Summative Feedback Research Articles

A pain in the neck: prototyping and testing of a patient simulator neck for spinal immobilization training

This paper presents the development and user-testing of a novel concept for patient simulators, aiming to enhance spinal immobilization training. Iterative prototype interactions with critical stakeholders revealed a need for evidence-based guidelines and training for suspected neck injuries. A realistic and compliant neck prototype with sensor feedback was developed to address the need for objective performance metrics. The conceptual prototype was used in an experimental study (n = 12) to obtain subjective and objective feedback on its characteristics and use in medical training. In the experiment, users were asked to perform spinal immobilization techniques on a simulator while sensor data recorded head and neck movements. Furthermore, a Likert-scale questionnaire and subjective feedback were gathered. Results are used to discuss proposed performance metrics and whether they can be used as quality performance indicators for formative and summative training feedback. The results also suggest the neck prototype to realistically simulate an unconscious patient regarding the obtained range of motion and spinal compliance.

Best practice rehabilitation pathway for the management of single and double-level lumbar fusion surgery: a modified Delphi Study.

There is limited evidence to guide the rehabilitation of patients following single or double-level lumbar fusion surgery (LFS). This is reflected in extensive variability in current rehabilitation regimes and subsequent low clinical success rates, which urges a call for a consensus rehabilitation pathway. To establish consensus on the optimal pre-, peri- and postoperative rehabilitation of LFS. A modified Delphi Study. Belgium and the Netherlands. A multidisciplinary panel of 31 experts in the field of LFS and rehabilitation participated. Nine patients validated the consensus pathway. A three-round online Delphi questionnaire was followed by an in-person consensus meeting. In each round, experts could suggest new statements, and received group summary statistics and feedback for reconsidered statements. Consensus threshold was set at ≥75% agreement. The resulting rehabilitation pathway was validated by patients through an online questionnaire and subsequent in-person focus group. A total of 31 experts participated in the first online round, with 27 (87%) completing all online rounds, and 17 (55%) attending the in-person consensus meeting. Consensus was reached on 122 statements relating to pre-, peri- and postoperative rehabilitation of LFS, and validated by patients. Key components of the rehabilitation pathway included prehabilitation, education, physiotherapy in every phase, early postoperative mobilization, and little movement restrictions. Patients emphasized the need for support during the return-to-work process. This process resulted in 122 expert-consensus statements on best practice rehabilitation for managing LFS, validated by patients. The proposed rehabilitation pathway can serve as guidance to support clinicians, reduce practice variability, and subsequently improve clinical outcomes after LFS.

Self-Reflection and Peer-Assessments Effect on Pharmacy Students’ Performance at Simulated Counselling Sessions

Verbal communication is a vital skill for pharmacists and essential for improving patient care. The aim of this study was to explore students' perception of the impact of self-reflection and self- and peer-assessment on simulated patient counselling sessions. Focus groups explored student perceptions of how this course and way of learning has impacted their performance at counselling patients. Data were analysed using iterative inductive thematic analysis procedures and mapped to the self-determination theory. Nine focus groups with 47 pharmacy students. We identified three main themes and ten associated subthemes. These were learning style (sub-themes gradual introduction to assessment, learning through self-reflection videos, authentic assessment, individual learning compared to group learning, and learning through observation of best practice), feedback (sub-themes inconsistent feedback, summative feedback, perception of self and relationship with peers informing peer assessment) and benefits in real life practice. These themes mapped well to self-determination theory and highlighted that additional focus may be required for benefits in real-life practice. Students' perceptions of self-reflection and self- and peer-assessment centred on learning style, feedback, and benefits in real-life practice. Additional focus on benefits of this unit of study in real-life practice and work integrated learning on placements may further strengthen the impact of these learning activities.

Comparative effectiveness of telesimulation versus standard simulation for pediatric Minimally Invasive Surgery (MIS) essential skills training

Proctored on site simulation-based surgical education has been integrated in our residents curricula since 2012. Due to COVID-19 pandemic and social distance protocols, we developed a Tele-assisted Essential Skills Training Module (T-ESTM). The aim of this study is to evaluate comparative effectiveness between Telesimulation (T) versus Standard Simulation (S) for minimally invasive surgery (MIS) essential skills training. ESTM includes academic lectures, tutorials for ergonomics and 7 hands-on tasks scheduled into 2 sessions of 3hours. Initial and final assessment scoring (adapted from GOALS) as well as timing for 3 of the tasks were registered. Telesimulation (T) group accessed the content online and completed their Hands-On practice through a digital communication platform. Standard Simulation (S) group attended conferences and Hands-On practice at the simulation center. Both groups were proctored by the same educators with summative and formative feedback and debriefing. Data was analyzed with the R-studio software program. Each group had 20 participants with a mean age of 28±5 years. 67.5% were surgeons in training, 47.5% had performed low complexity procedures and 40% had previous experience with simulation training. We observed a significant improvement in scoring and time reduction for all assessed tasks in Sand T groups (p<0.001), with no statistically significant differences when comparing both groups. Similar performance could be achieved with both strategies. Telesimulation is a reproducible and effective educational tool for remote MIS essential skills training, and should be considered as an alternative to on-site simulation programs. Level II. Clinical Research.

A Systematic Approach to Provide Feedback to Presenters at Virtual and Face-to-Face Professional Meetings.

To promote their personal and professional growth, medical educators need practical, actionable feedback on their scholarship, as well as guidance for documenting their scholarship in educator portfolios. We offer a framework and resources to provide formative and summative feedback to faculty, administrators, and/or learners delivering an oral presentation at a face-to-face or virtual health professions education meeting. In 2014, the leadership of the Central Group on Educational Affairs (CGEA) meeting planning committee developed and piloted a process to provide individuals with formative and summative feedback on their oral CGEA research presentations at face-to-face meetings and create a transparent process for determining the Best Presentation Award. The feedback process was implemented for 7 years until revised in 2021 for the CGEA's first virtual meeting. Past and present meeting organizers conducted four focus groups in 2021 with presenters and peer reviewers via Zoom. Transcripts were analyzed for major themes using conventional content analysis. To date, 102 presentation assessments have been conducted, including formative and summative assessments. Sixty-two volunteer assessors have participated, 19 (31%) of whom served for more than 2 years. Focus groups identified best practices and suggestions to improve the feedback process. This resource offers a feasible, systematic process to provide individuals with formative feedback on presentations at professional conferences, promote a community of practice for personal and professional development, and create a transparent process for determining a Best Presentation Award. Participants valued providing and receiving feedback and recommended implementation at other professional meetings.

Transdisciplinary Implementation of Heart Rate Monitors During Inpatient Rehabilitation

<h3>Research Objectives</h3> Clinical practice guidelines demonstrate clear benefits of cardiovascular intensity on movement recovery after a neurologic injury, particularly walking recovery. However, research shows a lack of sufficient intensity during inpatient rehabilitation for both physical and occupational therapy sessions. Knowledge translation efforts and implementation of wearable heart rate monitors have been shown to support increased intensity during physical therapy directed interventions. Through a year-long effort, we have investigated the feasibility of implementing transdisciplinary heart rate monitoring informed by the knowledge to action cycle. <h3>Design</h3> 1 year transdisciplinary feasibility study. <h3>Setting</h3> 114 bed inpatient rehabilitation hospital. <h3>Participants</h3> 16 clinicians (9 physical therapists, 6 occupational therapists, 1 recreational therapist). <h3>Interventions</h3> 1 year, 4 phase Multicomponent Knowledge Translation initiative using the Knowledge to Action Cycle Framework. <h3>Main Outcome Measures</h3> -Clinician Participation (session count). Clinician Satisfaction, Clinician Perceived Relevance (summative feedback questionnaire). <h3>Results</h3> This four phase study will end August 2022. The first 13-week phase included 6 therapists (4 PTs, 2 OTs) that engaged in 70 sessions with an average of 5.38 sessions/week. The second phase included 10 therapists (6 PTs, 4 OTs), engaging in 152 sessions, averaging 11.69 sessions/week. The third phase included 13 therapists (8 PTs, 5 OTs), engaging in 436 sessions, averaging 33 sessions/week. The final phase included 16 therapists (9 PTs, 6 OTs, 1 RT), engaging in 503 sessions, averaging 38 sessions/week. In the one year follow up survey responses, 81% of pilot group users reported high satisfaction with heart rate monitor use. Clinician perceived relevance of heart monitor use differed for persons with non-neurological and neurological diagnoses. <h3>Conclusions</h3> Current data suggests that implementation of wearable heart rate monitoring devices for a transdisciplinary inpatient rehab team is feasible and supported by a multicomponent knowledge to action framework. Majority of pilot group participants were very satisfied with participation in heart rate monitoring interventions and highest perceived clinical relevance was for patients with neurological injuries, consistent with clinical practice guideline recommendations. Future studies will expand implementation among onsite clinicians, further investigate barriers of use, and determine optimal interventions for promoting high intensity and specificity within each discipline. <h3>Author(s) Disclosures</h3> None.

Modifying Post-operative Opioid Stewardship Through a System of Educational Feedback.

Background: The opioid overdose epidemic remains one of the leading focuses of the United States' public health agenda. Current literature has suggested that many surgical procedures are associated with an increased risk of chronic opioid use in the post-operative period of opioid-naïve patients. We aimed to assess whether providing feedback on the average morphine milligram equivalents (MMED) and opioid utilization by selected post-operative patients would impact the provider opioid prescribing patterns.Methods: An opioid stewardship educational intervention provided didactic and email feedback to general surgeons about their prescribing patterns and summary feedback on opioid usage among post-operative patients from the pre-intervention period. We used descriptive statistics, Chi Square, Fisher's Exact test, Wilcoxon Rank Sum, two sample t test, and Spearman's rho to analyze the data gathered.Results: A total of 5142 patients with an average age of 43.9 years were included in the study period. Women accounted for 3096 (60.2%) and 2046 (39.8%) were men. The surgeries during the study period included 1928 (37.5%) appendectomies and 3214 (62.5%) cholecystectomies. The predominant surgical approach was laparoscopic 5028 (97.8%). In both groups, the total MMED and total number of pills prescribed decreased significantly after the intervention was implemented. There were no refill prescriptions nor 30-day readmissions among those discharged with an opioid prescription in either study phase.Discussion: An intervention that provided general surgeons with feedback about their post-operative prescription patterns and data on post-operative opioid utilization by patients decreased prescribed MMED.

A New Teaching Tool for Peer Review of Charting and Care in the Emergency Department

Poor documentation, incomplete medical decision-making, missing progress notes, and inappropriate care play a major role in medical malpractice cases. We introduced a new quality improvement (QI) process focused on evaluating and improving documentation and clinical care. We hypothesized that a modified, simplified QI scoring rubric would demonstrate inter-rater reliability among attending physicians and provide a useful new standardized tool for both QI departmental review and peer review. We modified a previously developed rubric template that demonstrated high inter-rater reliability for a more streamlined, simpler, and more generalized application. We developed a new system using three discrete templated sections with choices limited to five options. Eight experienced attending physicians evaluated the same 10 charts using our scoring rubrics. Consistency among raters was assessed using the Shrout-Fleiss relative: fixed set mean kappa scores.Our statistical analysis found excellent consistency among our experienced raters for both the documentation (κ = 0.91) and clinical care (κ = 0.84) scoring tools. We conclude that a modified, simplified QI scoring rubric demonstrates inter-rater reliability among experienced attending physicians. We believe this tool can be used as a standardized tool for a departmental review process by experienced quality leaders as well as by faculty to provide peer review while improving their own charting prowess. We further used this tool for peer review by having the attending staff participate in reviewing a specified number of charts using our modified template with explicit criteria so they could provide feedback as well, while gaining a better understanding of the elements of a "good" chart and of opportunities for improved care and resource utilization. By using this tool, we were able to provide more than 50 attendings summative feedback on their charting by a group of their peers that was both numerical and descriptive.

Metric-Based Simulation Training to Proficiency for Endovascular Thrombectomy in Ischemic Stroke.

Ischemic stroke is one of the leading causes of death and long-term disability in the West. Mechanical revascularization techniques are considered the standard of care for large vessel occlusive stroke. Traditional apprenticeship models involve doctors training their skills on patients. Simulation platforms have long been recognized as an alternative to this. There has however been very little robust assessment of the training outcomes achieved on some of these platforms. At best, these simulations increase understanding of the procedural process and may help improve some technical skills; at worst they may instill bad habits and poor technique. The prerequisite of any simulation process must be to teach what to do, with which devices, in the correct sequence as well as what not to do. It should provide valid metric-based feedback to the trainee that is objective, transparent, and fair for formative and summative performance feedback. It should deliver a training program that measures the performance progress of trainees against expert benchmarks—benchmarks that represent an evidence-based peer-reviewed standard. In this paper, we present a perspective for PBP training for thrombectomy based on our experience with the process of procedure characterization, metric validation, and early experience of using this approach for proficiency training. Patient outcomes are not only determined by optimal performance in the Angio Suite but also by an efficient patient procedure pathway. There will be value in utilizing the PBP training standard not only for the procedure itself but also for the constituent elements of the stroke pathway to further improve treatment outcomes for ischemic stroke patients.

E-assessment in mathematics in higher education: a student perspective

Assessment is among the inevitable components of a curriculum and directs students’ learning. E-assessment, as prepared and administered with the use of ICT, provides opportunities to make the process easier in some aspects, but also brings certain challenges. This paper presents an e-assessment framework from a student perspective. Our study lasted for one academic year and incorporated a total of 631 students’ responses to questionnaires conducted three times in two different mathematics courses. The courses are compulsory for undergraduate informatics students. The research included a three-step factor analysis: two exploratory factor analyses and a confirmatory factor analysis. It yielded a model of a student perspective on e-assessment consisting of four factors: Transparency and fairness of assessment, Formative and summative assessment and feedback, Meaningful use of technology in assessment and Difficulty of learning outcomes. The students’ opinion about the use of e-assessment was generally positive. The students appreciated the student-centred approach based on sound pedagogical alignment of all teaching and learning elements with assessment. They found it important that technology should not distract students during assessment tasks and considered cheating in a controlled e-assessment environment to be no more frequent than in face-to-face assessment.

Acceptability and Efficacy of the SMARxT Media Literacy Education Program to Counter Pharmaceutical Marketing Influences among Medical Trainees.

Evidence-based prescribing (EBP) results in decreased morbidity and reduces medical costs. However, pharmaceutical marketing influences medication requests and prescribing habits, which can detract from EBP. Media literacy, which teaches critical thinking, is a promising approach for buffering marketing influences and encouraging EBP. The authors developed the "SMARxT" media literacy education program around marketing influences on EBP decision-making. The program consisted of six videos and knowledge assessments that were delivered as an online educational intervention through the Qualtrics platform. In 2017, we assessed program feasibility, acceptability, and efficacy of enhancing knowledge among resident physicians at the University of Pittsburgh. Resident physicians (n=73) responded to pre-test items assessing prior knowledge, viewed six SMARxT videos, and responded to post-test items. A 6-month follow-up test was completed to quantitatively assess sustained changes in knowledge and to qualitatively assess summative feedback about the program (n=54). Test scores were assessed from pre- to post-test and from pre-test to follow-up using paired-sample t-tests. Qualitative results were synthesized through content analysis. Proportion of correct knowledge responses increased from pre-test to immediate post-test (31% to 64%, P<0.001) at baseline. Correct responses also increased from pre-test to 6-month follow-up (31% to 43%, P<0.001). Feasibility was demonstrated by 95% of enrolled participants completing all baseline procedures and 70% completing 6-month follow-up. Quantitative measures of acceptability yielded positive scores and qualitative responses indicated participants' increased confidence in understanding and countering marketing influences due to the intervention. However, participants stated they would prefer shorter videos, feedback about test scores, and additional resources to reinforce learning objectives. The SMARxT media literacy program was efficacious and acceptable to resident physicians. Participant suggestions could be incorporated into a subsequent version of SMARxT and inform similar clinical education programs. Future research should assess program impact on real-world prescribing practices.

This is a test: Oculomotor capture when the experiment keeps score.

Physically salient stimuli are difficult to ignore, frequently eliciting fixations even when they are known to be task-irrelevant. A recent study demonstrated that distractor fixation-contingent auditory feedback was highly effective in reducing the frequency of fixations on such stimuli. The present study explores more specifically what it is about feedback that makes it effective in curbing oculomotor behavior. In one experiment, we removed the immediacy of the feedback by informing participants after each trial via textual feedback if they had fixated the distractor. A comparable reduction in the frequency of oculomotor capture was observed. In a second experiment, we only provided summary feedback concerning the frequency of oculomotor capture after each block of trials. Not only were the benefits of feedback again robustly comparable, but a benefit was observed even in the first block before any feedback had actually been presented. Simply knowing that the frequency of distractor fixations was being monitored was sufficient to substantially reduce the frequency of oculomotor capture. Interestingly, trial-level feedback predominantly reduced the frequency of capture by slowing oculomotor responses, reflecting a speed-accuracy tradeoff, whereas block-wise feedback resulted in a reduction in the frequency of capture with saccadic reaction time equated, reflecting a bona fide improvement in task performance. Our findings have implications for our understanding of the role of motivation, strategy, and selection history in oculomotor control.

Assessment of neurosurgical resident milestone evaluation reporting and feedback processes.

Structured performance evaluations are important for the professional development and personal growth of resident learners. This process is formalized by the Accreditation Council for Graduate Medical Education milestones assessment system. The primary aim of this study was to understand the current feedback delivery mechanism by exploring the culture of feedback, the mechanics of delivery, and the evaluation of the feedback itself. Face-to-face interviews were conducted with 10 neurosurgery residents exploring their perceptions of summative feedback. Coded data were analyzed qualitatively for overriding themes using the matrix framework method. A priori themes of definition of feedback, feedback delivery, and impact of feedback were combined with de novo themes discovered during analysis. Trainees prioritized formative over summative feedback. Summative and milestone feedback were criticized as being vague, misaligned with practice, and often perceived as erroneous. Barriers to implementation of summative feedback included perceived veracity of feedback, high interrater variability, and the inconstant adoption of a developmental progression model. Gender bias was noted in degree of feedback provided and language used. Trainee perception of feedback provided multiple areas of improvement. This paper can serve as a baseline to study improvements in the milestone feedback process and optimize learning.

Driving, work, wound care and rehabilitation after carpal tunnel release: Consensus recommendations from a UK Delphi study.

There is variability in the information available for patients after carpal tunnel release (CTR). We aimed to establish (i) what advice should be provided regarding return to driving after CTR; (ii) how work activities should be categorised and defined in relation to CTR, and when patients should be recommended to return to these activities; (iii) what wound care and rehabilitation advice should be provided after CTR. We developed consensus recommendations from an expert panel of hand surgeons, primary care surgeons and hand therapists using an electronic Delphi process. Participants were recruited from clinical organisations using pre-defined criteria. Delphi questionnaires included open text and tick-box responses. Consensus was defined as ≥75% agreement and summary feedback was provided after each round. There were 33 panellists (21 surgeons and 12 hand therapists), of which 27 (82%) completed all rounds. Expected return to driving was agreed as 5-14days. Expected timescales were also agreed for return to seven selected occupational activities. Post-operative advice focused on using and moving the hand, rather than specific rehabilitation. While consensus was reached for most items, there were important areas of disagreement, including divergent views on driving with sutures in situ and the need to inform car insurers. Recommendations from this study expand on existing advice by including functional descriptors for occupational activities and guidance timescales generated through a formal consensus process. Areas where consensus was not reached warrant further exploration to assess whether different practices impact clinical and functional outcomes for patients.

Providing choice of feedback affects perceived choice but does not affect performance.

BackgroundAutonomy or choice can lead to improved learning in various educational domains. The purpose of this online study was to examine whether giving participants a choice regarding the frequency of their received feedback (either after each individual trial or after a block of trials) in a computerized alternate task-switching task, will affect their performance.MethodsParticipants (n = 148) were randomly assigned to three groups: choice group (n = 49), online feedback group (n = 51), and summary feedback group (n = 48). From those three groups we created two groups: a choice group and a no-choice group (n = 49 in each group). All participants performed eight familiarization trials, a pre-test of 24 trials, five blocks of 24 trials for practice, and a post-test of 24 trials. After completing the task, the participants were asked about their perceived feeling of choice and completed the short form of the International Positive and Negative Affect Schedule.ResultsThe participants in the choice group had higher perceived choice compared with the participants in the no-choice group (8.41 vs 5.47 out of 10, respectively). However, this higher perceived choice did not materialize into better performance during practice or in the post-test.

Rapid Feedback: Assessing Pre-clinical Teaching in the Era of Online Learning.

Introduction Medical schools vary in their approach to providing feedback to faculty. The purpose of this study was to test the effects of rapid student feedback in a course utilizing novel virtual learning methods.MethodsSecond-year medical students were supplied with an optional, short questionnaire at the end of each class session and asked to provide feedback within 48 h. At the close of each survey, results were emailed to faculty. After the course, students and faculty were asked to rate the effectiveness of this method. This study did not affect administration of the usual end-of-course summative evaluations.ResultsNinety-one percent of students who participated noted increased engagement in the feedback process, but only 18% on average chose to participate. Faculty rated rapid feedback as more actionable than summative feedback (67%), 50% rated it as more specific, and 42% rated it as more helpful. Some wrote that comments were too granular, and others noted a negative personal emotional response.ConclusionRapid feedback engaged students, provided actionable feedback, and increased communication between students and instructors, suggesting that this approach added value. Care must be taken to reduce the student burden and support relational aspects of the process.

Use of a Novel Manikin for Neonatal Resuscitation Ventilation Training.

All providers who attend deliveries independently should be well versed in the performance of effective ventilation, assessment of the quality of ventilation/interventions supplied and able to troubleshoot in situations where these may be ineffective. A novel manikin serves as a unique ventilation-focused training tool to practice these clinical skills and decision-making. The data generated by the manikin, with the aid of a facilitator, may be used for formative and summative feedback on an individual level or curricular development on a larger level. This communication describes the importance of focused ventilation training for front-line providers and illustrates how this manikin can be incorporated into an individualized ventilation training program.

An Interactive, Multimodal Curriculum to Teach Pediatric Cardiology to House Staff.

Pediatricians must be able to diagnose, triage, and manage infants and children with congenital heart disease. The pediatric cardiology division at the Medical University of South Carolina updated their curriculum for pediatric residents to a format supported by constructivist learning theory. The purpose of this study is to determine if shorter, interactive learning with fellow and faculty involvement improved pediatric cardiology knowledge demonstrated through test scores and resident satisfaction. A curriculum of short lectures and interactive workshops was delivered over 6 weeks in August and September 2018. Residents answered a 10-question pretest prior to the curriculum, followed by a post-test immediately after the last session and a delayed post-test 8 months later. Residents also provided summative feedback on the educational sessions. Sixty-six residents were eligible to participate in the curriculum with 44 (67%) completing the pretest, 40 (61%) completing the post-test, and 33 (50%) completing the delayed post-test. The mean score increased significantly from 56 to 68% between the pretest and post-test (p = 0.0018). The delayed post-test mean score remained high at 71% without significant change (p = 0.46). Overall feedback was positive highlighting the interactive nature of lectures and the participation of cardiology fellows. Using an interactive, multimodal educational series, pediatric residents had a significant increase in pediatric cardiology test scores and demonstrated good retention.

Adapting to the algorithm: how accuracy comparisons promote the use of a decision aid

In three experiments, we sought to understand when and why people use an algorithm decision aid. Distinct from recent approaches, we explicitly enumerate the algorithm’s accuracy while also providing summary feedback and training that allowed participants to assess their own skills. Our results highlight that such direct performance comparisons between the algorithm and the individual encourages a strategy of selective reliance on the decision aid; individuals ignored the algorithm when the task was easier and relied on the algorithm when the task was harder. Our systematic investigation of summary feedback, training experience, and strategy hint manipulations shows that further opportunities to learn about the algorithm encourage not only increased reliance on the algorithm but also engagement in experimentation and verification of its recommendations. Together, our findings emphasize the decision-maker’s capacity to learn about the algorithm providing insights for how we can improve the use of decision aids.

Development of Citizen’s Charter to Improve the Service Provision at a Regional Health Services Directorate in Sri Lanka

Introduction: Citizen’s charter is a means to improve service delivery processes and foster greater customer satisfaction. Unacceptable delays in providing services by the Office of Regional Director of Health Services, Kurunegala (RDHSK) and subsequent re-visits had created customer dissatisfaction. A citizen’s charter was developed to improve the service provision at RDHSK. Methods: Ten services being provided to nursing officers by the Establishment Branch (EB) of RDHSKwere prioritized for incorporating in the charter. The services were mapped and redesigned, and deficiencies were dealt with developing and implementing the charter, its sub-components and supplementary interventions. The charter and sub-components were designed and implemented as per the Public Administration circular issued in 2008, adopting the participatory approach. To enhance the effectiveness of charter, several supplementary interventions were designed. A focal point, a steering committee, and monitoring, review and appraisal mechanisms were established. Documents that need access by nursing officers were kept at their workplaces in addition to RDHSK and its website. New developments were effectively communicated to the staff of RDHSK through training and to service recipients through multiple routes. Results: The new developments included the citizen’s charter, its sub-components and supplementary interventions. Sub-components include summary charter and feedback and response system with complaint and feedback formats, feedback box and feedback and response register. The supplementary interventions comprise document submission checklists, compilations of formats to be filled for receiving services with a relevant checklist on the top, guidelines for nursing officers and their work institutions on new developments, and a booklet on work steps for MAs providing services at EB. Conclusion: The participatory approach, stakeholder involvement throughout, wider publicity of charter among service recipients and service providers, effective feedback and response system, and mechanisms for monitoring, evaluation, review and appraisal of the charter are useful means to successfully develop, implement and sustain charters.