Quality Assurance Initiatives Research Articles

Examination of Patient Safety and Experience in Ghanaian Healthcare Facilities

Objective: This paper analyzes Ghana’s healthcare quality challenges utilizing the Donabedian model covering structures, processes and outcomes to inform comprehensive systems improvement recommendations. Methods: A mixed methods approach compiles empirical findings from multiple clinical studies across Ghana assessing healthcare infrastructure, service delivery patterns, and resultant patient consequences. Qualitative case reports provide context while quantitative metrics spotlight nationwide deficiencies. An adapted Donabedian framework incorporated expanded quality domains for rigorous evaluation. Results: Significant infrastructure limitations, disjointed processes and alarming patient outcomes signify major quality gaps tied to wider health financing shortfalls. Specific issues include resource distribution inequities, medical supply unreliability, poor referral systems, limited staff accountability and infection control breaches—culminating in high preventable complications. Conclusions: Interdependencies exist between financing, tools, clinical workflows and patient experiences whereby strengthening isolated aspects risks continued quality issues without addressing root causes holistically. Sustainable reforms necessitate coordinated investments in infrastructure, oversight, coordination and worker training. Recommendations: A 10-step roadmap details structural upgrades, delivery protocols and monitoring mechanisms health authorities must institute in tandem to raise care standards for patient welfare and trust. Scientific Significance: This paper advances use of mixed, multi-level modeling to diagnose complex health sector challenges in resource-limited contexts. Practical Relevance: The blueprint formulated provides an evidence-based guide for policymakers to sequentially address identified healthcare deficiencies through coordinated quality assurance initiatives.

Examination of Patient Safety and Experience in Ghanaian Healthcare Facilities

Objective: This paper analyzes Ghana’s healthcare quality challenges utilizing the Donabedian model covering structures, processes and outcomes to inform comprehensive systems improvement recommendations. Methods: A mixed methods approach compiles empirical findings from multiple clinical studies across Ghana assessing healthcare infrastructure, service delivery patterns, and resultant patient consequences. Qualitative case reports provide context while quantitative metrics spotlight nationwide deficiencies. An adapted Donabedian framework incorporated expanded quality domains for rigorous evaluation. Results: Significant infrastructure limitations, disjointed processes and alarming patient outcomes signify major quality gaps tied to wider health financing shortfalls. Specific issues include resource distribution inequities, medical supply unreliability, poor referral systems, limited staff accountability and infection control breaches—culminating in high preventable complications. Conclusions: Interdependencies exist between financing, tools, clinical workflows and patient experiences whereby strengthening isolated aspects risks continued quality issues without addressing root causes holistically. Sustainable reforms necessitate coordinated investments in infrastructure, oversight, coordination and worker training. Recommendations: A 10-step roadmap details structural upgrades, delivery protocols and monitoring mechanisms health authorities must institute in tandem to raise care standards for patient welfare and trust. Scientific Significance: This paper advances use of mixed, multi-level modeling to diagnose complex health sector challenges in resource-limited contexts. Practical Relevance: The blueprint formulated provides an evidence-based guide for policymakers to sequentially address identified healthcare deficiencies through coordinated quality assurance initiatives.

Optimizing Machine Selection and Cost of Quality: A Comprehensive Approach for Enhanced Industrial Efficiency and Economic Growth

Abstract: In today's modern industrial economy, selecting suitable machinery and efficiently managing quality costs are critical for achieving sustainable growth and competitiveness. This research paper presents a comprehensive approach to optimizing machine selection and cost of quality (COQ) within industrial operations. The study commences by delineating the criteria for machine selection and determining their respective weights using the Analytic Hierarchy Process (AHP). Subsequently, the VIKOR method is applied to select the most suitable machine based on the established criteria and weights. Moreover, the paper explores the concept of COQ, underscoring its importance as a performance measurement tool for organizations. The research investigates various strategies for minimizing quality-related expenses and maximizing benefits, including defect prevention, quality assurance, and continuous improvement initiatives. A case study analysis, focusing on the selection between mechanical cutting CNC machines and laser cutting CNC machines, provides practical insights into the implementation of the proposed methodologies. Real data analysis of cost and quality metrics, coupled with formula-based calculations, offers valuable insights into the decision-making process. The research underscores the significance of market analysis and leveraging modern technology trends to inform machine selection decisions. Overall, the findings contribute to enhancing industrial efficiency and promoting economic growth by facilitating informed decision-making in machine selection and COQ management

Nursing students' perceptions and attitudes towards dementia care in Namibia.

Dementia is a significant public health concern and a leading cause of disability and dependency among elderly individuals globally. However, there is currently limited research examining the perceptions and attitudes of healthcare providers, including nursing students, in Namibia. This study aimed to examine nursing students' perceptions and attitudes of caring for patients with dementia. The study was conducted at two university campuses in Namibia. A quantitative correlational design was employed to conveniently recruit 196 third- and fourth-year nursing students between April and August 2023, utilising the Geriatric In-Hospital Nursing Care Questionnaire (GerINCQ) online survey. Data were analysed using SPSSv28 for descriptive and inferential statistics. The perception score ranged from 2.26 to 2.43, indicating negative attitudes and perceptions towards dementia care. The highest mean perception of 2.43 (95% CI = 2.3-2.55) was on reacting to challenging behaviour and the lowest was on professional responsibility 2.26 (95% CI = 2.12-2.4). Correlations were observed between age and performed interventions (r = 0.66; p = 0.01) and gender and dementia-sensitive care (r = 0.52; p = 0.01). The study revealed unfavourable attitudes and perceptions towards dementia care among nursing students, contrary to the optimistic anticipation. The results highlight the urgent need to develop and integrate dementia care strategies and practices into nursing education curricula. This study provides valuable data for informing quality assurance initiatives aimed at improving nursing training in dementia care.

The Way of Kaizen: Implementation of Kaizen Philosophy in Quality Assurance in Bangladeshi Higher Education

Quality assurance in higher education is a pressing global concern, with particular challenges in implementation and maintenance evident in developing nations like Bangladesh. This study addresses the multifaceted challenges facing higher education in Bangladesh, including financial, political, cultural, bureaucratic, and governmental obstacles. Through a focused examination, this research proposes a methodology for continuously developing higher educational institutions, emphasizing the trouble-free sustainability of changes. By shifting from current inefficient policies to a task-oriented approach rooted in the kaizen philosophy, this study aims to enhance the outcomes of higher education institutions in Bangladesh. Embedding the kaizen concept within quality assurance initiatives holds promise for elevating Bangladesh’s standing in the global education landscape. By embracing kaizen principles, higher education institutions in Bangladesh can incrementally overcome challenges and enhance educational quality, thereby contributing to sustainable development objectives and positioning Bangladesh as a leader in global education.

Strategic Planning For Foreign Language Program Accreditation In Higher Education

In response to expanding demand for access to higher education globally, governments and private sectors have reacted through massification, both in terms of numbers and sizes of institutions. While this has generated quantity, many argue that a corresponding rise in quality is lacking. This increasingly consumer-driven marketplace is under pressure from stakeholders - students, parents, governments, funders - to demonstrate quality. This may occur through internally generated reports, or from external accrediting bodies. For many higher education institutions, particularly in developing countries, these are novel practices. The purpose of this study is to analyze the outcomes of a program-level accreditation process implementation, and through the lens of a relevant case study, propose a framework to guide programs pursuing accreditation. Frameworks such as Bolman and Deal's Four Frames as well as Spillane, Halverson, and Diamond's Distributed Leadership can offer those charged with planning and implementing quality assurance initiatives the tools to effectively diagnose the current readiness within their organization to undergo a quality assurance initiative.

Public perception and community-level impact of national action plans on antimicrobial resistance in Vietnam.

Vietnam was the first country from the WHO Western Pacific Region to adopt a national action plan (NAP) on antimicrobial resistance (AMR) in 2013. The multilayered nature of AMR requires coordination across 'One Health' sectors, dedicated financing, multistakeholder involvement, and widespread community engagement to implement the action plans. This study explores the perceived impact of NAP implementation at the community level. Key informant interviews (KIIs) were used for data collection during 2021. An interview tool was used for the KIIs and purposive sampling was used to identify study participants from Vietnam. The study participants were those engaged with a substantial scale of antimicrobial usage, diagnosis of infections or concerned with antimicrobial content in effluents in their professional life. Twelve KIIs were conducted with participants from human health, animal health and the environmental sector. The data were entered into Microsoft Excel, and manifest and latent content analysis was done. The analysis highlighted themes such as limited public awareness of AMR, ongoing capacity building and quality assurance initiatives, implementation of guidelines and regulations for AMR containment, sustained investment in improving infrastructure, and challenges relating to accountability whilst prescribing and selling antibiotics. There were many positive critical developments during the NAP implementation period in Vietnam towards AMR mitigation. For better impact, there is a need to revitalize the implementation machinery of NAPs by improving the enforcement capacity of regulations, cross-sectoral collaboration and promoting community ownership.

Safety attitudes culture remain stable in a transplant center: evidence from the coronavirus pandemic.

We sought to understand how safety culture may evolve during disruption, by using the COVID-19 pandemic as an example, to identify vulnerabilities in the system that could impact patient outcomes. A cross-sectional analysis of transplant personnel at a high-volume transplant center was conducted using the Safety Attitudes Questionnaire (SAQ). Survey responses were scaled and evaluated pre- and post-COVID-19 (2019 and 2021). Two-hundred and thirty-eight responses were collected (134 pre-pandemic and 104 post-pandemic). Represented organ groups included: kidney (N = 89;38%), heart (N = 18;8%), liver (N = 54;23%), multiple (N = 66;28%), and other (N = 10;4%). Responders primarily included nurses (N = 75;34%), administration (N = 50;23%), and physicians (N = 24;11%). Workers had high safety, job satisfaction, stress recognition, and working conditions satisfaction (score >75) both before and after the pandemic with overlapping responses across both timepoints. Stress recognition, safety, and working conditions improved post-COVID-19, but teamwork, job satisfaction, and perceptions of management were somewhat negatively impacted (all p > 0.05). Despite the serious health care disruptions induced by the pandemic, high domain ratings were notable and largely maintained in a high-volume transplant center. The SAQ is a valuable tool for healthcare units and can be used in longitudinal assessments of transplant culture of safety as a component of quality assurance and performance improvement initiatives.

Associations with Prehospital Antibiotic Receipt among Combat Casualties with Open Wounds: A Department ofDefense Trauma Registry Study.

Current Tactical Combat Casualty Care (TCCC) guidelines recommend antibiotic administration for all open wounds to prevent infection. We identified associations between demographics, procedures, and medicines with the receipt of prehospital antibiotics among combat casualties. We used a series of emergency department procedure codes to identify adult subjects within the Department of Defense Trauma Registry from January 2007 to August 2016 who sustained open wounds. We compared demographics, procedures, and medicines administered among casualties receiving prehospital wound prophylaxis versus casualties not receiving antibiotic prophylaxis. We controlled for confounders with multivariable logistical regression. We identified 18,366 encounters meeting inclusion criteria. Antibiotic recipients (n = 2384) were comparable to nonrecipients (n = 15,982) with regard to age and sex. Antibiotic recipients were more likely to sustain injuries from firearms and undergo all procedures examined related to hemorrhage control, airway management, pneumothorax treatment, and volume replacement except for intraosseous access. Antibiotic recipients were less likely to sustain injuries from explosives. Antibiotic recipients had a modestly higher survival than nonrecipients (97.4% versus 96.0%). Associations with prehospital antibiotic receipt in multivariable logistic regression included non-North Atlantic Treaty Organization military force affiliation (odds ratio (OR) 4.65, 95% CI, 1.0-20.8), tachycardia (OR 3.4, 95% CI, 1.1-10.5), intubation (OR 2.0, 95% CI, 1.1-3.8), and administration of tranexamic acid (OR 5.6, 95% CI, 1.2-26.5). The proportion of combat casualties with open wounds receiving prehospital antibiotics was low despite published recommendations for early antibiotics in patients with open wounds. These findings highlight the ongoing need for additional educational and quality assurance initiatives to continue improving adherence to TCCC guidelines with regard to prehospital antibiotic administration. Future studies are necessary to determine reasons for suboptimal TCCC guideline compliance.

Quality Assurance and Competency Initiatives in Higher Education

Quality Assurance and Competency Initiatives in Higher Education

Developing quality culture in higher education in Taiwan: the changes within quality assurance mechanisms

ABSTRACT This paper presents an analysis of quality culture (QC) development in Taiwan which has recently undergone major reforms of quality assurance (QA) policies. The implementation of internal quality assurance (IQA) initiatives has been an indispensable condition to form a QC in higher education which contributes to a fundamental and comprehensive evolution of Taiwanese higher education. To explore the government’s policy strategies and transformation of QA approaches, this paper interviews policymakers, QA experts and academics. This paper identifies common features and distinct characteristics of QC in Taiwan’s higher education, and its relations to QA mechanisms. These perspectives offer a different way of conceptualising QC in QA policies. Furthermore, QC development has not only served the purpose of enhancing quality in higher education but has also acted as a driver for QA and higher education changes.

Exploring An Approach Towards Measuring Student Learning Outcomes: A Case Study For A Pre-Service Teacher Education Programme at A University In Vietnam

Higher education in South-East Asia as elsewhere in the world has been under transformations as it aims to meet increasing demands for quality workforce to fuel the economic growth and global integration. Higher education institutions are striving for quality of student learning and measures have been taken, be they quality assurance initiatives or responsible educational practices, to ultimately demonstrate their accountability towards their educational outputs – the achievement of their student learning outcomes. This paper presents an approach to measuring the attainment of student learning outcomes for a pre-service teacher education programme at a university in Vietnam. It shows attempts being made to an assessment plan to determine whether the intended learning outcomes have been achieved and to what extent. The process involves establishing a set of performance indicators (PIs) which well correspond to the set learning outcomes and identifying various types of direct student achievement data being collected and benchmarked against the set targets The findings allow some generalisations to be drawn on the overall performance of student learning with certain aspects being reported to outperform their counterparts in the programme, especially in the outcomes towards lifelong learning, personal and professional development. The paper also suggests the use of indirect evidence collected via surveys to stakeholders to allow a more comprehensive picture of the performance of student learning from which better-informed decisions could be made on changes in curricular design and delivery.

Experience and Hospital Context Influence Fall Prevention Practice by Physical Therapists: A Survey Study.

Falls in and following hospitalization are common and problematic. Little is understood about the factors that impede or promote effective implementation of fall prevention practices. Physical therapists are commonly consulted for acute care patients at risk for falling. The purpose of this study is to understand therapist perceptions of their effectiveness in fall prevention and to explore the impact of contextual factors on practice patterns to prevent falls surrounding hospitalization. Survey questions were tailored to the constructs of hospital culture, structural characteristics, networks and communications, and implementation climate, in addition to inquiries regarding practice patterns and attitudes/beliefs. Overall, 179 surveys were analyzed. Most therapists (n = 135, 75.4%) affirmed their hospital prioritizes best practices for fall prevention, although fewer agreed that therapists other than themselves provide optimal fall prevention intervention (n = 105, 58.7%). Less practice experience was associated with greater odds of affirming that contextual factors influence fall prevention practice (odds ratio 3.90, p < .001). Respondents who agreed that their hospital system prioritizes best practices for fall prevention had 14 times the odds of believing that their system prioritizes making improvements ( p = .002). As experience influences fall prevention practice, quality assurance and improvement initiatives should be used to ensure minimum specifications of practice.

Conceptual framework for acute community health care services – Illustrated by assessing the development of services in Denmark

Acute community health care services can support continuity of care by acting as a bridge between the primary and secondary health care sectors in the early detection of acute disease and provision of treatment and care. Although acute community health care services are a political priority in many countries, the literature on their organization and effect is limited.We present a conceptual framework for describing acute community health care services that can be used to support the policies and guidelines for such services. For illustrative purposes, we apply the framework to the Danish acute community health care services using implementation data from 2020 and identify gaps and opportunities for learning.The framework identifies two key pairs of dimensions: (1) capacity & capability, and (2) coordination & collaboration. These dimensions, together with the governance structure and quality assurance initiatives, are of key importance to the effect of acute community health care services. While all Danish municipalities have implemented acute community health care services, application of the framework indicates considerable variation in their approaches.The conceptual framework provides a systematic approach supporting the development, implementation, evaluation, and monitoring of acute community health care services and can assist policymakers at both national and local levels in this work.

Risk-Based Auditing, Quality Assurance and Improvement Program in the Practices of Internal Auditing

The purpose of this article is to outline internal auditing approaches' risk-based audits, quality assurance, and improvement programs. This paper provides a comprehensive review of risk-based auditing, quality assurance, and improvement initiatives for internal audit practitioners, audit committees, and senior management in organizations. Internal audits are designed to find flaws in a firm's operational procedures and internal controls so they may be quickly remedied to avoid harm to the company or its stakeholders. To identify the functional areas where a corporation is most exposed, the internal audit plan should be risk-driven. The internal audit plan ought to consider the organization's strategic needs. Similarly, each internal audit purpose should be in line with the audit strategy. The researcher combed through a vast number of academic publications. This study was created using desk-based research and secondary data. The study's findings will be of interest to academics and policymakers.

Defining the gap in heart failure treatment in patients with cardiac implantable electronic devices.

The use of guideline-directed medical therapy (GDMT) is poorly described in patients with heart failure and reduced ejection fraction (HFrEF) with cardiac resynchronization therapy (CRT) and/or implantable cardioverter defibrillators (ICDs). To define the eligibility, uptake, dose, contraindications, and barriers to uptake of contemporary medical therapy in this population. Retrospective analysis of consecutive adults with ICD and/or CRT attending two Canadian tertiary centre device clinics between 1 March and 31 May 2021. From 1005 device clinic consultations, 227 (22.6%) patients with HFrEF and CRT and/or ICD were included. GDMT eligibility was high: beta-blockers (99.6%), mineralocorticoid receptor antagonists (MRA) (89.0%), angiotensin receptor-neprilysin inhibitors (ARNI) (84.6%), and sodium-glucose cotransporter-2 inhibitors (SGLT2I) (87.7%). Contraindications were rare: beta-blockers (0.4%), MRA (11.0%), ARNI (15.4%), and SGLT2I (12.3%). Uptake of GDMT was high for beta-blockers (97.4%) but low for other medications: MRA (63.0%), ARNI (46.7%), SGLT2I (22.9%). Except for SGLT2I (84.6%) and beta-blockers (57.9%), less than one-half of patients were prescribed target-doses of MRA (10.5%), and ARNI (47.7%). Of the visits, GDMT was already optimal in 16%, electrophysiologists acted in 33% (21% prescribed, 7% ordered investigations, 5% referred to heart function services), and in the remaining visits, optimization was either deferred to another cardiologist (20%) or no plan was mentioned (25%), besides other reasons (4%). Despite broad eligibility for GDMT in patients with HFrEF and ICD/CRT, significant gaps in prescription and titration exist. Our results highlight the need to embed quality assurance initiatives in cardiac device clinics to improve HFrEF care.

Emergency department return visits and hospital admissions in trauma team assessed patients initially discharged from the emergency department: A population-based cohort study.

Many injured patients are transported directly to trauma centers, found to be minimally injured, and discharged directly home from the emergency department (ED). Our objectives were to characterize the short-term outcomes in this discharged patient population and to identify patient factors predictive of ED return visits. We conducted a retrospective population-based cohort study using linked administrative data sets involving patients assessed at trauma centers in Ontario, Canada between April 1, 2009, and March 31, 2020. Patients who were assessed by a trauma team and discharged directly home from ED were included. The primary outcome was the percentage of patients with an ED return visit within 14 days. We used multivariate logistic regression analyses to identify patient characteristics predictive of at least one ED return visit. There were 5,550 patients included in the study. A total of 1,004 (18.1%) of patients had at least one ED return visit, but only 100 patients (1.8%) were admitted to hospital following initial discharge. Common reasons for ED return visits included wound care concerns (17.2%), head injury complaints (15.6%), and substance misuse (6.8%). Rural residence (odds ratio [OR], 1.83; 95% CI, 1.45-2.29), history of anxiety disorder (OR, 2.05; 95% CI, 1.54-2.73), high baseline ED usage (OR, 2.58; 95% CI, 2.03-3.28), penetrating injury (OR, 1.42; 95% CI, 1.20-1.68), and extremity fracture (OR, 1.52; 95% CI, 1.24-1.88) predicted return visits. Patients discharged directly have high rates of ED return visits but low rates of hospital admission or delayed surgical intervention. Trauma services should expand quality assurance initiatives to capture return visits, understand any gaps in clinical service provision, and aim to minimize unnecessary ED return visits. Prognostic/Epidemiological; Level IV.

5 - Broadening Perceptions and Parameters for Quality Assurance in University Operations in Uganda

This article explores the stakeholders’ perceptions of quality in university operations in Uganda, specifically in terms of the core functions of teaching, research and community engagement. Conceptually, universities aim to transform, modernise and develop science and technology. A review of the literature suggests that many university communities are an elite group of professors and students who live in relative isolation. Within this ‘protective environment’ occurs a significant research milieu which is more basic than applied and, thereby, not relevant to local systems and somewhat foreign to community members. Further, the linkage between research results and institution policy makers is minimal or non-existent. In light of this background, it is argued that typical quality assurance (QA) initiatives in many universities focus on establishing operational efficiency of conventional structures of teaching and research. The study investigates comprehensiveness of parameters used by various stakeholders to determine quality in and of university education. Making reference to community engagement as one of the universities’ core functions, this study investigates whether community issues and social welfare are central in the conceiving, planning and implementing QA initiatives. Qualitative and quantitative approaches were used to generate data; specifically, questionnaires, interviews, content analysis of academic and non-academic programme and documents reviews were analysed. Preliminary findings reveal a stronger focus on conventional teaching and scholarly research than on community engagement initiatives. Conceptualisation of a quality university education by various stakeholders (students, lecturers, administration, parents and policy makers) is influenced by concerns of effectiveness and regularity of activities at the universities. Monitoring and evaluation activities emphasise: a) effectiveness of teaching and learning; b) relevancy of academic programmes to job-markets; c) quality of basic research; d) number of publications in accredited international journals; and e) concerns regarding ranking of the university relative to others in the country, region, continent and the globe. A lack of emphasis on community engagement initiatives could be explained by the fact that a number of practitioners could be products of the same existing structures and may not be in position to detect the discrepancies. Conversely, local communities, within which these institutions operate as expected immediate beneficiaries, often perceive universities as abstract institutions for the super-elite, and that the ‘ivory tower’ has little applicability to the day-to-day lives of grassroots communities. It is proposed that debates and dialogues should be organised to engage various stakeholders in re-definition of expectations, duties and responsibilities of higher education in relation to community engagement.

Creating a Culture of Online Quality: The People, Policies, and Processes that Facilitate Institutional Change for Online Course Quality Assurance

ABSTRACT The success of quality assurance initiatives in online education is dependent on the successful implementation of the processes, resources, and tools created to ensure quality. There is scant research, however, on the factors that most enable quality assurance implementation at higher education institutions. This research examined a specific population of institutions who were assessed as engaging in high levels of online course quality assurance efforts, as measured by their activity level of using the Quality Matters (QM) framework. The specific people, policies, and processes that enabled and supported institutional course design quality assurance are examined using a mixed-methods approach. Forty-three implementation coordinators from high-activity institutions completed a survey on institutional quality assurance efforts specific to course design and development. Seventeen of those coordinators also engaged in an individual interview to provide greater depth and insight into the institutional journey of quality assurance implementation for online course quality. Key takeaways showed an impact for focused, institutionally-supported goals for course design; choosing an experienced person who was passionate about quality assurance as the implementation lead; and utilizing an inclusive, flexible, collaborative implementation approach, rather than a top-down approach or mandates. The respondents also indicated that adapting the implementation to the institutional context was a key success factor, as was focusing on creating buy-in and shared goals for quality learning as a pathway toward creating an institutional culture shift.

Linkage of Emergency Medical Services and Hospital Data: A Necessary Precursor to Improve Understanding of Outcomes of Prehospital Care

Objective: Linking emergency medical services (EMS) data to hospital outcomes is important for quality assurance and research initiatives. However, non-linkage due to missing or incomplete patient information may increase the risk of bias and distort findings. The purpose of this study was to explore if an optimization strategy, in addition to an existing linkage process, improved the linkage rate and reduced selection and information bias. Methods: 4,150 transported patients in a metropolitan EMS system in Alberta, Canada from 2016/17 were linked to two Emergency Department (ED) databases by a standard strategy using a unique health care number, date/time of ED arrival, and hospital name. An optimized strategy added additional linkage steps incorporating last name, year of birth, and a manual search. The strategies were compared to assess the rate of linkage, and to describe event and patient-level characteristics of unlinked records. Results: The standard strategy resulted in 3,650 out of 4,150 (88.0%) linked records (95% CI 86.9%-88.9%). Of the 500 non-linked records, an additional 381 were linked by the optimized strategy (n = 4,031/4,150 [97.1%; 95% CI: 96.6%-97.6%]). There were no false positive linkages. The highest linkage failure was in 25 to 34 year-old patients (n = 93/478, 19.5%), males (n = 236/1975, 12.0%), Echo level events (n = 15/77, 19.5%), and emergency transport (45/231, 19.5%). The optimized strategy improved linkage in these groups by 68.8% (64/93), 79.2% (187/236), 40.0% (6/15), and 51.1% (23/45) respectively. For dispatch card, the highest linkage failure occurred in Card 24-Pregnancy/Childbirth/Miscarriage (n = 30/44, 68.2%), Card 27-Stab/Gunshot/Penetrating Trauma (n = 6/17, 35.3%), and Card 9-Cardiac/Respiratory Arrest/Death (n = 12/46, 26.1%). The optimized strategy improved linkage by 10.0% (3/30), 83.3% (5/6), and 41.7% (5/12) respectively. For the 119 unlinked records, 71 (59.7%) had sufficient information for linkage, but no appropriately matching records could be found. Conclusion: An optimized sequential deterministic strategy linking EMS data to ED outcomes improved the linkage rate without increasing the number of false positive links, and reduced the potential for bias. Even with adequate information, some records were not linked to their ED visit. This study underscores the importance of understanding how data are linked to hospital outcomes in EMS research and the potential for bias.