed options for land repurposing to maximize ecological, social, and economic benefits, including habitat restoration, installation of solar farms, grazing, groundwater recharge, temporary fallowing, and recreation and parks. Finally, we propose recommendations to maximize the benefits and minimize the harms from the retirement and repurposing of agricultural land: (1) increasing regional planning and cross-stakeholder communication for strategic land repurposing, (2) minimizing the burden of policies that may restrict land repurposing options, and (3) ensuring financial incentives exist for landowners to repurpose their land.

Risk of Severe Maternal Morbidity in Birthing People With Opioid Use Disorder.

We examined severe maternal morbidity (SMM) among birthing people with opioid use disorder (OUD) and evaluated the extent to which differences in SMM exist by race and ethnicity. We performed a retrospective cohort study using hospital discharge data for all Massachusetts births between 2016 and 2020. SMM rates for all SMM indicators, except transfusions, were computed for those diagnosed with and without OUD. Multivariable logistic regression was used to examine the association between OUD and SMM after adjusting for patient and hospital characteristics, including race and ethnicity. Among 324,012 childbirths, the SMM rate was 148 (95% confidence interval [CI]. 115-189) per 10,000 childbirths among birthing people with OUD compared with 88 (95% CI, 85-91) for those without. In adjusted models, both OUD and race/ethnicity were significantly associated with SMM. Birthing people with OUD had 2.12 (95% CI, 1.64-2.75) times the odds of experiencing an SMM event compared with those without. Non-Hispanic Black and Hispanic birthing people were at 1.85 (95% CI, 1.65-2.07) and 1.26 (95% CI, 1.13-1.41) higher odds of experiencing SMM compared with non-Hispanic White birthing people. Among birthing people with OUD, the odds of SMM were not significantly different between birthing people of color and non-Hispanic White individuals. Birthing people with OUD are at an elevated risk of SMM, underscoring the need for improved access to OUD treatment and increased support. Perinatal quality improvement collaboratives should measure SMM in bundles aimed at improving outcomes for birthing people with OUD.

Working alongside next of kin to enhance discharge: A quality improvement collaboration to co-design discharge for mental health patients.

Mental health (MH) patients seen in the emergency department (ED) setting are often viewed in isolation, outside of the context of their loved ones, the next of kin (NOK). This is especially problematic when a patient is detained under the mental health act. This project aimed to improve this engagement. A sense of urgency was created from a guiding coalition of the local MH and ED executive of a rural hospital. The vision was communicated to the team for action. This was then institutionally incorporated as best practice during a 3month trial. NOK were engaged more frequently as a result of this quality improvement strategy, rising to 90.8% (2021) from 63.2% (2020) compared to the previous year χ2 (1, N=166) =18.75, p = .000015. Admissions for all MH patients from the emergency department fell to 28.3% (2021) from 39% (2020) χ2 (1, N=652) =8.32, p = .0039. Working with NOK is a best practice strategy that was embraced by clinicians when highlighted. This resulted in less restrictive practice and more community treatment. Creating a frame for the patient that is standardised, provides containment and co-designs future health care is beneficial.

A Spotlight on Friedreich Ataxia: Optimising the Patient Journey from Diagnosis to Disease Management

This symposium was held on the first day of the European Academy of Neurology (EAN) Congress, with four main objectives: to raise awareness of Friedreich ataxia (FA) as a rare, progressive neurodegenerative disorder; to summarise the patient journey from identifying first symptoms in childhood and adolescence to reaching an accurate diagnosis; to discuss the burden of living with FA and highlight the benefit of improved communication and collaboration between members of the multidisciplinary team on reducing this burden on patients and their caregivers; and to summarise current management options within the field of FA and provide an overview of emerging therapies and active clinical trials. The symposium was chaired by Sylvia Boesch, a neurologist and senior staff member at the Medical University of Innsbruck, Austria, and Head of the Centre for Rare Movement Disorders, Innsbruck, Austria, who presented an overview of rare diseases in general and of FA. Mathieu Anheim, a neurologist at the Movement Disorders Unit, University Hospital of Strasbourg, France, followed with a description of the aetiology and symptomatology of FA. Lastly, Paola Giunti, a professorial research associate in the Department of Clinical and Movement Neurosciences, University College London Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, UK, explained the best approach to FA management, including a summary of clinical trials for emerging therapies in FA.

Comparing Patient-reported Functional Outcomes After Radical Prostatectomy in Historical and Contemporary Practice.

Modifications to surgical technique, particularly the widespread adoption of robotic surgery, have been proposed to improve functional recovery after prostate cancer surgery. However, rigorous comparison of men in historical vs contemporary practice to evaluate the cumulative effect of these changes on urinary and sexual function after radical prostatectomy is lacking. We compared prospectively collected patient-reported urinary and sexual function from historical (PROSTQA [Prostate Cancer Outcomes and Satisfaction With Treatment Quality Assessment study], n=235) and contemporary (MUSIC-PRO [Michigan Urological Surgery Improvement Collaborative Patient Reported Outcome] registry, n=1,215) cohorts at the University of Michigan to understand whether modern techniques have resulted in functional improvements for men undergoing prostate cancer surgery. We found significant differences in baseline function, with better urinary (median [IQR]; 100 [93.8-100] vs 93.8 [85.5-100], P < .001) and sexual scores (median [IQR]; 83.3 [66.7-100] vs 74.4 [44.2-87.5], P < .001) prior to treatment in PROSTQA compared to MUSIC-PRO patients, respectively. There was no statistically significant difference in the pattern of urinary incontinence recovery after surgery from 6-24 months between groups (P = .14). However, men in the contemporary MUSIC-PRO group did have significantly better recovery of sexual function compared to men in the historical PROSTQA group (P < .0001). Further, we found that contemporary practice consists of men with more unfavorable demographic and clinical characteristics compared to historical practice. Our results demonstrate that the widespread alterations in prostate cancer surgery over the past 2 decades have yielded improvements in sexual, but not urinary, function recovery.

PERCEPTION AND KNOWLEDGE OF BRAIN TUMOR BANKING AMONG CANADIAN NEUROSURGEONS

Abstract Brain tumor banking provides an important resource for understanding the underlying pathophysiology of brain tumors. It requires a multidisciplinary team, including neurosurgeons who must recognize the importance of these banks and actively contribute. The perceptions and involvement of neurosurgeons regarding Canadian brain tumor banking remains to be studied. OBJECTIVE: This study aims to 1) assess current Canadian tumor tissue banking practices 2) determine the perception of neurosurgeons towards brain tumor tissue banks, and 3) uncover obstacles to tissue sample access. METHODS: A 26 question survey was conducted using Qualtrics and distributed to 178 Canadian neurosurgeons. Questions pertained to respondent demographics, tissue samples being banked, funding, and collaboration. RESULTS: 35 neurosurgeons completed the survey (19.66%). The majority of respondents treated adult populations (65.71%) and practiced in Ontario (57.14%). Most centers banked a variety of primary and metastatic brain tumors. 25.00% of respondents stated that their center collaborates with others. Personal communication was the most frequently stated method (58.33%) used to raise awareness of tumor banks. Funding was the most commonly mentioned obstacle to successful banking (70.37%). Banks are funded through research grants (30.76%), departmental support (30.76%), government funding (11.54%) and donations (26.92%). CONCLUSIONS: This study investigated neurosurgeons’ perceptions of brain tumor banking and the state of Canadian tumor banking. Despite numerous centers banking a variety of brain tumors, collaboration between institutes was limited. The greatest perceived obstacle is funding. Canadian brain banking may benefit from improved communication, collaboration, and funding.

Does Urologist-level Utilization of Active Surveillance for Low-risk Prostate Cancer Correspond with Utilization of Active Surveillance for Small Renal Masses?

Active surveillance (AS) for prostate cancer (CaP) or small renal masses (SRMs) helps in limiting the overtreatment of indolent malignancies. Implementation of AS for these conditions varies substantially across individual urologists. We examined the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry to assess for correlation of AS between patients with low-risk CaP and patients with SRM managed by individual urologists. We identified 27 urologists who treated at least ten patients with National Comprehensive Cancer Network low-risk CaP and ten patients with SRMs between 2017 and 2021. For surgeons in the lowest quartile of AS use for low-risk CaP (<74%), 21% of their patients with SRMs were managed with AS, in comparison to 74% of patients of surgeons in the highest quartile (>90%). There was a modest positive correlation between the surgeon-level risk-adjusted proportions of patients managed with AS for low-risk CaP and for SRMs (Pearson correlation coefficient 0.48). A surgeon’s tendency to use AS to manage one low-risk malignancy corresponds to their use of AS for a second low-risk condition. By identifying and correcting structural issues associated with underutilization of AS, interventions aimed at increasing AS use may have effects that influence clinical tendencies across a variety of urologic conditions. Patient summaryThe use of active surveillance (AS) for patients with low-risk prostate cancer or small kidney masses varies greatly among individual urologists. Urologists who use AS for low-risk prostate cancer were more likely to use AS for patients with small kidney masses, but there is room to improve the use of AS for both of these conditions.

Exploring the Benefits of Virtual Reality Adoption for Successful Construction in a Developing Economy

Existing literature has shown that Virtual Reality (VR) is widely utilized in advanced economies to enhance sustainable construction practices. However, its adoption in developing economies remains limited. To this end, this study aims at exploring the potential benefits of implementing VR technology in a developing country. The study collected information on the beneficial aspects of VR from previous research and conducted questionnaire surveys to gather relevant insights from construction project experts in Nigeria. The collected data were analyzed using the Measurement of Alternatives and Ranking According to the Compromise Solution (MARCOS) method and Exploratory Factor Analysis (EFA). The MARCOS method revealed that the key potential benefits of VR include improved communication and collaboration, enhanced project performance, risk identification, digitalization, and safety planning. Furthermore, the study conducted an in-depth investigation of the beneficial areas of VR using EFA, which identified six component groups: pre-contract stage planning, post-contract stage planning, quality control and sustainability, design flexibility and reputation, resource management, and risk management and digitalization. The study provides a comprehensive discussion of the advantages of implementing virtual building methods in developing countries.

Cost analysis of an intrapartum quality improvement package for improving preterm survival and reinforcing best practices in Kenya and Uganda.

Preterm birth is a leading cause of under-5 mortality, with the greatest burden in lower-resource settings. Strategies to improve preterm survival have been tested, but strategy costs are less understood. We estimate costs of a highly effective Preterm Birth Initiative (PTBi) intrapartum intervention package (data strengthening, WHO Safe Childbirth Checklist, simulation and team training, quality improvement collaboratives) and active control (data strengthening, Safe Childbirth Checklist). In our analysis, we estimated costs incremental to current cost of intrapartum care (in 2020 $US) for the PTBi intervention package and active control in Kenya and Uganda. We costed the intervention package and control in two scenarios: 1) non-research implementation costs as observed in the PTBi study (Scenario 1, mix of public and private inputs), and 2) hypothetical costs for a model of implementation into Ministry of Health programming (Scenario 2, mostly public inputs). Using a healthcare system perspective, we employed micro-costing of personnel, supplies, physical space, and travel, including 3 sequential phases: program planning/adaptation (9 months); high-intensity implementation (15 months); lower-intensity maintenance (annual). One-way sensitivity analyses explored the effects of uncertainty in Scenario 2. Scenario 1 PTBi package total costs were $1.11M in Kenya ($48.13/birth) and $0.74M in Uganda ($17.19/birtth). Scenario 2 total costs were $0.86M in Kenya ($23.91/birth) and $0.28M in Uganda ($5.47/birth); annual maintenance phase costs per birth were $16.36 in Kenya and $3.47 in Uganda. In each scenario and country, personnel made up at least 72% of total PTBi package costs. Total Scenario 2 costs in Uganda were consistently one-third those of Kenya, largely driven by differences in facility delivery volume and personnel salaries. If taken up and implemented, the PTBi package has the potential to save preterm lives, with potential steady-state (maintenance) costs that would be roughly 5-15% of total per-birth healthcare costs in Uganda and Kenya.

Continuous glucose monitoring with data sharing in older adults: A qualitative study.

This study examined the perceptions of the SHARE plus intervention and its effects on communication, collaboration, and involvement in day-to-day diabetes management in older adults with Type 1 diabetes (T1D) and their care partners. The SHARE plus intervention includes continuous glucose monitoring with a data sharing app that allows care partners to view glucose data on a smartphone and receive alerts. People with T1D and their care partners are educated about communication strategies, problem-solving strategies, and action planning when using glucose data sharing. Qualitative descriptive design. Older adults with T1D wore a continuous glucose monitor for 3 months (n = 10). Care partners (n = 10) used a data-sharing app. The SHARE plus intervention consisted of one 90-min education session. Semi-structured interviews were conducted across 10 dyads (person with diabetes and care partner) following the 12-week study. A qualitative description and a constant comparison approach were used to examine similarities and differences in experiences. Interviews were transcribed, coded, and analysed for common themes. The manuscript adheres to COREQ EQUATOR checklist. The SHARE plus intervention increased diabetes knowledge across the dyads, improving confidence and helping partners understand how to navigate symptoms and behaviours and when to intervene. Dyads worked together to optimise diabetes management through improved communication, collaboration, and management of disagreements. Although the majority of persons with diabetes and their care partners reported no conflictual communication, disagreements about diabetes management remained in some dyads. The SHARE plus intervention impacted care partners in various ways from a psychological perspective. While live-in-care partners felt peace of mind, care partners living away from persons with diabetes had some increased worry and concern. The SHARE plus intervention results can help guide future development of diabetes dyadic care and education interventions using diabetes technology. The SHARE plus intervention is a brief, practical intervention that can help diabetes clinicians improve communication and collaboration among spouses living with older adults with T1D who use continuous glucose monitoring with data sharing. A person with diabetes was part of the research team and assisted with design of the intervention and subsequent interviews and analysis.

Building a Roadmap for Surveillance of Renal Masses Using a Modified Delphi Method to Help Achieve Consensus

To establish a consensus for initial evaluation and follow-up of patients on active surveillance (AS) for T1 renal masses (T1RM). A modified Delphi method was used to gather information about AS of T1RM, with a focus on patient selection, timing/type of imaging modality, and triggers for intervention. A consensus panel of Michigan Urological Surgery Improvement Collaborative-affiliated urologists who routinely manage renal masses was formed. Areas of consensus (defined >80% agreement) about T1RM AS were established iteratively via 3 rounds of online questionnaires. Twenty-six Michigan Urological Surgery Improvement Collaborative urologists formed the panel. Consensus was achieved for 321/587 scenarios (54.7%) administered through 124 questions. Life expectancy, age, comorbidity, and renal function were most important for patient selection, with life expectancy ranking first. All tumors <3 cm and all patients with life expectancy <1 year were considered appropriate for AS. Appropriateness also increased with elevated perioperative risk, increasing tumor complexity, and/or declining renal function. Consensus was for multiphasic axial imaging initially (contrast CT for GFR >60 or MRI for GFR >30) with first repeat imaging at 3-6 months and subsequent imaging timing determined by tumor size. Consensus was for chest imaging for tumors >3 cm initially and >5 cm at follow up. Renal biopsy was not felt to be a requirement for entering AS, but useful in several scenarios. Consensus indicated rapid tumor growth as an appropriate trigger for intervention. Our consensus panel was able to achieve areas of consensus to help define a clinically useful and specific roadmap for AS of T1RM and areas for further discussion where consensus was not achieved.

‘The objective was about not blaming one another’: a qualitative study to explore how collaboration is experienced within quality improvement collaboratives in Ethiopia

BackgroundQuality improvement collaboratives are a common approach to improving quality of care. They rely on collaboration across and within health facilities to enable and accelerate quality improvement. Originating in high-income settings, little is known about how collaboration transfers to low-income settings, despite the widespread use of these collaboratives.MethodWe explored collaboration within quality improvement collaboratives in Ethiopia through 42 in-depth interviews with staff of two hospitals and four health centers and three with quality improvement mentors. Data were analysed thematically using a deductive and inductive approach.ResultsThere was collaboration at learning sessions though experience sharing, co-learning and peer pressure. Respondents were used to a blaming environment, which they contrasted to the open and non-blaming environment at the learning sessions. Respondents formed new relationships that led to across facility practical support. Within facilities, those in the quality improvement team continued to collaborate through the plan-do-study-act cycles, although this required high engagement and support from mentors. Few staff were able to attend learning sessions and within facility transfer of quality improvement knowledge was rare. This affected broader participation and led to some resentment and resistance. Improved teamwork skills and behaviors occurred at individual rather than facility or systems level, with implications for sustainability. Challenges to collaboration included unequal participation, lack of knowledge transfer, high workloads, staff turnover and a culture of dependency.ConclusionWe conclude that collaboration can occur and is valued within a traditionally hierarchical system, but may require explicit support at learning sessions and by mentors. More emphasis is needed on ensuring quality improvement knowledge transfer, buy-in and system level change. This could include a modified collaborative design to provide facility-level support for spread.