Quality Improvement Team Research Articles

Establishing purposeful oncology care disparities reduction strategies.

166 Background: Quality thought leaders have noted the oneness of care quality and equity. Yet, quality improvement (QI) often ignores equity. We implemented a holistic approach to quality specifically designed to facilitate equity. We report the components of the approach and how it is being used to address disparities in unplanned acute care events (ACEs) among chemotherapy patients. Methods: We used the Institute for Health Improvement Whole System Quality framework to integrate care equity in an established quality program. We started by stratifying oncology dashboards by race, ethnicity, and language (REAL) as well as other factors (monitoring). We developed and implemented an Umbrella Action Plan Policy that specified an accountability structure to identify and address disparities (planning) and via goal setting (planning), prioritized, developed, and executed action plans to address disparities once identified (improvement). Results: In February 2023 a system-level senior leadership committee charged with priority setting cancer care quality initiatives approved the Umbrella Action Policy. This led to REAL-stratified, quarterly performance reports being shared with senior leadership who voted for this year’s annual goals to include identification and use of rapid cycle testing to eliminate ACE disparities. The organization-level goal engendered central QI coaching resources, established local entity QI teams within each System-affiliated entity with dedicated oncology program (N=6), and formed a learning collaborative across entities. One of each local QI team chose to focus on reducing race-related, language-related, and payor-related (Medicaid) disparities. The other organizations chose otherwise (e.g., age or gender). Teams are using two approaches to identify ACE root causes among target populations: (1) a structured chart abstraction form to search for, among other things, communication breakdowns, gaps in symptom management or other supportive care, and access barriers; and (2) a semi-structured interview guide to engage patients and caregivers for input and suggestions. In September, teams will work collaboratively to identify and execute small tests of change to alleviate identified drivers contributing to ACE disparities. Data from chart abstractions and patient engagement interviews will be shared along with results from tests of change tried to date. Conclusions: Facilitating the identification of disparities via REAL stratified dashboards, leadership teams setting expectations regarding gap closure, and allocation of resources to support local QI teams has focused the quality planning, monitoring, and, to some extent, improvement activities on care equity among marginalized populations. Prescriptively focusing local organization efforts may be needed for appropriate selection of target populations when wanting to infuse REAL equity in QI programming.

Improving the longevity of intravenous cannulas in sick neonates admitted to NICU in a tertiary care centre: a quality improvement project

BackgroundNeonatal intravenous cannulation, especially in preterms, is more challenging than in children or adults. Placement of an intravenous cannula is painful and many cannulas need frequent changing due to complications....

Improving ambulatory infusion drug delivery through alarm management using a quality improvement model and team learning.

472 Background: A quality outpatient cancer program depends on the accurate delivery of chemotherapy using a computerized ambulatory infusion pump to deliver a therapeutic dose of chemotherapy for patients. Between April and July 2021, our cancer center hotline reported an excessive rate of 60% of ambulatory pump were generating alarms. This resulted in interruptions in dose delivery, disruptions in clinical workflows, and negatively impacted patient satisfaction. Methods: A multidisciplinary team of frontline nurses, pharmacists, nurse leaders, and quality specialists was assembled to analyze six months of alarm data using a plan-do-study-act (PDSA) model. Quality tools were utilized to determine the root cause of the alarms and arrive at solutions to improve drug delivery by reducing alarms and calls to the infusion hotline. The team discovered 49% (n=22/45) of alarm could not be resolved, resulting in a dose interruption of the planned chemotherapy infusions. Patients returned to the infusion suite without receiving the total dose of chemotherapy as ordered. A full 70% of the hotline calls (n=16/22) were due to a “No Disposable” alarm code. Analysis of these returned units by both our group and the vendor led us to recommend a more advanced replacement model which was implemented in June/July of 2022. Results: Between July and December 2022, MCI outpatient ambulatory pump medication variances related to “No Disposable” improved by 100%. A total of 34 calls were received by the Hotline Nurse with 91% (31/34) of calls were successfully resolved. None of the ambulatory patients experienced an interruption in chemotherapy drug delivery. Conclusions: Forming a multidisciplinary working group resulted in a timely and significant improvement in chemotherapy safety using the PDSA model of quality improvement. Most importantly, confidence in chemotherapy drug delivery using ambulatory infusion pump was expressed by infusion nurses, pharmacists, and medical providers.

Interventions to Reduce Inappropriate Physical Therapy Consultation in the Inpatient Setting: A Quality Improvement Initiative.

Physical therapy (PT) in inpatient settings is a limited and valuable resource. Inappropriate PT consultation is costly and can lead to delays in care and discharge planning. Baseline data at an academic hospital revealed that approximately one in four PT consults were inappropriate (n = 29,230) across all services, as defined by an activity measure post-acute care "6-Clicks" basic mobility score of >22. Our interdisciplinary quality improvement team used the Six Sigma methodology to address this problem. We performed a root-cause analysis that identified high-impact root causes and implemented two targeted interventions: (1) A modified electronic health record PT order with clinical-decision support, and (2) nursing role change to assume PT-ordering responsibility. The rate of inappropriate PT consults decreased from 23.9% to <10% postintervention across all inpatient units, with the nursing role change reaching statistical significance (p < .0019). Our multifaceted intervention contributed to a significant reduction in unnecessary PT consults, expediting evaluation of patients qualifying for skilled inpatient therapy.

A Quality Improvement Project to Improve the Utilization of an Intraoperative Rapid Response System

Introduction: Rapid response teams (RRTs) improve morbidity by reducing the incidence of cardiac arrests. Although providers commonly activate RRTs on acute care wards, they are infrequently used perioperatively. At our institution, two intraoperative calls for help exist: staff assists (SAs) and code blues (CBs). The SA functions analogously to an RRT, and the CB indicates cardiopulmonary arrest. Given the success of RRTs, this project aimed to increase the use of the SA system. Our primary goal was to increase the ratio of SA to CB alerts by 50% within 6 months. Methods: A quality improvement team led this project at an academic pediatric hospital in Northern California. The team analyzed the current state and identified an achievable goal. After developing key drivers, they implemented monthly simulations to teach providers the signs of clinical deterioration and to practice activating the SA system. In addition to measuring the ratio of SA to CB alerts, the team surveyed the etiologies of SA and measured process satisfaction. Results: Before the introduction of this initiative, the ratio of SA to CB alerts were 1:13.3. These improvements efforts led to an increase of SA to CB alerts to 1.5:1 (P = 0.0003). Twenty-three anesthesiologists provided etiologies for SA, reporting laryngospasm as the most common reason (30.4%). Nineteen nurses completed the SA survey and reported high satisfaction. Conclusion: This project successfully increased the utilization of a rapid response protocol in a pediatric perioperative setting using improvement methodologies and a simulation-based educational program.

Hospital Adaptions to Mitigate the COVID-19 Pandemic Effects on MARQUIS Toolkit Implementation and Sustainability.

To explore the perceived effects of COVID-19 on MARQUIS toolkit implementation and sustainability, challenges faced by hospitals in sustaining medication reconciliation efforts, and the strategies used to mitigate the negative effects of the pandemic. Primary qualitative data were extracted from a Web-based survey. Data were collected from hospitals that participated in MARQUIS2 ( n = 18) and the MARQUIS Collaborative ( n = 5). A qualitative, cross-sectional study was conducted. Qualitative data were extracted from a Research Electronic Data Capture survey databased and uploaded into an Excel data analysis template. Two coders independently coded the data with a third coder resolving discrepancies. Thirty-one team members participated, including pharmacists ( n = 20; 65%), physicians ( n = 9; 29%), or quality-improvement (QI) specialists ( n = 2; 6%) with expertise in medication reconciliation (MedRec) (14; 45%) or QI (10; 32%). Organizational resources were limited, including funding, staffing, and access to pharmacy students. To support program continuation, hospitals reallocated staff and used new MedRec order sets. Telemedicine, workflow adaptations, leadership support, QI team involvement, and ongoing audits and feedback promoted toolkit sustainability. COVID-19 affected the capacity of hospitals to sustain the MARQUIS toolkit. However, hospitals adapted various strategies to sustain the toolkit.

Using a Quality Improvement Approach to Implement Measurement-Based Care (MBC) in Outpatient General Psychiatry.

Measurement-based care (MBC) is the clinical practice of using patient-reported symptom measurement to inform treatment decisions. MBC has been shown to improve patient outcomes and quality of care in outpatient psychiatry. Despite these benefits, MBC is not routinely used in most psychiatric outpatient settings. This quality improvement (QI) project aimed to achieve 75% completion of symptom scales using an online MBC platform in a general psychiatry clinic in Toronto, Canada, by June 2022. The QI team used the Model for Improvement methodology. The main outcome measure was completion of symptom scales using an online MBC platform. Process measures included counts of invitations to join the MBC platform, counts of online MBC account creation, and counts of symptom scale assignment by clinicians. Balancing measures included administrative task completion and physician workload assessment. Stakeholder interviews explored barriers and facilitators to MBC utilization. Completion of symptom scales increased from 7/65 (10.8%) preintervention to 40/70 (57.1%) during the 26-week intervention. Clinician reminders and coaching clinicians about how to incorporate MBC into the care process facilitated uptake of MBC. Stakeholders identified several barriers to implementation, particularly physician attitudes toward MBC and perceived administrative burden. Completion of symptom scales increased over the course of this QI initiative. Successful implementation of MBC in general psychiatry outpatient settings requires the availability of a broad range of measurement scales given the diversity of mental health diagnoses. Implementation must also consider health equity, including access to technology and availability of symptom scales in multiple languages.

Improving handoff with the implementation of I-PASS at a tertiary oncology hospital

BackgroundLack of consistent and standardised handoffs is a leading cause of patient harm. With increased census in our hospital medicine (HM) service, failure to handoff using a standardised method has...

Improving colorectal cancer screening disparities among Somali-speaking patients in an Internal Medicine Residency Clinic

Colorectal cancer (CRC) is the third-most lethal cancer in the USA, and early detection through screening is crucial for improving outcomes. However, significant disparities in access and utilisation of CRC...

Application of Participatory Ergonomics to the Dissemination of a Quality Improvement Program for Optimizing Blood Culture Use.

Blood cultures are overused in pediatric ICUs (PICUs), which may lead to unnecessary antibiotic use and antibiotic resistance. Using a participatory ergonomics (PE) approach, the authors disseminated a quality improvement (QI) program for optimizing blood culture use in PICUs to a national 14-hospital collaborative. The objective of this study was to evaluate the dissemination process and its impact on blood culture reduction. The PE approach emphasized three key principles (stakeholder participation, application of human factors and ergonomics knowledge and tools, and cross-site collaboration) with a six-step dissemination process. Data on interactions between sites and the coordinating team and site experiences with the dissemination process were collected using site diaries and semiannual surveys with local QI teams, respectively, and correlated with the site-specific change in blood culture rates. Overall, participating sites were able to successfully implement the program and reduced their blood culture rates from 149.4 blood cultures per 1,000 patient-days/month before implementation to 100.5 blood cultures per 1,000 patient-days/month after implementation, corresponding to a 32.7% relative reduction (p < 0.001). Variations in the dissemination process, as well as in local interventions and implementation strategies, were observed across sites. Site-specific changes in blood culture rates were weakly negatively correlated with the number of preintervention interactions with the coordinating team (p = 0.057) but not correlated with their experiences with the six domains of the dissemination process or their interventions. The authors applied a PE approach to disseminate a QI program for optimizing PICU blood culture use to a multisite collaborative. Working with local stakeholders, participating sites tailored their interventions and implementation processes and achieved the goal of reducing blood culture use.

Impact of an Interprofessional HIV Quality Improvement Team on Patient Care and Resident Learning Opportunities.

Although human immunodeficiency virus (HIV) care is a recommended competency for family medicine training, many programs report a lack of HIV expertise among faculty. After the departure of faculty with HIV care experience, an interprofessional HIV quality improvement team (HIV-QIT) of physicians and pharmacists aimed to maintain on-site HIV care and retain learning opportunities for residents, using process improvement and panel reviews with a remote HIV specialist faculty member. This study reports on a multicycle quality improvement pilot project with pre- and postintervention chart reviews between December 2019 and May 2021. All patients received primary care and HIV-QIT chart reviews on-site. We compared patients with integrated HIV care on-site to those receiving external HIV specialty care. Primary outcomes included virologic suppression, CD4 count ≥200 cells/mm3, and adherence to guideline-recommended HIV care. In cycle 1 (January-June 2020), the HIV-QIT reviewed patient charts and sent guideline-based recommendations to physicians. In cycle 2 (July 2020-May 2021), the HIV-QIT implemented several HIV-specific processes, including decision support updates, note templates, order sets, and reference materials. Sustained process improvements included HIV panel chart audits every 3 to 6 months and subsequent provider education. Of 29 patients, more than half (55%, n=16) received integrated HIV care at the primary care site. We found no significant difference in care quality measures between primary and specialty care. Barriers to care completion included missed or canceled follow-up visits, on-site phlebotomy service closures, and declined HIV services. The HIV-QIT maintained on-site HIV treatment and retained experiential learning opportunities through process improvement and specialist-supported care recommendations to primary care physicians.

Incidence of infections associated with the use of invasive devices in an ICU after application of the Improvement Science Method

Objective: To reduce the incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI) in the intensive care unit (ICU) using the Improvement Science method. Methods: This was a single-center retrospective cohort study. A collaborative quality improvement team developed and implemented local changes to HAI-related processes and protocols. Pre-intervention, intervention, and post-intervention periods were compared. The study was conducted at the Adult ICU of a hospital in southern Brazil. Variables were analyzed using interrupted time series analysis with segmented linear regression, simple correlation, and hypothesis testing. Results: There was a reduction in the incidence density of all infections. VAP was reduced from 27.2% to 7.2% (p &lt; 0.001), CLABSI from 3.0% to 0.9% (p = 0.017), and CAUTI from 8.3% to 1.8% (p &lt; 0.001). The ICU stay was also reduced from 6.7 to 6 days (p = 0.018). Conclusion: There was an improvement in all the evaluated parameters. Ongoing monitoring of related indicators and adherence to implemented measures are essential to sustain improvements. Applying the Improvement Science methodology can reduce the incidence of HAIs in the ICU.

Improving Handoffs After Osteoporotic Fractures

Osteoporotic fractures among long-term care residents have substantial economic and human costs. After a fracture, many older adults do not receive an osteoporosis diagnosis or evidence-based treatment, which leads to increased risk of recurrent fractures. Optimal processes are well defined for transitioning medical care after a hip or vertebral fracture for osteoporosis evaluation, but the handoff process from the specialist back to a primary care practitioner (PCP) or to a rehabilitative setting is not well defined. Our interdisciplinary quality improvement team developed and evaluated a program for transitioning care from a hospital-based fracture liaison clinic (FLC) to PCPs caring for older adults across the care continuum. To understand the current process of postfracture care transitions, we analyzed the postfracture patient experience. We surveyed PCPs to assess barriers to osteoporosis treatment, and retrospectively conducted a baseline analysis of 87 patients who had sustained an osteoporotic fracture in 2020. This preliminary work showed several opportunities for practice improvement and helped us develop a practical multicomponent intervention aimed at improving care transitions from the FLC to PCPs. The intervention (June-September 2021) comprised a standardized documentation template in the electronic health record (EHR) for FLC clinicians, a structured handoff process, and an engagement tool for patients outlining the roles and responsibilities of each care team member. We compared care transition measures before and after intervention. EHR documentation of an osteoporosis diagnosis increased from 56% (49 of 87 patients) before intervention to 92% (48 of 52) after intervention (P < .001). Additionally, increases were observed in documentation of treatment recommendations, associated risk factors, and PCP discussions with patients regarding osteoporosis and related treatment. This practical, commonsense intervention established clear roles for each care team member. The intervention addressed systemwide barriers in facilitating a safe transition from a subspecialty care team to PCPs providing care to older adults with osteoporosis.

Improving management of hyponatraemia by increasing urine testing in the emergency department

Hyponatraemia on hospital admission is associated with increased length of stay, healthcare expenditures and mortality. Urine studies collected before fluid or diuretic administration are essential to diagnose the underlying cause...

573 Proforma for Referrals to the Paediatric Surgery Ward from General Practice (GP) Surgeries and Urgent Care Centres for Foundation Year One (FY1) Doctors

Abstract Introduction The foundation year one (FY 1) doctors hold a bleep and receive referrals from primary care centres especially from the General Practice (GP) surgeries and Urgent Care centres. For many FY 1 doctors, this job may be their first experience in the NHS in taking referrals and it could be quite challenging to take a good referral from primary care centres in the NHS. This was the basis to conduct this quality improvement project (QIP) to help the FY 1 doctors in taking good primary care referral documentation. Aim To develop a primary care centre referral proforma as a guide for the FY 1 doctors in taking referrals and to assess the junior doctors and other ward staff satisfaction in using the proforma. Method This QIP was registered and approved by the Continuous Quality Improvement Team of Hull University Teaching Hospital NHS Trust. This was a prospective study with designed proforma for FY 1 doctors to be used following primary care centres referral to the Paediatric Surgery ward. Results There were 38 primary care referrals between 16th October 2022 and 20th December 2022 with 30 referrals from the GP surgeries and 8 referrals from the Urgent Care centres. The overall satisfaction was excellent with the use of the designed proforma by the FY 1 doctors and other ward and we had 100% completion in filling in the designed proforma. Conclusions A well designed referral proforma could improve the confidence and quality of referral documentation from primary care centres by FY 1 doctors.

Effectiveness of the contingency plan for social and health care during the COVID-19 pandemic in a health district in northwestern Spain

IntroductionDuring the COVID-19 pandemic, healthcare facilities have implemented contingency plans to minimize the consequences of this pathology however, the deployment and results of these contingency plans are scarcely shared. ObjectivesTo describe the implementation of the contingency plan in the social and health care in the COVID-19 pandemic in the Public Hospital of Monforte (Lugo, Spain) and to evaluate the effectiveness of the measures included in this plan. MethodPhenomenological sampling conducted between March 10 and May 15, 2020. Evaluation qualitative assessment by an external quality improvement team of the Galician Health Service (SERGAS), based on the Practicum Direct rapid structured checklist in risk management, organizational management, and evaluation of decision making. As outcome indicators, we assessed the number of hospital admissions, number of PCRs performed, telephone attention to social and health social-healthcare patients, number of hospitalizations avoided and estimation of their direct cost. ResultsAfter assessing and managing the risks, an information security plan was developed and solutions to minimize complications in our patients derived from this pandemic. An emergency decision making team was created, as well as an employee communication mechanism for employees through standardized documents and documentation channels. ConclusionsThe adaptation of the Practicum Direct rapid model to the healthcare setting is a useful and easy-to-apply tool that allows us to identify weak points and areas for improvement in our Service and thus to strengthen patient care in all clinical areas, improving the quality of care.

A Quality Improvement Study to Improve Oxygen Prescription in the PICU of a Tertiary Care Centre in Delhi, India.

Introduction Oxygen has been gravely misused since its inception as a therapeutic agent. There is a deficit of audits and baseline data for the Indianpopulation, especially in the pediatric age group, which doesn't allow for standardization of protocols and guidelines. Objective Our study aimed at increasing valid prescription rates to 90% by implementation of quality improvement interventions, and assessing knowledge and perception of healthcare workers towards oxygen therapy. Methodology It followed a before-and-after prospective observational study model where baseline audit data was compared with data observed after the implementation of quality improvement strategies. The data was collected through an audit of the medical records of all pediatric patients receiving oxygen therapy in the PICU. Knowledge and perception of healthcare workers about oxygen therapy were assessed via a self-designed questionnaire. The study was undertaken in three phases, including Quality Improvement (QI) team formation and data collection, root cause analysis, and implementation of Plan-Do-Study-Act (PDSA) cycles. Observations and results In the baseline audit, 1.4% of the prescriptions were complete and valid. Subsequently, over the course of four PDSA cycles, valid prescription rates increased; 62.07% in the first, 79.51% in the second, 81.81% in the third, and 91.42% in the fourth cycle respectively. After applying the chi-square test to compare PDSA4 and baseline data, the p-values for written prescriptions and target saturation were found to be statistically significant. In the healthcare worker survey, we found that 100% of them were aware of indications of oxygen prescription, FiO2, and side effects of excessive usage of oxygen therapy, 95% were aware of conditions affecting pulse-oximetry in the pediatric age group, and 75% knew about target saturation and its significance and the procedure to change alarm settings on the monitor. Conclusion Currently, there exists a lack of effective oxygen prescription audits, especially in India, which can be attributed to a lack of awareness and partly, a lack of initiative. Quality improvement initiatives are effective in improving the valid oxygen prescription rate. However, sustained goals can be achieved through regular audits only.

A quality improvement initiative to improve folic acid supplementation counseling for adolescent females with epilepsy.

We designed a quality improvement (QI) project to improve rates of documented folic acid supplementation counseling for adolescent females with epilepsy, consistent with a quality measure from the American Academy of Neurology and American Epilepsy Society. Our SMART aim was to increase the percentage of visits at which folic acid counseling was addressed from our baseline rate of 23% to 50% by July 1, 2020. This initiative was conducted in female patients ≥12 years old with epilepsy who were prescribed daily antiseizure medication and were seen by the 13 providers in our Neurology QI Program. Using provider interviews, we undertook a root cause analysis of low counseling rates and identified the following main factors: insufficient time during clinic visit to counsel, lack of provider knowledge, and forgetting to counsel. Countermeasures were designed to address these main root causes and were implemented through iterative plan-do-study-act (PDSA) cycles. Interventions included provider education and features within the electronic health record, which were introduced sequentially, culminating in the creation of a best practice advisory (BPA). We performed biweekly chart reviews of visits for applicable patients to establish baseline performance rate and track progress over time. We used a statistical process control p-chart to analyze the outcome measure of documented counseling. As a balancing measure, clinicians were surveyed using the Technology Adoption Model survey to assess acceptance of the BPA. From September 2019 to August 2022, the QI team improved rates of documented folic acid counseling from 23% to 73% through several PDSA cycles. This level of performance has been sustained over time. The most successful and sustainable intervention was the BPA. Provider acceptance of the BPA was overall positive. We successfully used QI methodology to improve and sustain our rates of documented folic acid supplementation counseling for adolescent females with epilepsy.

From purists to pragmatists: a qualitative evaluation of how implementation processes and contexts shaped the uptake and methodological adaptations of a maternal and neonatal quality improvement programme in South Africa prior to, and during COVID-19

BackgroundDespite progress, maternal and neonatal mortality and still births remain high in South Africa. The South African National Department of Health implemented a quality improvement (QI) programme, called Mphatlalatsane, to reduce maternal and neonatal mortality and still births. It was implemented in 21 public health facilities, seven per participating province, between 2018 and 2022.MethodsWe conducted a qualitative process evaluation of the contextual and implementation process factors’ influence on implementation uptake amongst the QI teams in 15 purposively selected facilities. Data collection included three interview rounds with the leaders and members of the QI teams in each facility; intermittent interviews with the QI advisors; programme documentation review; observation of programme management meetings; and keeping a fieldwork journal. All data were thematically analysed in Atlas.ti. Implementation uptake varied across the three provinces and between facilities within provinces.ResultsBetween March and August 2020, the COVID-19 pandemic disrupted uptake in all provinces but affected QI teams in one province more severely than others, because they received limited pre-pandemic training. Better uptake among other sites was attributed to receiving more QI training pre-COVID-19, having an experienced QI advisor, and good teamwork. Uptake was more challenging amongst hospital teams which had more staff and more complicated MNH services, versus the primary healthcare facilities. We also attributed better uptake to greater district management support. A key factor shaping uptake was leaders’ intrinsic motivation to apply QI methodology. We found that, across sites, organic adaptations to the QI methodology were made by teams, started during COVID-19. Teams did away with rapid testing of change ideas and keeping a paper trail of the steps followed. Though still using data to identify service problems, they used self-developed audit tools to record intervention effectiveness, and not the prescribed tools.ConclusionsOur study underscores the critical role of intrinsic motivation of team leaders, support from experienced technical QI advisors, and context-sensitive adaptations to maximise QI uptake when traditionally recognised QI steps cannot be followed.

The process of implementing culture change across a city-operated long-term care home and the importance of stakeholder engagement.

This article describes the Quality Improvement (QI) initiative of a culture change model, CareTO. CareTO is a made-in-Toronto, resident-driven, person-centred approach to care that was implemented across all units of a City of Toronto-operated Long-Term Care (LTC) home during the COVID-19 pandemic. The City of Toronto's Seniors Services and Long-Term Care (SSLTC) Division partnered with an external QI team to support the implementation of CareTO at the pilot site. This team employed a multi-method approach (fact-gathering conversations, stakeholder survey, and meeting) to understand how residents, families, and professionals defined CareTO, and identified implementation facilitators, barriers, and priorities. Emerging findings were shared with SSLTC to inform the delivery of CareTO in real time. Results suggested that stakeholder engagement, and collaborations between external partners and municipal governments are an effective means of mobilizing implementation initiatives by encouraging reflection, developing a shared understanding, and refining objectives.