Healthcare Quality Improvement Research Articles

Stakeholder Perspectives and Experiences of Implementation of Accreditation and the ISO 9001 Programs in Hospitals of Iran: A Qualitative Study

Background: Accreditation and ISO 9001 programs in hospitals are widely adopted for quality control and quality improvement in healthcare. Objectives: The objective of this study is to identify stakeholders’ perspectives and experiences regarding the implementation of accreditation and ISO 9001 programs in hospitals affiliated with the Social Security Organization in Alborz Province, Iran. Methods: In this qualitative study, participants were selected based on purposive sampling. For data collection, semi-structured one-to-one interviews were conducted with hospital staff in different positions (n = 30). All interviews were digitally recorded, transcribed verbatim, and analyzed using thematic analysis. Results: Based on the analysis, 10 primary themes and 88 subthemes were identified. The 10 primary themes were categorized as experiences, strengths, weaknesses, effective factors, and recommendations for the implementation of accreditation and ISO 9001 programs in hospitals. Proper planning, benchmarking, physician involvement, increased resources, and more training are suggested for the successful implementation of accreditation in hospitals. Additionally, fostering a positive culture, focusing on the executive dimension, changing managerial attitudes, training, and supporting and motivating staff are the most important recommendations for the implementation of the ISO 9001 program. Conclusions: The results provide important insights into the dimensions of implementing accreditation and ISO programs in hospitals, which can be used by health policymakers and managers to improve the implementation of these programs in Iranian hospitals.

Policy suggestions for improving nursing education in a low- and middle-income country: A modified Delphi study

BackgroundHealth policy critically influences a national healthcare system and nurse's roles, working conditions, and professional development opportunities, especially in low- and middle-income countries. PurposeTo explore and prioritize the major challenges and solution, and establish policy directions for improving nursing education in the Kyrgyz Republic. MethodsThe key stakeholders of nursing practice, education, policymaking, and regulation were involved in this modified Delphi study. Following two rounds of exploring priority issues and potential strategies, the participants of the final round assembled for consensual discussions on the establishment of policy directions. ResultsInnovations in nursing education systems, building educational capacity, and ensuring educational outcomes were suggested and agreed upon for the sequential improvement of nursing education. DiscussionThe policy suggestions derived from this study, including the improvement of nursing education quality and the assurance of nurses' competencies, have great potential for improving quality healthcare practice and sustaining an effective healthcare system.

Student Engagement in Patient Safety and Healthcare Quality Improvement: A Brief Educational Approach.

Achieving optimal patient safety (PS) remains a challenge in healthcare. Effective educational methods are critical for improving PS. Innovative teaching tools, like case-based learning, augmented reality, and active learning, can help students better understand and apply PS and healthcare quality improvement (HQI) principles. This study aimed to assess activities and tools implemented to improve PS and HQI education, as well as student engagement, in medical schools. We designed a two-week course for fourth-year medical students at the Autonomous University of Guadalajara, incorporating Fink's taxonomy of significant learning to create engaging activities. The course featured daily synchronous and asynchronous learning, with reinforcement activities using tools, like augmented reality and artificial intelligence. A total of 394 students participated, with their performance in activities and final exam outcomes analyzed using non-parametric tests. Students who passed the final exam scored higher in activities focused on application and reasoning (p = 0.02 and p = 0.018, respectively). Activity 7B, involving problem-solving and decision-making, was perceived as the most impactful. Activity 8A, a case-based learning exercise on incident reporting, received the highest score for perception of exam preparation. This study demonstrates innovative teaching methods and technology to enhance student understanding of PS and HQI, contributing to improved care quality and patient safety. Further research on the long-term impact is needed.

Developing the Knowledge Translation and Impact Planner (KTIPs): a resource to enhance research translation and impact in health and rehabilitation.

Knowledge translation (KT) is an essential skill to assist health academics to better develop, disseminate, and implement research findings to improve health care quality and impact, but many academics lack knowledge and skills in this area. This study aimed to describe the KT-informed approach used to develop the Knowledge Translation and Impact Planner (KTIPs) to improve the quality of KT planning, and to examine the acceptability of the KTIPs. The process of developing the tool is described, including use of published literature, application of integrated KT, and consultation with end-users (n=18), including university academics, higher degree research (HDR) candidates, and experts in the KT field. The Expert Recommendations for Implementing Change (ERIC) framework was used to categorize strategies used during pilot implementation. The tool includes a comprehensive instructional guide and accompanying template that systematically takes researchers through each step of the KT process: synthesis, exchange, dissemination, and implementation, as well as guidance on planning for impact following effective KT. Academic staff and HDR candidate stakeholders, and comprehensive advice from experts shaped development of the tool. The tool went through three rounds of concurrent feedback with different end-users. End-users confirmed its acceptability, indicating the KTIPs was adaptable, comprehensive, instructional, and facilitated development of KT and impact plans addressing varied KT goals. The KTIPs was acceptable among academic staff and HDR candidates and facilitated the KT and impact planning process. The KTIPs is freely available and is designed to be navigated, completed, and saved electronically to facilitate implementation of developed plans. http://links.lww.com/IJEBH/A253.

Development and implementation of evidence-based, nurse-leading early warning model and healthcare quality improvement project for transplant-associated thrombotic microangiopathy: a mixed-methods, before-and-after study

ObjectiveThe early identification and diagnosis of transplant-associated thrombotic microangiopathy (TA-TMA) are essential yet difficult in patients underwent hematopoietic stem cell transplantation (HSCT). To develop an evidence-based, nurse-leading early warning model for TA-TMA, and implement the healthcare quality review and improvement project.MethodsThis study was a mixed-methods, before-and-after study. The early warning model was developed based on quality evidence from literature search. The healthcare quality review and improvement project mainly included baseline investigation of nurse, improvement action and effectiveness evaluation. The awareness and knowledge of early parameter of TA-TMA among nurses and the prognosis of patients underwent HSCT were compared before and after the improvement.ResultsA total of 1 guideline, 1 evidence synthesis, 4 expert consensuses, 10 literature reviews, 2 diagnostic studies, and 9 case series were included in the best evidence. The early warning model including warning period, high-risk characteristics and early manifestation of TA-TMA was developed. The improvement action, including staff training and assessment, suspected TA-TMA identification and patient education, was implemented. The awareness and knowledge rate of early parameter of TA-TMA among nurses significantly improved after improvement action (100% vs. 26.7%, P < 0.001). The incidence of TA-TMA was similar among patients underwent HSCT before and after improvement action (2.8% vs. 1.2%, P = 0.643), while no fall event occurred after improvement action (0 vs. 1.2%, P < 0.001).ConclusionThe evidence-based early warning model and healthcare quality improvement project could enhance the awareness and knowledge of TA-TMA among healthcare providers and might improve the prognosis of patients diagnosed with TA-TMA.

The contribution of logistics to improving health care quality: a case study approach

ABSTRACT This research in a managerial vision tries to understand how inter-organisational logistical collaboration on physical (drugs, consumables, medical equipment and kits) and information flows contributes to improving the quality of care. The analysis of the content of the semi-structured interviews allowed us to discuss the two research proposals resulting from the literature review and their level of acceptance. The results show that the collaboration between the operators of the two supply chains, internal and external supply chains, contributes to improving care but under certain conditions. Recommendations have been made to many entities to improve logistical practices and the quality of care provided to patients. In doing so, our research thus contributes to compiling literature on hospital logistics and paves the way for more future research in the field of logistics in healthcare establishments.

Using Behavioral Insights to Strengthen Strategies for Change. Practical Applications for Quality Improvement in Healthcare.

For over 30 years, quality improvement (QI) methods have been used as a means of increasing the quality and safety of healthcare services, but with mixed success. One explanation highlighted in the literature for this outcome is the overemphasis on technical elements of change, and a failure to fully appreciate the human side of change. Behavioral insights (BI) is an approach that utilizes knowledge and tools from a broad range of scientific disciplines, such as neuroscience and behavioral psychology, to support behavior change. The aim of this paper is to explore the possibility of supplementing QI methods with tools and understanding from BI. We outline a practical case that involved applying aspects BI methods into a QI program aimed at reducing the use of intravenous antibiotics in patients accessing services at a busy university hospital in Copenhagen, Denmark. We exemplify how to use BI tools to guide the analysis of staff behaviors during standard clinical processes and develop targeted interventions aimed at increasing actions and behaviors more aligned to best clinical practice. Outcomes suggest that it is possible to combine the models and methods from BI and QI in a way that is helpful in focusing attention on the human side of change when developing strategies for change. Potential psychological barriers identified from the analysis included the following: 'default inertia,' 'decision complexity,' 'risk aversion,' and biases related to confidence, confirmation, and omission. Future quality improvement projects could benefit from integrating models and tools from BI to guide and support behavior change.

The Interplay Between Healthcare Quality Improvement, Temporality, and Materiality

The Interplay Between Healthcare Quality Improvement, Temporality, and Materiality

Suicide in individuals with eating disorders who had sought mental health treatment in England: a national retrospective cohort study

Although studies have suggested a high risk of suicide in people with eating disorders, most studies have focused on suicidal ideation and attempts. There is little research on the characteristics of people with eating disorders who died by suicide, nor investigation of trends over time. We aimed to compare the characteristics of patients with eating disorders who died by suicide versus patients with other mental health diagnoses who died by suicide in England and to examine the trends in rates. In this national retrospective cohort study, data on all people (aged ≥10 years) who died by suicide in England, UK, between Jan 1, 1997, and Dec 31, 2021, while under the care (within the previous 12 months) of mental health services were obtained from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), in which clinical information is collected via a questionnaire completed by the mental health professional responsible for the patient's care. Incidence of suicide in, and demographic, clinical, and treatment characteristics of, patients with a diagnosis of eating disorder (as recorded by the treating clinician) who died by suicide were compared with patients with other mental health diagnoses who died by suicide within the same timeframe using univariable logistic regression analysis. People with related lived experience were involved in the study design, implementation, interpretation, and writing of the manuscript. Of 119 446 people for whom NCISH were notified of dying by suicide in England, 30 795 were under the recent care of mental health services, of whom 30 246 had known diagnoses and were included in analyses. Of these individuals, 10 373 (34%) were female and 19 873 (66%) were male; 2236 (8%) were of minority ethnicity; 382 (1%) had a diagnosis of eating disorder and 29 864 (99%) had another mental health diagnosis. Compared with patients with other mental health diagnoses who died by suicide, patients with eating disorders were younger (median age 33 years [range 15-90] vs 45 years [10-100]), more often female (343 [90%] female and 39 [10%] male in the eating disorders group; 10 030 [34%] female and 19 834 [66%] male in the other diagnoses group), and less likely to have evidence of conventional risk factors for suicide such as living alone (odds ratio [OR] 0·68, 95% CI 0·55-0·84). 22 (6%) of 382 were from a minority ethnic group. Patients with an eating disorder were characterised by a greater clinical complexity (eg, self-harm [OR 2·31, 95% CI 1·78-3·00], comorbidity [9·79, 6·81-14·1], and longer duration of illness [1·95, 1·56-2·43]), and were more likely to have died following overdoses (2·00, 1·62-2·45) than patients with other diagnoses. Childhood abuse (52 [37%] of 140) and domestic violence (18 [20%] of 91) were common in patients with eating disorders. Similar to patients with other diagnoses, most (244 [75%] of 326) of those with eating disorders who died by suicide were rated as low risk by clinicians at last contact. The number of suicide deaths in patients with eating disorders rose between 1997 and 2021 (incidence rate ratio [IRR] 1·03, 95% CI 1·02-1·05; p<0·0001), but rates fell when accounting for the greater number of patients entering mental health services (IRR 0·97, 0·95-1·00; p=0·033). This study was focused on people who sought help from mental health services. It did not consider subtypes of eating disorders or include a control group, but it does highlight possible areas for intervention. The comprehensive provision of evidence-based treatment for eating disorders and underlying conditions to address the clinical complexity in these patients might help to reduce suicide. Recognising limitations in clinical risk assessment, addressing early life experiences and current adversities, and appropriate prescribing might also be of benefit. Suicide prevention must remain a priority for eating disorder services and mental health care more widely. The Healthcare Quality Improvement Partnership.

A qualitative study of the barriers and facilitators impacting the implementation of a quality improvement program for emergency departments: SurgeCon

BackgroundThe implementation of intervention programs in Emergency Departments (EDs) is often fraught with complications due to the inherent complexity of the environment. Hence, the exploration and identification of barriers and facilitators prior to an implementation is imperative to formulate context-specific strategies to ensure the tenability of the intervention.ObjectivesIn assessing the context of four EDs prior to the implementation of SurgeCon, a quality improvement program for ED efficiency and patient satisfaction, this study identifies and explores the barriers and facilitators to successful implementation from the perspective of the healthcare providers, patients, researchers, and decision-makers involved in the implementation.SettingsTwo rural and two urban Canadian EDs with 24/7 on-site physician support.MethodsData were collected prior to the implementation of SurgeCon, by means of qualitative and quantitative methods consisting of semi-structured interviews with 31 clinicians (e.g., physicians, nurses, and managers), telephone surveys with 341 patients, and structured observations from four EDs. The interpretive description approach was utilized to analyze the data gathered from interviews, open-ended questions of the survey, and structured observations.ResultsA set of five facilitator-barrier pairs were extracted. These key facilitator-barrier pairs were: (1) management and leadership, (2) available resources, (3) communications and networks across the organization, (4) previous intervention experiences, and (5) need for change.ConclusionImproving our understanding of the barriers and facilitators that may impact the implementation of a healthcare quality improvement intervention is of paramount importance. This study underscores the significance of identifing the barriers and facilitators of implementating an ED quality improvement program and developing strategies to overcome the barriers and enhance the facilitators for a successful implementations. We propose a set of strategies for hospitals when implementing such interventions, these include: staff training, champion selection, communicating the value of the intervention, promoting active engagement of ED staff, assigning data recording responsibilities, and requiring capacity analysis.Trial registrationClinicalTrials.gov. NCT04789902. 10/03/2021.

The Steep Decline in Reporting to the National Practioner Data Bank, and a Look at Reporting Levels from “Plaintiff-Favorable” and “Defendant-Favorable” States

The establishment of the National Practitioner Data Bank (NPDB) was authorized in the Health Care Quality Improvement Act of 1986, and it mandated a federal database to collect information related to adverse actions initially against just physicians and dentists throughout the United States, including payments from malpractice lawsuits, restrictions on clinical privileges by hospitals, and medical licensure limitations and revocations by state licensing boards. The aggregate data reports made by this federal data bank began in 1991. The reporting level for the first ten years remained relatively stable in the nationwide range of 16,000 to 18,000 reports per year, but then a steady decline occurred over the second and third decades to under 8,000 reports per year by the year 2021. The researchers in this study explored a theory that might explain at least part of the drop in the states’ reporting levels. That is, states that could be called “Plaintiff-Favorable” (Arizona, Kentucky, New York, Pennsylvania, and Washington) would demonstrate a lesser rate of decline or even an increase in the reporting levels, and states that could be characterized as “Defendant-Favorable” (California, Michigan, Nevada, North Carolina, and Texas) would demonstrate a comparatively greater rate of decline in the reporting levels. The decline in reporting to the NPDB proved fairly consistent for both Plaintiff-Favorable and Defendant-Favorable states. The larger question as to why there occurred an overall negative trend in reporting to the NPDB across the United States during the second and third decades remains an intriguing area for future exploration.

Evidence-Based Practice Quality Improvement Critical Appraisal Tool.

Optimal quality improvement in health care is based on research and other types of evidence. Critical appraisal of evidence is a fundamental component of evidence-based practice (EBP) and is also needed to evaluate the quality of quality improvement (QI) projects. Currently available EBP or QI critical appraisal tools can be challenging for students learning the critical appraisal process and for practicing clinicians who desire access to a standardized EBPQI approach to inform health care decision-making. The currently available tools are incomplete, too brief, or too complicated for ease of use in education and practice. This article introduces the first combined EBP and QI (EBPQI) critical appraisal tool, which is aligned with the new EBPQI mountain model. This newly developed appraisal tool may be used in appraising evidence for an EBPQI initiative and to appraise the quality of disseminated EBPQI.

Quality improvement development in Swedish healthcare and welfare services

Purpose Quality improvement has developed and spread, and today, all Swedish Regions emphasize that their strategies are based on systematic improvement. This paper aims to describe and illuminate the development of Quality Improvement (QI) in Swedish healthcare and welfare organizations by using publications in a Swedish context. Design/methodology/approach The overview synthesis is inspired by a scoping literature review approach of relevant literature. All publications relevant to Swedish healthcare and welfare settings between 1992 until 2020 were included. Findings In all, 213 papers, 29 books and chapters and 34 dissertations related to QI and research in Swedish healthcare and welfare context were identified. From 2011 to 2020, the publication rate increased rapidly. Six different focus areas emerged: systematic and value-creating improvement work; collaboration between organizations and healthcare providers; use of improvement methods and (theoretical) models; leadership and learning; measurements, quality registers and follow-up; and involvement and patient safety. Further QI development in Swedish healthcare and welfare points to an increased importance of collaboration between organizations and coproduction with beneficiaries for the healthcare and welfare services. Originality/value This paper is one of the first to describe and illuminate the QI development in the healthcare and welfare sector in a country. The trajectory also points to a need for coproduction to handle future challenges.

E-learning Interventions for Quality Improvement Continuing Medical Education-A Scoping Review.

Improving health care quality and patient safety are top priorities for the medical field. Robust continuing medical education (CME) programs represent major interventions to effectively teach quality improvement (QI) principles to practicing physicians. In particular, eLearning, a term describing online and distance learning interventions using digital tools, provides a means for CME interventions to reach broader audiences. Although there has been a focus on CME addressing QI, no knowledge synthesis has focused specifically on eLearning interventions. The purpose of this review was to examine the current landscape of eLearning interventions in QI-focused CME. We conducted a scoping review using the framework developed by Arksey and O'Malley as revised by Levac. We searched five databases and identified 2467 prospective publications, which two authors independently screened for inclusion. From each included article, two authors independently extracted data on the instructional modalities and QI tools used and met regularly to achieve consensus. Twenty-one studies were included. Most studies used blended instruction (n = 12) rather than solely eLearning interventions. Salient findings included the importance of coaching from QI experts and institutional support for planning and implementing eLearning interventions. Lack of protected time and resources for participants were identified as barriers to participation in CME activities, with small practices being disproportionately affected. Partnerships between CME developers and sponsoring organizations are vital in creating sustainable eLearning interventions for QI-focused CME. Remote coaching can be an effective strategy to provide ongoing support to geographically separated learners.

System‐failing creativity in health care

AbstractIntroductionHealth care professionals often generate novel solutions to solve problems during day‐to‐day patient care. However, less is known about generating novel and useful (i.e., creative) ideas in the face of health care system failure. System failures are high‐impact and increasingly frequent events in health care organizations, and front‐line professionals may have uniquely valuable expertise to address such occurrences.MethodsOur interdisciplinary team, blending expertise in health care management, economics, psychology, and clinical practice, reviewed the literature on creativity and system failures in health care to generate a conceptual model that describes this process. Drawing on appraisal theory, we iteratively refined the model by integrating various theories with key concepts of system failures, creativity, and health care worker's well‐being.ResultsThe SFC model provides a conceptualization of creativity from front‐line care professionals as it emerges in situations of failure or crisis. It describes the pathways by which professionals respond proactively to a systems failure with creative ideas to effectively address the situation and affect these workers' well‐being.ConclusionsOur conceptual model guides health care managers and leaders to use managerial practices to shape their systems and support creativity, especially when facing system failures. It introduces a framework for examining system‐failing creativity (SFC) and general creativity, aiming to improve health care quality, health care workers' well‐being, and organizational outcomes.

New technology and working methods to improve healthcare for suspected malignant skin lesions: Implementation of teledermatoscopy in comprehensive healthcare

AbstractBackgroundSuspected malignant skin lesions are common and challenging in terms of diagnostic accuracy and lead time. Efficient use of teledermatoscopy has the potential to improve these factors.ObjectivesThis report aims to explore the implementation of teledermatoscopy for quality improvement in a comprehensive healthcare system.MethodsA stepwise implementation started in 2012 in the Stockholm Region, Sweden, serving 2.4 million inhabitants across approximately 240 primary healthcare centres. The full‐scale implementation occurred from May 2021 to February 2023, utilising a double‐reading teledermatoscopy system. The RE‐AIM framework (reach, effectiveness, adoption, implementation, maintenance) guided the evaluation, including measures such as participant engagement, referrals, diagnoses, staff participation, and centres going on post‐implementation. Descriptive statistics were used.ResultsIn the full‐scale implementation period, 10,862 referrals were transmitted, with 17% recommended for biopsy or excision. Among these, 282 (15%) were confirmed melanomas and 516 (28%) non‐melanoma skin cancers. Challenges were observed during the stepwise phase, particularly in engaging primary healthcare and establishing dermatologic consultation capacity. However, all centres and 1263 primary care physicians participated in the fully scaled implementation. Challenges included contractual compliance, adopting a collective system perspective, effective management transition of referrals, cost allocation, and communication improvements. Six months post‐study, most centres used the system, with around 1500 monthly referrals.ConclusionsThe evaluation revealed the overall satisfactory performance of the teledermatoscopy system in terms of reach, effectiveness, adoption, implementation, and maintenance during the fully scaled phase. Results underscore the effectiveness of a stepwise implementation to successfully address contextual challenges. The findings emphasise the system's potential for a broader patient outreach. In conclusion, implementation of teledermatoscopy for quality improvement in a comprehensive healthcare system is an organisational challenge but has the potential to improve healthcare quality for suspected malignant skin lesions.

Leveraging Lean Six Sigma principles in an Indian tertiary care hospital: a case study

PurposeWorkflow optimisation is crucial for establishing a viable acute stroke (AS) intervention programme in a large tertiary care centre. This study aims to utilise Lean Six Sigma (LSS) principles to enhance the hospital's workflow.Design/methodology/approachThe Action Research methodology was used to implement the project and develop the case study. The study took place in a large tertiary care academic hospital in India. The Define-Measure-Analyse-Improve-Control approach optimised the workflow within 6 months. Lean tools such as value stream mapping (VSM), waste audits and Gemba were utilised to identify issues involving various stakeholders in the workflow. Sigma-level calculations were used to compare baseline, improvement and sustainment status. Additionally, statistical techniques were effectively employed to draw meaningful inferences.FindingsLSS tools and techniques can be effectively utilised in large tertiary care hospitals to optimise workflow through a structured approach. Sigma ratings of the processes showed substantial improvement, resulting in a five-fold increase in clinical outcomes. Specifically, there was a 43% improvement in outcome for patients who underwent acute stroke revascularisation. However, certain sigma ratings deteriorated during the control and extended control (sustainment) phases. This indicates that ensuring the sustainability of quality control interventions in healthcare is challenging and requires continuous auditing.Research limitations/implicationsThe article presents a single case study deployed in a hospital in India. Thus, the generalisation of outcomes has a significant limitation. Also, the study encounters the challenge of not having a parallel control group, which is a common limitation in quality improvement studies in healthcare. Many studies in healthcare quality improvement, including this one, are limited by minimal data on long-term follow-up and the sustainability of achieved results.Originality/valueThis study pioneers the integration of LSS methodologies in a large Indian tertiary care hospital, specifically targeting AS intervention. It represents the first LSS case study applied in the stroke department of any hospital in India. Whilst most case studies discuss only the positive aspects, this article fills a critical gap by unearthing the challenges of applying LSS in a complex healthcare setting, offering insights into sustainable quality improvement and operational efficiency. This case study contributes to the theoretical understanding of LSS in healthcare. It showcases its real-world impact on patient outcomes and process optimisation.

How did whistleblowing and the duty of candour get onto the agenda of the British national health service

PurposeThis paper compares how the two interacting themes of “Whistleblowing” or “Speaking Up” and the duty of candour (DoC), which are both concerned with safety and quality improvement in health care, got onto the agenda of the British National Health Service (NHS).Design/methodology/approachIt uses the approach of multiple streams and the methodology of interpretive content analysis in a deductive approach that focusses on both manifest and latent content. It examines official documents that discuss the DoC or whistleblowing or cognate terms in connection with the British NHS from 1999 to 2019.FindingsThe main conceptual finding, which mirrors many previous studies, is that it seems difficult to operationalise many of the sub-components of the multiple streams approach. The main empirical finding points to the “focusing event” of the Francis Report into the Mid Staffordshire Trust of 2013 and the importance of its Chair, Sir Robert Francis, as a policy entrepreneur.Originality/valueThis is one of the first studies to focus on both issues of whistleblowing and the DoC and the first to compare them through the lens of the multiple streams approach. It has two main conceptual advantages over most previous studies in the field: it compares whistleblowing and the duty of candour rather than the dominant approach of a single case study and explores the different outcomes of failed as well as successful couplings of the streams.

How personnel diversity and affective bonds affect performance-based financing: a moderator analysis of a difference-in-difference estimator.

To spur improvement in health-care service quality and quantity, performance-based financing (PBF) is an increasingly common policy tool, especially in low- and middle-income countries. This study examines how personnel diversity and affective bonds in primary care clinics affect their ability to improve care quality in PBF arrangements. Leveraging data from a large-scale matched PBF intervention in Tajikistan including 208 primary care clinics, we examined how measures of personnel diversity (position and tenure variety) and affective bonds (mutual support and group pride) were associated with changes in the level and variability of clinical knowledge (diagnostic accuracy of 878 clinical vignettes) and care processes (completion of checklist items in 2485 instances of direct observations). We interacted the explanatory variables with exposure to PBF in cluster-robust, linear regressions to assess how these explanatory variables moderated the PBF treatment's association with clinical knowledge and care process improvements. Providers and facilities with higher group pride exhibited higher care process improvement (greater checklist item completion and lower variability of items completed). Personnel diversity and mutual support showed little significant associations with the outcomes. Organizational features of clinics exposed to PBF may help explain variation in outcomes and warrant further research and intervention in practice to identify and test opportunities to leverage them. Group pride may strengthen clinics' ability to improve care quality in PBF arrangements. Improving health-care facilities' pride may be an affordable and effective way to enhance health-care organization adaptation.

Optimizing Quality Improvement Methods in Practice: A Case Study Approach.

Quality improvement (QI) initiatives help ensure patients are receiving high-quality care. Iterative Plan-Do-Study-Act (PDSA) cycles are used to test change. Data are evaluated over time, and tests of change can be modified or discarded as needed. Health care QI teams lack the flexibility to conduct PDSA cycles, often conducting pre/post quasi-experimental research studies instead. This article reviews a case study of a "personal improvement" initiative as an example of QI methods and data evaluation for an individual trying to lose weight. The purpose of this article is to provide guidance on best practices for conducting QI initiatives; common pitfalls that clinicians may face when leading their own QI initiatives are identified and recommendations to overcome these challenges are discussed. Concepts from this case study, along with supplemental resources provided, can help clinicians optimize QI methodologies in the health care setting.