System-wide Approaches Research Articles

Unhealthy food outlets and outdoor advertisements in urban South African primary school students' food environments.

Children's exposure to outlets selling, and outdoor advertisements marketing, unhealthy foods is an important risk factor for obesity. Yet few policies address the food retail and/or outdoor advertising environment, and research about children's perceptions is limited, especially in low- and middle-income countries. We used a participatory, multimodal visual/verbal approach to explore urban-dwelling South African primary school students' perceptions of unhealthy food outlets and outdoor advertisements they encountered on their journeys to school. Forty-one grade 7 students aged 11-14 years participated in drawing and/or photography activities and elicitation discussions. A mixed-methods, triangulated analysis involving the content analysis and extraction of data from research artefacts (33 journey to school drawings and 10 food advertisement photo collages) and thematic analysis of discussion transcripts was conducted. Drawings depicted 175 food outlets, two-thirds (64%) of which sold only unhealthy foods and 125 advertisements, most of which marketed unhealthy food. Unbranded, deep-fried foods prepared and sold by informal traders and independent shops were prominent. Informal and independent traders also sold unhealthy branded foods. Advertisements were primarily for unhealthy foods, especially branded, sugar-sweetened beverages. Participants thought extensive advertising bans, regulation of the sale of unhealthy food to children and other measures were needed to promote children's health in urban contexts. The results point to the need for food system-wide approaches that address multiple commercial determinants of health, including 'big food' advertising, unhealthy food sales by informal and independent traders and programs to address socio-economic influences such as poverty, unemployment and parents' poor work conditions.

“It Just Galls Me, as a Taxpayer”: Trust Implications of School Closure Decision-Making in Ontario

More than 400 publicly funded schools in Ontario, Canada, permanently closed between 2011 and 2017. This study examines the impact of highly criticized closure decisions on trust, guided by the OECD competence-values framework for citizens’ trust in public institutions. Interviews with key informants reveal factors affecting trust, including timing and format of public consultations, reliability of data informing closure recommendations, silencing of community concerns, timeliness of government coordination, asset management horizons, and system-wide approaches to planning. This study underscores the need for an alternative school-closure decision-making model for Ontario.

Key requirements for achieving EU-wide programme change

Abstract Issue Across the world, thousands of projects aim for equitable improvement in health for people who are experiencing ongoing avoidable stigma, discrimination and disadvantage however very little change is often achieved. Description of the problem In this presentation we explore key requirements for project-level change to ensure EU-wide programme change is achieved. Results The two most common causes of project failure are a) the innovation is not suitable, needed or wanted (also called theory failure) or b) implementation failure. This presentation shares strategies to mitigate risks of project failure through co-design processes and communication, drawing from 30 years of experience from the entire implementation process from ideation to scale up. These experiences include projects from over 30 countries, including partnerships with the World Health Organization, governments and industry focused on health literacy, self-management, care pathways, workplace health, hospital services redesign, First Nations health and migrant health. Common success factors include balancing top-down needs with co-designed inputs and with previous preferred or good practice (which may have come from controlled trial evidence generated in different contexts). The intervention must co-implemented to serve stakeholder’s needs at all levels, from citizens to decision makers. Lessons The United Nations (UN) and private sector apply system-wide approaches to affect large scale change. This knowledge is valuable for large public health programmes aiming to integrate equity and diversity in project processes to minimize implementation failure.

Addressing Challenges of Postsecondary Disability Service Provision: A System-Wide Approach

Over the past 25 years, substantial legal changes, research advances, and rapidly developing technology have resulted in dramatic changes in the postsecondary disability landscape. As a result, disability service professionals have seen their job duties significantly expand while serving a rapidly increasing and diversifying postsecondary population with disabilities. The current study details the relevant developments of the past 25 years, reviews literature documenting emerging challenges, and provides a case study of the system-wide approach developed by the University System of Georgia to support its disability service professionals during this period of rapid evolution. The services and supports provided by the three independent components (i.e., the Regents Centers for Learning Disorders, the Center for Inclusive Design and Innovation, and the Regents' Administrative Committee on Accessibility and Disability Services) are described. In addition, the authors describe how the components work in a collaborative way to leverage the benefits of a multidisciplinary approach. The authors close by describing how system-wide approaches or aspects of the University System of Georgia approach could be adopted in other states and settings.

Creating a renewable energy-powered energy system: Extreme scenarios and novel solutions for large-scale renewable power integration

The large-scale integration of renewable power sources, such as wind and solar, is pivotal in achieving climate change mitigation goals and reducing dependency on fossil fuels within energy systems. This manuscript explores the integration of substantial wind and solar power capacities into Luxembourg's energy framework, addressing challenges like variability, intermittency, and curtailment. It delves into scenarios that include power-to-heat (P2H) and vertical farming (VF) technologies to improve system flexibility and promote the incorporation of renewable energy. Utilising a mixed-integer linear programming (MILP) algorithm, an energy balance model with hourly resolution optimises the system. This algorithm guides the operation of individual plants, ensuring optimal performance based on a variety of criteria. Notable findings underscore the significant influence of an appropriate mix of renewable power resources, indicating a potential increase in renewable power consumption by up to 50% within the system. Furthermore, curtailment management solutions are shown to enhance renewable power integration by as much as 30%, highlighting the importance of strategic, system-wide approaches. Additionally, vertical farming emerges as a promising avenue for significantly augmenting the utilisation of surplus solar power, potentially by up to 100%. While the integration of large-scale renewable power is demonstrably viable, it necessitates a meticulously crafted strategy that considers technological innovations and strategic planning.

Is There a Problem With Evidence in Health Professions Education?

What constitutes evidence, what value evidence has, and how the needs of knowledge producers and those who consume this knowledge might be better aligned are questions that continue to challenge the health sciences. In health professions education (HPE), debates on these questions have ebbed and flowed with little sense of resolution or progress. In this article, the authors explore whether there is a problem with evidence in HPE using thought experiments anchored in Argyris' learning loops framework.From a single-loop perspective ("How are we doing?"), there may be many problems with evidence in HPE, but little is known about how research evidence is being used in practice and policy. A double-loop perspective ("Could we do better?") suggests expectations of knowledge producers and knowledge consumers might be too high, which suggests more system-wide approaches to evidence-informed practice in HPE are needed. A triple-loop perspective ("Are we asking the right questions?") highlights misalignments between the dynamics of research and decision-making, such that scholarly inquiry may be better approached as a way of advancing broader conversations, rather than contributing to specific decision-making processes.The authors ask knowledge producers and consumers to be more attentive to the translation from knowledge to evidence. They also argue for more systematic tracking and audit of how research knowledge is used as evidence. Given that research does not always have to serve practical purposes or address the problems of a particular program or institution, the relationship between knowledge and evidence should be understood in terms of changing conversations and influencing decisions.

Consensus recommendations for acute trauma care & outcomes in LMICs from the transdisciplinary research, advocacy & implementation network for trauma in India.

Background & objectives Injuries profoundly impact global health, with substantial deaths and disabilities, especially in low- and middle-income countries (LMICs). This paper presents strategic consensus from the Transdisciplinary Research, Advocacy, and Implementation Network for Trauma in India (TRAIN Trauma India) symposium, advocating for enhanced, system-level trauma care to address this challenge. Methods Five working groups conducted separate literature reviews on pre-hospital trauma care, in-hospital trauma resuscitation and training, trauma systems, trauma registries, and India's Towards Improving Trauma Care Outcomes (TITCO) registry. Using a Delphi approach, the TRAIN Trauma India Symposium generated consensus statements and recommendations for interventions to streamline trauma care and reduce preventable trauma mortality in India and LMICs. Experts prioritized interventions based on cost and difficulty. Results An expert panel agreed on four pre-hospital consensus statements, eight hospital resuscitation consensus statements, six system-level consensus statements, and six trauma registry consensus statements. The expert panel recommended six pre-hospital interventions, four hospital resuscitation interventions, nine system-level interventions, and seven trauma registry interventions applicable to the Indian context. Of these, 14 interventions were ranked as low cost/low difficulty, five high cost/low difficulty, five low cost/high difficulty, and three high cost/high difficulty. Interpretation & conclusions This consensus underscores the urgent need for integrated and efficient trauma systems to reduce preventable mortality, emphasizing the importance of comprehensive care that includes community engagement and robust pre-hospital and acute hospital trauma care pathways. It highlights the critical role of inclusive, system-wide approaches, from enhancing pre-hospital care and in-hospital resuscitation to implementing effective trauma registries to improve outcomes and streamline care across contexts.

Experiences with Negative Behavior and Incivility: Perspectives of Unlicensed Assistive Personnel and Registered Nurses.

Healthcare professionals experience negative behaviors such as incivility from various sources within the hospital environment. However, little is known regarding the experience of unlicensed assistive personnel with these behaviors. Using a cross-sectional survey design, the research team aimed to examine the presence, sources, and impact of negative behaviors among registered nurses and unlicensed assistive personnel within a US hospital. Descriptive and inferential statistics were used to analyze quantitative data, while thematic analysis was used to analyze the qualitative responses. A total of 309 participants completed the survey, and 135 participants responded to three qualitative questions. Most respondents identified inadequate staffing/resources to handle workload (87%) and job stress leading to loss of control over behavior as contributing factors to lateral/vertical aggression in the work environment (71%). Impacts of negative behavior on job performance were related to both personal well-being and the work environment. Demoralization was identified as a common consequence of negative behaviors for individuals and within the work environment. The results suggested that registered nurses, unlicensed assistive personnel, and nursing leadership may benefit from system-wide approaches addressing negative behaviors such as incivility within the clinical environment. Specifically, efforts and policies aimed at aiding clinicians in responding to negative behaviors could potentially improve the clinical environment.

Organizational Routines and Theorizing in Large-Scale School Improvement—Exploring a Swedish Design

ABSTRACT In many countries, we can see a movement to more large-scale and system-wide approaches to school improvement. The aim of this article is to study and theorize on conditions for school actors’ knowledge building within such large-scale school improvement reforms. Using a Swedish large-scale school improvement program, “Collaboration for the Best School Possible” (CBSP), as a case and the concepts of organizational routines and theorizing as theoretical lenses, we explore questions linked to school improvement design and conditions for school actors’ knowledge building. Internal policy documents from the Swedish National Agency of Education and interviews with responsible officials constitute the empirical material for the study. The results point to a great variation concerning the degree of standardization and formalization of the CBSP design. This implies that some parts of the CBSP process are to a large degree conditional on individuals’ competences, experiences, and attitudes. An important conclusion from the study is that an efficient large-scale school improvement design should contain organizational routines that can reinforce the interplay between the different levels of the school systems, but also create conditions for integrating research to nurture different types of theorizing. Such design will generate conditions for professional knowledge building and educational change.

Building Capacity and Advancing Regulatory Measures to Improve Food Environments in the Region of the Americas.

Noncommunicable diseases (NCDs) are the main cause of death globally (70%) and in the Region of the Americas (80%), and poor diets are a leading driver of NCDs. In response, the Pan American Health Organization (PAHO)/World Health Organization (WHO) introduced a set of evidence-based regulatory measures to help countries improve diets through the reduced consumption of processed and ultra-processed foods. This paper aims to describe the needs of and propose actions for key actors to advance these measures. A workshop was designed to assess member states' regulatory capacity. A thematic analysis was conducted to analyze regional needs, successes and challenges. Thereafter, the Government Capacity-Building Framework for the prevention and control of NCDs was used to examine findings. The findings were organized in two sets: (i) PAHO/WHO actions to support member states and (ii) key actors' actions to advance regulatory policies. The results show notable regulatory progress across the Region of the Americas. However, progress differs between countries, with opportunities to strengthen measures in most countries, mainly in conflict of interest management. The results identified important actions to strengthen the regulatory capacity of PAHO/WHO member states. To maximize momentum for these actions, timelines must be identified, and political commitment can be boosted by applying human rights-based and food system-wide approaches.

Representations of obesity in Australian and UK news coverage: A diachronic comparison

In both Australia and the UK, the number of adults living with obesity has been increasing over the last 30 years (AIHW, 2023; Baker, 2023). Although policy has emphasised ‘community-based interventions’ in Australia (AIHW, 2017) and ‘system-wide approaches’ in the UK (Ulijaszek and McLennan, 2016) for overcoming the challenges of obesity, previous research has shown that media representations have been dominated by representations promoting individual responsibility (e.g., Kim & Willis, 2007). In this paper, we report our observations of representations documented in corpora of media coverage from Australia and the UK between 2008-2017. The corpora amount to 16.4 million tokens and 36 million tokens, respectively. We identify key semantic domains for each year of the corpora and discuss both consistent and shifting themes in the data. Our findings show that the Australian coverage provides a more sustained focus on responses to obesity at the societal level, referring to practices in the food industry and differences between communities that can lead to health disparities. By comparison, while there is an increase in the amount of coverage in the UK press referring to obesity, the content became more narrowly focussed on food consumption and weight loss over the study period. The findings demonstrate how media coverage contributes to public understanding of how to respond to the challenges of obesity.

ВИДы ОЦЕНИВАНИЯ ДЕЯТЕЛьНОСТИ ПРЕПОДАВАТЕЛЕЙ ВыСШЕГО ОБРАЗОВАНИЯ (НА ПРИМЕРЕ США И ВЕЛИКОБРИТАНИИ)

Evaluation of the activities of higher education teachers is an important component of the education system in many countries, including the US and the UK. While maintaining differences in system-wide approaches, teacher assessment in the US and the UK has similar goals based on ensuring the quality of teaching and stimulating professional growth. We found that in countries such as the US and the UK, different assessment approaches are used, such as student assessment of teachers, class analysis, their scientific contribution, administrative work assessment, but more detailed analysis of teachers’ performance is often practiced. In the USA, for example, teachers are given separate goals and objectives, expected results from them, and even contracts are signed. Teachers are also evaluated using special algorithms that take into account both quantitative and qualitative parameters. In the UK, in addition to the above methods, you can add an assessment of services and services, an assessment of his international experience. The findings allow us to talk about a multifaceted, complex, not always objective assessment of the activities of university teachers in the countries under consideration, which still requires modernization for more efficient use.

Training and Educational Pathways for Clinicians (Post-graduation) for the Assessment and Diagnosis of Autism Spectrum Disorders: A Scoping Review.

This review aimed to identify the post-graduation training pathways available for both clinicians and trainers in the assessment and diagnosis of Autism Spectrum Disorder (ASD). The study was guided by two research questions: What is known about ASD-specific educational, training, or other pathways available to support clinicians of any discipline, post-graduation, to meet the required expertise relevant to assessments of ASD concerns? What is known about the educational pathways available to clinicians seeking to provide training to other clinicians, post-graduation, in the assessment of ASD concerns? A scoping review was undertaken with searches completed across five databases (PubMed, PsycINFO, PsycEXTRA, ERIC and CINAHL). A Google search strategy was also executed using the "advanced" search function. Eligible records were literature, written in English, that examined post-graduation training and/ or education of clinicians to assess and/ or diagnose ASD.Fourteen relevant records were identified. Post-graduate training has the potential to enhance clinician confidence and service provision in ASD assessment and diagnosis. System-wide training approaches show promise in building large-scale, diagnostic capacity and the use of tele-mentoring offers a cost-effective, convenient mode of training delivery. A lack of evidence to support ASD diagnostic training pathways was found and may pose a challenge for clinicians and service users.The limited evidence found suggests that high quality research will be fundamental in determining how to build clinician capacity in ASD assessment and diagnosis and to ascertain whether training pathways are a necessary component.

Evaluation of the implementation of advanced practice nursing roles in France: A multiple case study.

The aims of the study were to describe the processes used to introduce advanced practice nursing roles and factors that facilitated or hindered role implementation, examine the time advanced practice nurses (APNs) spend in role activities and how these activities relate to domains of advanced practice nursing and examine how implementation processes influenced APN integration within healthcare teams. A multiple case study was conducted. Five cases were included, representing the four population areas approved for advanced practice nursing in France. Data were collected from January to March 2021 using observation, interview and document analysis methods. Data were examined using thematic analysis. Participants included APNs (n = 5), nurses/allied health providers (n = 5), physicians (n = 5), managers (n = 4) and decision-makers (n = 4). Stakeholder engagement and leadership provided by decision-makers, managers, physicians and APNs facilitated role implementation. Poor stakeholder role understanding, uncertain role funding, and the COVID-19 pandemic hindered role implementation. APNs spent the most time in clinical activities. Participants perceived the integration of APNs within the healthcare team and their impact on patient care to be positive. Stakeholder engagement and organizational and APN leadership facilitated the implementation of the roles, especially related to team-based patient care. Further efforts are needed to strengthen APN involvement in non-clinical activities and address role barriers. Systematic and system-wide approaches are needed to improve role clarity, role autonomy and health systems integration of APNs. Research should examine patient perspectives about APNs in France. The results highlight how policies can create favourable conditions for advanced practice nursing role implementation in France. Internationally, this study serves as a reminder to APNs and nurse leaders about the strategies for and importance of implementation evaluation to support the optimal development of advanced practice nursing roles. The study reporting followed the Consolidated Criteria for Reporting Qualitative Research. No Patient or Public Contribution.

The RNA-binding protein landscapes differ between mammalian organs and cultured cells

System-wide approaches have unveiled an unexpected breadth of the RNA-bound proteomes of cultured cells. Corresponding information regarding RNA-binding proteins (RBPs) of mammalian organs is still missing, largely due to technical challenges. Here, we describe ex vivo enhanced RNA interactome capture (eRIC) to characterize the RNA-bound proteomes of three different mouse organs. The resulting organ atlases encompass more than 1300 RBPs active in brain, kidney or liver. Nearly a quarter (291) of these had formerly not been identified in cultured cells, with more than 100 being metabolic enzymes. Remarkably, RBP activity differs between organs independent of RBP abundance, suggesting organ-specific levels of control. Similarly, we identify systematic differences in RNA binding between animal organs and cultured cells. The pervasive RNA binding of enzymes of intermediary metabolism in organs points to tightly knit connections between gene expression and metabolism, and displays a particular enrichment for enzymes that use nucleotide cofactors. We describe a generically applicable refinement of the eRIC technology and provide an instructive resource of RBPs active in intact mammalian organs, including the brain.

Approaches to improving patient safety in integrated care: a scoping review

ObjectivesThis scoping review aimed to establish the approaches employed to improving patient safety in integrated care for community-dwelling adults with long-term conditions.DesignScoping review.SettingAll care settings.Search strategySystematic searches of seven academic...

Trends and Rural-Urban Differences in the Initial Prescription of Low-Value Inhaled Corticosteroids among U.S. Veterans with Chronic Obstructive Pulmonary Disease.

Rationale: Guidelines recommend inhaled corticosteroids (ICS) for patients with chronic obstructive pulmonary disease (COPD) and select indications, including asthma history, high exacerbation risk, or high serum eosinophils. ICS are commonly prescribed outside of these indications, despite evidence of harm. We defined a "low-value" ICS prescription as the receipt of an ICS without evidence of a guideline-recommended indication. ICS prescription patterns are not well characterized and could inform health system interventions to reduce low-value practices. Objectives: To evaluate the national trends in initial low-value ICS prescriptions in the U.S. Department of Veterans Affairs and to determine whether rural-urban differences in low-value ICS prescribing exist. Methods: We performed a cross-sectional study between January 4, 2010, and December 31, 2018, identifying veterans with COPD who were new users of inhaler therapy. We defined low-value ICS as prescriptions in patients with 1) no asthma, 2) low risk of future exacerbation (Global Initiative for Chronic Obstructive Lung Disease group A or B), and 3) serum eosinophils <300 cells/μl. We performed multivariable logistic regression to evaluate trends in low-value ICS prescription over time, adjusting for potential confounders. We performed fixed effects logistic regression to assess rural-urban prescribing patterns. Results: We identified a total of 131,009 veterans with COPD starting inhaler therapy, 57,472 (44%) of whom were prescribed low-value ICS as initial therapy. From 2010 to 2018, the probability of receiving low-value ICS as initial therapy increased by 0.42 percentage points per year (95% confidence interval, 0.31-0.53). Compared with urban residence, rural residence was associated with a 2.5-percentage-point (95% confidence interval, 1.9-3.1) higher probability of receiving low-value ICS as initial therapy. Conclusions: The prescription of low-value ICS as initial therapy is common and increasing slightly over time for both rural and urban veterans. Given the widespread and persistent nature of low-value ICS prescribing, health system leaders should consider system-wide approaches to address this low-value prescribing practice.

Addressing the end-of-life actions in the National Safety and Quality Health Service Standards (2nd edn): a national survey.

Objectives To describe current and planned processes and outcome measures to address implementation of the six end-of-life actions in the National Safety and Quality Health Service (NSQHS) Standards (2nd edn) and explore associated barriers and enablers. Methods This study used an exploratory mixed methods national survey of acute healthcare facilities between September 2018 and March 2019. This study involved public and private facilities (N = 765) that provided end-of-life care, which are required to be accredited to the NSQHS Standards. Participants include those responsible for reporting implementation of end-of-life care actions at a facility providing end-of-life care. Participants were asked what processes and outcome measures were implemented or being planned to address the end-of-life care actions, and the associated barriers and enablers. Results Fifty respondents (6.5% response rate) from across Australia contributed data, reporting greater confidence in addressing Actions 5.16: Clinicians have access to Specialist Palliative Care Services; 5.17: Advance care plans can be received from patients and stored in medical records; and 5.18: Supervision and support is available for workforce providing end-of-life care. Barriers associated with the actions that were the most challenging to address included: competing clinical priorities, and insufficient resources to provide best practice end-of-life care; and the burdensome nature of conducting audits. Enablers included: (1) local, jurisdictional, and national strategic plans and policies; (2) support from Specialist Palliative Care Services; (3) access to resources and data; (4) standardised approaches to implementation and measuring outcomes; and (5) clinician, consumer and community engagement and education on end-of-life care. Conclusion Enablers and barriers in implementing the six end-of-life care actions were identified. Respondents reported that high-level support and direction, system-wide approaches, practical clinical support, and widespread community and clinician engagement would enable their facility to better address the end-of-life actions.

An audit of high oral broad-spectrum antibiotic prescribing within a Bristol-based general practice

Abstract Introduction Oral broad-spectrum antibiotics (OBSAs), defined here as cephalosporins, fluoroquinolones and co-amoxiclav, are associated with AMR and adverse events in the elderly (ie. over 60s). Despite stringent national and local system-wide approaches aimed at reducing their inappropriate prescribing, the regional care commissioning group (CCG) alerted that OBSA prescribing within this practice between February and August 2021 at up to 14% of antibiotics prescriptions, has exceeded both the national and CCG limit which is 10%.1,2 This necessitates minimising OBSA prescribing among the over 60s in this practice. Aim To identify the percentage of inappropriate prescribing of OBSAs at Downend Health Group and investigate factors leading to their high prescribing rates using the following standard: 0% of OBSAs were prescribed inappropriately within a 7-month period, which includes prescribing outside of regional guidance without specialist input or evidence of infection. Methods The study design, data collection and analysis were conducted by the foundation trainee, supervised by the lead pharmacist. A retrospective population reporting search was run on our prescribing system (EMIS) to identify active patients over 60 years prescribed OBSAs between February and August 2021. To produce our IT data collection tool, the inclusion criteria were ages over 60 years, name of antibiotic, location of consultation, authorising user and prescribing indication. The search was piloted with 235 patients and narrowed down to 208 patients by adding acute (ie. one-off) prescription type as another inclusion criteria. Inactive and deceased patients at the time of the search were excluded. Data from the search was then compared against the regional guidance and further analysed. Ethics approval was not required for this audit. Results The results did not meet the set standard. Out of 208 active patients over 60 years prescribed OBSAs on acute during the defined period, 107 (51%) prescriptions were inappropriate. 63 (30%) prescriptions had the wrong antibiotic choice whereas 44 (21%) prescriptions had no evidence of infection. The top conditions with inappropriate OBSA prescriptions include UTI (22%), diverticulitis without pyrexia (15%) and cellulitis (11%). Furthermore, remote consultations had higher inappropriate prescribing as the error bar comparison between face-to-face vs remote consultations on influencing inappropriate OBSA prescribing showed statistical significance (p &amp;lt; 0.05). Although GPs authorised 188 (90%) of OBSA prescriptions, 15 out of the 20 (75%) OBSA prescriptions authorised by non-GPs were inappropriate. Despite the similar rates of appropriate (51%) and inappropriate (49%) OBSA prescribing among the GPs, four GPs had disproportionately high inappropriate OBSA prescribing. Discussion/Conclusion Further to excluding deceased patients from the sample size, another limitation is the lack of investigations to rule out the confounding variables of researcher bias and the potential influence of lockdowns in the high levels of remote consultations. Regardless, the results suggest that the practice can meet the national and CCG OBSA prescribing limit by reducing inappropriate OBSA prescribing from 51% to 0%. Following an internal clinical governance meeting with the authorising users, we will update relevant internal EMIS alerts and antimicrobial stewardship protocols, followed by a reaudit 7-months after implementing the updates.

On Inconsistency of the Overidentification Test for the Model-implied Instrumental Variable Approach

In the context of structural equation modeling, the model-implied instrumental variable (MIIV) approach has been shown to be more robust against model misspecification than the systemwide approaches (e.g., maximum likelihood and least squares). Besides the goodness-of-fit tests that test the fit of the entire hypothesized covariance structure, the overidentification tests for MIIV can be used to test model specification on an equation-by-equation basis. However, it is known in the econometrics literature that the overidentification tests are inconsistent against general misspecification, if it is used to test a zero correlation between the instrumental variables and the error terms. In this paper, we show that such inconsistency can also occur for the MIIV approach. Numerical examples where the powers of the tests converge to the size are presented. Theoretical results are proved to support the numerical findings. Implications on when the overidentification tests are consistent are also presented.