BMJ Open Quality最新文献

{"title":"Implementing discharge summary documentation: a quality improvement initiative in a Nigerian hospital.","authors":"Henry Omon, Oluwafemi Funso Owagbemi, Chinedu Ndegbu, Abdulhafiz Adesunkanmi, Simon Balogun, Temitope Ajekwu, Christopher Anele, Olalekan Olasehinde, Adewale Adisa, Edward O Komolafe","doi":"10.1136/bmjoq-2025-003762","DOIUrl":"10.1136/bmjoq-2025-003762","url":null,"abstract":"<p><p>Discharge summaries (DS) are essential for ensuring safe and effective transitions from inpatient to outpatient care, yet completion rates are often suboptimal in low-resource settings. This quality improvement project (QIP) was undertaken in the General Surgery and Neurosurgery units of the Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Nigeria, to increase DS completion to at least 50% within 12 weeks. Using the Plan-Do-Study-Act (PDSA) model, baseline performance was established via a 3-month retrospective audit, revealing DS completion rates of 0% (0/56) in General Surgery and 33% (7/21) in Neurosurgery, with an overall rate of 9% (7/77). A survey of surgical trainees and house officers identified poor knowledge of DS practice and the absence of a standardised template as key barriers.Interventions included DS training at induction, dissemination of prestructured templates, deployment of visual management tools and appointment of unit-based DS champions. Change ideas were tested in 1-week to 2-week PDSA cycles with continuous monitoring of process and outcome measures. Data were analysed using IBM SPSS Statistics V.25, and significance was assessed via χ² testing.Following implementation, DS completion rates improved to 82% (68/83), consistently surpassing the target and reaching 100% during some cycles (χ²=85.35, p<0.0001). Median daily discharges were 2.0 in General Surgery and 1.5 in Neurosurgery, with median completion rates of 93.4% and 100%, respectively. These improvements reflected the effectiveness of targeted training, standardised documentation and role designation in addressing systemic and behavioural barriers.This QIP demonstrates that structured, context-appropriate interventions can substantially and sustainably increase DS completion rates in resource-limited settings, thereby strengthening continuity of care. Future directions include scaling these strategies to other departments, integrating electronic DS systems and embedding routine audits to sustain compliance.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"15 3","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-08-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13504876/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148788044","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of scenario-based simulation on students' learning outcomes and satisfaction in perioperative anaphylaxis: a pilot randomised controlled trial.","authors":"Xiuli Yang, Hui Jiang, Huan Wang, Lixia Wang, Lijian Chen","doi":"10.1136/bmjoq-2025-003713","DOIUrl":"10.1136/bmjoq-2025-003713","url":null,"abstract":"<p><strong>Background: </strong>Perioperative anaphylaxis is a rare but complex clinical crisis, with outcomes heavily dependent on prompt and effective management by anaesthesiologists. However, evidence supporting the efficacy of scenario-based simulation (SBS) training in perioperative anaphylaxis management remains limited. This study aimed to evaluate the impact of SBS versus video-based training (VBT) on learning outcomes and satisfaction among undergraduate anaesthesia students.</p><p><strong>Methods: </strong>In this prospective randomised study, 84 fourth-year anaesthesia undergraduate students from Anhui Medical University were assigned to either SBS or VBT for perioperative anaphylaxis education. Knowledge assessments were conducted before (pretest) and after (post-test) training. Outcomes included post-test scores, student satisfaction (assessed via a 5-point Likert scale) and performance in a simulated clinical scenario 1 week later. Scenario performance was evaluated using a technical checklist and the Anesthesiologists' Non-Technical Skills scoring system.</p><p><strong>Results: </strong>Baseline characteristics (age, sex and pretest scores) were comparable between groups. The post-test scores were higher in the SBS group than those of the VBT group (80.0 (73.7<b>-</b>85.0) vs 70.0 (65.0<b>-</b>75.0), respectively, p<0.001). Both groups improved in post-test scores after training. The SBS group's post-test score increased significantly more than that of the VBT group (39.2% (30.7%<b>-</b>44.6%) vs 16.6% (8.3%<b>-</b>20.0%), respectively, p<0.001). In the simulation scenario test, the SBS group outperformed the VBT group in both technical (33.5 (31.0-36.0) vs 28.0 (26.0-30.0), p<0.001) and non-technical skills (47.5 (44.0-51.0) vs 43.0 (42.0-48.0), p=0.002).</p><p><strong>Conclusions: </strong>SBS demonstrates greater efficacy than VBT in improving anaesthesia students' learning outcomes, including technical and non-technical skills in managing perioperative anaphylaxis, with higher student satisfaction.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"15 3","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-08-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13479509/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148757275","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implementing a RPM-enabled transitional care pathway for adults with poorly controlled diabetes: a quality improvement initiative.","authors":"Michelle Elsener, Cigi Mathew, Farrukh N Jafri","doi":"10.1136/bmjoq-2025-004134","DOIUrl":"10.1136/bmjoq-2025-004134","url":null,"abstract":"<p><strong>Background: </strong>Adults discharged from the hospital with poorly controlled diabetes face elevated readmission risk, yet health systems lack practical models for integrating remote glucose monitoring into post-discharge care. Existing approaches often exclude patients at the highest risk who have limited English proficiency, adverse social determinants of health or limited smartphone access.</p><p><strong>Local problem: </strong>At a 292-bed community hospital in White Plains New York, patients discharged with haemoglobin A1c ≥8% showed higher rates of hospital utilisation. Local mortality data revealed disparities affecting Black/African American and Hispanic/Latino residents, prompting a programme design with equity as a core objective.</p><p><strong>Methods: </strong>We integrated remote patient monitoring (RPM) into our nurse-led transitional care programme through five Plan-Do-Study-Act (PDSA) cycles from April 2024- to January 2025. Patients received RPM services and care coordination for 90 days. Enrolment, appointment attendance, A1c completion and demographic representation were evaluated through each cycle.</p><p><strong>Results: </strong>Among 442 screened patients, 46 were enrolled (enrolment grew from 10.5% to 39.7%, p<0.001). Enrolled patients closely matched the eligible population across targeted demographic groups. Follow-up appointment attendance reached 78.3% for primary care and 69.6% for endocrinology. A1c testing completion improved to 48% in the final cycle. The most substantial gains in feasibility occurred after redistributing monitoring to a team-based model.</p><p><strong>Conclusions: </strong>Iterative PDSA cycles enabled the development of an equitable RPM-enabled transitional care pathway for diabetes, achieving proportional enrolment across all targeted demographic groups. Key implementation insights included workforce capacity as the primary constraint to enrolment, workflow simplification through continuous glucose monitoring standardisation and the importance of pre-arranged ambulatory follow-up. Health systems implementing RPM for transitional care should prioritise adequate monitoring workforce, streamline device protocols and coordinate ambulatory integration from programme inception to enable scalable, equitable implementation.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"15 3","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13475455/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148720770","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Reducing postoperative length of stay in low-risk caesarean section: a system-level quality improvement initiative.","authors":"Wenqian Grace Su, Rachel Phoy Cheng Chun, Hong Chan, Xin Ni Chua, Bi Wei Cai, Katherine Concepcion Tesalona, Hui He, Yih Yann Tay, Tze Tein Yong, Devendra Kanagalingam, Liying Yang, Xiaohong Joella Ang, Wan Yu Yvonne Wong, Yingke He, Jia Xuan Yeo, Jia Hao Alvin Ngeow, Hairil Rizal Abdullah, Jason Shau Khng Lim","doi":"10.1136/bmjoq-2026-004151","DOIUrl":"10.1136/bmjoq-2026-004151","url":null,"abstract":"<p><p>A structured, system-level quality improvement (QI) initiative at Singapore General Hospital was undertaken to reduce postoperative length of stay (LOS) after uncomplicated lower segment caesarean section (LSCS) and improve performance on the national Value-Driven Care clinical quality index. This project specifically targeted an increase in postoperative day 3 (POD3) discharge rates towards the 88% internal benchmark without compromising safety or increasing readmissions.Uncomplicated LSCS cases between October 2023 and September 2025 were included, with complicated caesarean sections and severe neonatal morbidity excluded. A single-centre pre-post design was used, with October 2023-September 2024 as the baseline period and October 2024-September 2025 as the intervention period. Root causes of delayed discharge were identified using a fishbone (Ishikawa) analysis, informing a three-phase, system-level intervention: department-wide performance sharing, a bundled intervention (standardised patient education, multidisciplinary discharge coordination via Microsoft Teams and coding support) and clinician-specific feedback.Baseline POD3 discharge performance was 80.0% (n=352) after correction of coding inaccuracies. Following phased implementation, the postoperative LOS ≤3 days rate increased to 84.5% (n=241) overall, with a more marked improvement from 83.3% to 92.5% after introduction of the bundled system-level intervention. Run charts showed an upward shift and reduced monthly variation in POD3 discharge rates, indicating more consistent practice. There was no clinically significant increase in 30-day readmissions, emergency attendances or postoperative complications, and a simple cost analysis estimated savings of SGD 70 884 from reduced LOS.This multidisciplinary, enhanced recovery after surgery-aligned QI project successfully shortened postoperative LOS for uncomplicated LSCS without evidence of harm. Core components-clear discharge expectations, coordinated mother-baby discharge planning, accurate coding and non-punitive clinician feedback-are conceptually transferable to similar obstetric units seeking to optimise postcaesarean LOS within value-based care frameworks.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"15 3","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13475075/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148721049","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient experience and stroke care quality: a quality improvement initiative in Northeastern Ontario.","authors":"Venkadesan Rajendran, Susan Bursey, Chantal Liddard, Lisa Zeman, Ravinder-Jeet Singh","doi":"10.1136/bmjoq-2025-003751","DOIUrl":"10.1136/bmjoq-2025-003751","url":null,"abstract":"<p><strong>Background: </strong>Patient-reported experience measures (PREM) are key indicators of healthcare quality linked to improved outcomes. The Canadian Stroke Best Practice Recommendations emphasise the importance of capturing patient perceptions of health services to enhance clinical outcomes in stroke care. Building on our previously established stroke-specific PREM, this quality improvement (QI) observational project aimed to gather stroke patient experience data to identify strengths and opportunities for improvement.</p><p><strong>Methods: </strong>This QI initiative was implemented in an acute stroke unit as part of the mobile transient ischaemic attack (TIA) and stroke with adaptive workflow project funded by Ontario's Ministry of Health. An interdisciplinary team of healthcare professionals and leadership members developed a survey focusing on patient journey themes. The survey was reviewed for readability and comprehension by two patients to ensure its appropriateness and relevance. The Institute for Healthcare Improvement model guided the initiative, with a project lead identifying eligible patients and a reactivation worker administering the surveys.</p><p><strong>Results: </strong>A total of 110 patients with stroke or TIA completed the survey over a 12-month observational period. Positive experience rates ranged from 90.0% to 99.1% across all seven domains, and no respondent selected disagree or strongly disagree on any item. Discharge readiness was the lowest-rated domain (90%), whereas a coordinated transition to the stroke unit achieved the highest ratings (99.1%). Inductive thematic analysis of open-ended responses identified three themes: (1) overall satisfaction, gratitude and quality of care; (2) patient-centred communication and emotional support and (3) isolated concerns.</p><p><strong>Conclusion: </strong>This QI initiative, building on previous work, showed positive patient experiences across all seven domains, with discharge readiness as a priority for improvement. The mixed-methods approach, which integrates quantitative Likert data with thematic analysis, offers a replicable model for patient-centred quality monitoring of stroke care.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"15 3","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13475454/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148720104","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Development of a checklist to support management of older patients with <i>Clostridioides difficile</i> infection.","authors":"Tone Rubak, Simon M Dahl Baunwall, Sara E Paaske, Marianne Ørum, Rikke Kongensgaard, Troels Kjærskov Hansen, Merete Gregersen, Christian L Hvas","doi":"10.1136/bmjoq-2026-004174","DOIUrl":"10.1136/bmjoq-2026-004174","url":null,"abstract":"<p><strong>Background: </strong>Older patients with <i>Clostridioides difficile</i> infection (CDI) are often frail and multimorbid, with reported 90-day mortality rates of 28%-36%. Despite this, treatment often fails to align with infection severity, and care coordination remains complex. This study describes the development and iterative refinement of a clinical checklist to support structured treatment and care planning in this high-risk group.</p><p><strong>Methods: </strong>We conducted a two-phase model development study to identify key management factors. Checklist development followed an iterative quality improvement framework using Plan-Do-Study-Act cycles and driver diagrams. In phase I, older patients with CDI were followed to identify key treatment and care priorities, informing the initial checklist version. In phase II, the checklist was used in a pragmatic, randomised trial investigating Comprehensive Geriatric Assessment (CGA) in older patients with CDI. The checklist was iteratively revised based on clinical use and feedback.</p><p><strong>Results: </strong>In phase I, treatment courses of 10 older patients with CDI were reviewed, identifying three key priorities for the initial checklist: (1) CDI treatment planning with frailty assessment, (2) medication review and (3) attention to rehydration and nutrition. In phase II, the CDI checklist was applied in 108 patients allocated to CGA. Standardised treatment planning was ensured, including assessment of faecal microbiota transplantation (FMT) eligibility. Among those treated with non-CDI related antibiotics or proton-pump inhibitors, 52% (26/50) and 70% (39/56), respectively, had treatment discontinued. Nutritional and rehydration support was provided in 64 (59%) and 61 (56%) patients. The CDI checklist was subsequently expanded based on clinical use to include new elements, such as post-FMT laxative treatment and cross-specialty coordination.</p><p><strong>Conclusion: </strong>A clinical checklist can support structured and holistic care planning in older adults with CDI. Core components include CDI treatment planning, assessment of FMT eligibility, frailty evaluation, medication review and supportive therapies such as nutrition and rehydration.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"15 3","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13475560/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148723936","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"System-level barriers to breast cancer screening completion in community-based navigation: lessons from a quality improvement initiative.","authors":"Lisa Carter-Bawa, Miriam Lucca-Susana, Ebony Orr, Subha Jamal, Elan N Shoulders","doi":"10.1136/bmjoq-2026-004170","DOIUrl":"10.1136/bmjoq-2026-004170","url":null,"abstract":"<p><strong>Background: </strong>Black and Latina women experience persistent breast cancer screening disparities. Patient navigation has demonstrated effectiveness in clinic-based populations, but evidence regarding navigation for women engaged through community outreach remains limited.</p><p><strong>Local problem: </strong>In Northern New Jersey, late-stage breast cancer diagnosis rates among black women range from 38% to 44% compared with 27% among all women. Our institution lacked a systematic community-based outreach-to-screening navigation pathway.</p><p><strong>Methods: </strong>This quality improvement initiative, conducted from December 2023 through December 2025 within a large integrated health system, leveraged existing Community Outreach and Engagement infrastructure across 230 community events, tracking a navigation process cascade from engagement through screening completion. Eligibility: women aged 40+ years without a mammogram in the past 12 months (United States Preventive Services Task Force/American Cancer Society).</p><p><strong>Interventions: </strong>The programme included community outreach, eligibility screening, navigation enrolment, navigator follow-up (4-6 contact attempts over 4-6 weeks), scheduling support and social needs screening.</p><p><strong>Results: </strong>The programme engaged 1318 women; among 277 with demographic data, 80.9% identified as black or Latina and 78.8% were uninsured. Of 564 screened for eligibility, 333 (59.0%) enrolled in navigation. Contact success was 73% (210/288 with documented contact attempts in 2024). A critical gap emerged at scheduling: only 5 women (1.5% of enrolled) had mammography scheduled. Post-hoc analysis revealed navigators lacked operational authority to schedule appointments directly. Among 400 women completing social needs screening, 96.0% reported food insecurity.</p><p><strong>Conclusions: </strong>This initiative identified an immediately actionable infrastructure gap: navigators lacked direct scheduling authority, appearing to be a critical barrier to translating engagement into completed care. The 96% food insecurity prevalence characterises a population facing compounding structural barriers, suggesting self-scheduling may be a structurally inequitable expectation. We propose that direct scheduling authority is a potentially necessary condition for effective community-based navigation-a hypothesis warranting prospective testing.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"15 3","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13475140/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148721100","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Development of the UK Severe Asthma Registry as a performance-monitoring quality improvement platform.","authors":"Paul E Pfeffer, Thomas Brown, Adriana Kramer Fiala Machado, Mitesh Patel, Sherif Gonem, Pujan H Patel, Elfaith Idris, Dinesh Shrikrishna, Kathryn Prior, Adel H Mansur, Hassan Burhan, Rekha Chaudhuri, Robin Gore, Alexandra M Nanzer, Shamsa Naveed, Ian J Clifton, Thomas Pantin, Shoaib Faruqi, Rahul Shrimanker, Martin Doherty, David J Jackson, Simon Doe, Simon Message, Charlene Redmond, John Busby, Liam G Heaney, Hitasha Rupani","doi":"10.1136/bmjoq-2025-004112","DOIUrl":"https://doi.org/10.1136/bmjoq-2025-004112","url":null,"abstract":"<p><p>The UK Severe Asthma Registry (UKSAR) was established to facilitate research and quality improvement including performance monitoring across UK severe asthma centres. We here describe its development and refinement for the latter of those objectives. The selection of performance outcome measures for severe asthma clinical outcomes from clinician and patient perspectives, data collection and assessment of clinical variation across severe asthma centres is described. We report on the aim of UKSAR to assess for unwarranted clinical variation in those clinical outcomes between severe asthma centres and discuss the utility of UKSAR and associated registry meetings in addressing clinical variation and providing optimal severe asthma care. After stakeholder consultation, outcomes measures relating to exacerbations, oral corticosteroid exposure, asthma control and quality of life were selected with appropriate case-mix adjustment to help identify unexplained clinical variation. The registry data fields were then modified to collect the required data. Twice-yearly meetings of the registry steering committee were held to discuss data quality. Over 2018-2025 the number of participating centres increased from 17 to 42. To date, baseline data have been entered for 18 473 patients, with data meeting the agreed quality threshold for 12 792 patients. Analysis of variation in outcomes between centres, after case-mix adjustment and allowing for effect of centre size, shows relatively few examples of significant variation in outcomes between centres. Best-practice case studies from high-performing centres are presented. Twice-yearly discussion at registry meetings, attended by representatives from each severe asthma centre, of outcome measures and related research, together with sharing of best practice may explain the relatively low variation in clinical outcomes between centres. However, a limitation of UKSAR is that it cannot evaluate the presence and clinical impact of 'hidden' severe asthma not known to specialist services.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"15 3","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148688549","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Designing the work week in healthcare: a systems agenda for safer, sustainable work.","authors":"Dale F Whelehan, Paul F Ridgway","doi":"10.1136/bmjoq-2026-004272","DOIUrl":"10.1136/bmjoq-2026-004272","url":null,"abstract":"<p><strong>Background: </strong>Healthcare systems internationally face persistent workforce shortages, rising burnout and increasing concerns regarding patient safety. While these challenges are often addressed through staffing, resilience or wellbeing initiatives, less attention has been paid to the temporal architecture through which healthcare work is organised. This paper argues that fatigue represents a systems-level signal of maladaptive temporal design rather than an inevitable consequence of clinical work and proposes temporal governance as a novel framework for redesigning healthcare work.</p><p><strong>Methods: </strong>An integrative review was undertaken combining evidence from empirical studies, policy evaluations, organisational pilots and systems theory. International working-time reduction initiatives published between 2015 and 2025 were identified through targeted searches of academic databases, government reports and grey literature. Cases were analysed comparatively to identify recurring mechanisms linking temporal redesign with workforce and organisational outcomes.</p><p><strong>Results: </strong>Across heterogeneous international settings, reductions in working time were consistently associated with improvements in workforce wellbeing, lower burnout, reduced sickness absence, improved retention and preservation or enhancement of organisational performance. Four convergent mechanisms emerged across studies: physiological recovery, cognitive clarity, temporal autonomy and organisational focus. These mechanisms provide a plausible systems-level explanation for how redesigning working time can simultaneously improve human sustainability and organisational effectiveness. Drawing upon complexity science, the paper proposes a mechanism-based theory of change in which temporal redesign stabilises reinforcing fatigue loops and strengthens adaptive capacity within healthcare systems.</p><p><strong>Conclusions: </strong>Fatigue should be understood not solely as an occupational health issue but as an indicator of systemic temporal imbalance. Working-time redesign offers a promising governance intervention capable of improving workforce sustainability while maintaining organisational performance. Rather than framing shorter working hours as a workforce benefit alone, healthcare organisations should recognise time as critical infrastructure that can be intentionally designed, governed and evaluated as a core patient safety variable. Future research should determine the optimal temporal architectures for different healthcare contexts and establish time as a measurable dimension of healthcare quality and safety.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"15 3","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13448586/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148677078","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Quality improvement in emergency units in low resource settings: a qualitative assessment for understanding challenges and delivering solutions.","authors":"Indrakantha Welgama, Daniel Lange, Gerard O'Reilly, Aurore Nishimwe, Agnieszka Ignatowicz, Justine Davies","doi":"10.1136/bmjoq-2026-004186","DOIUrl":"10.1136/bmjoq-2026-004186","url":null,"abstract":"<p><strong>Objective: </strong>This study aimed to identify the barriers and facilitators for quality improvement (QI) in emergency units (EUs) in low- or middle-income countries (LMICs) and to understand the prioritisation of care quality domains to inform the development of EU-specific guidance for QI across all World Health Organisation (WHO quality domains for LMICs.</p><p><strong>Methods: </strong>We conducted in-depth interviews (IDIs) with specialist emergency physicians from LMICs and convened a workshop with global technical experts in emergency care. A structured topic guide was used for the IDIs. Interviews were conducted virtually, transcribed and thematically analysed using the WHO quality domains and the WHO Health Systems Framework. Data collection and analysis continued until saturation was reached. The 2-day workshop included presentations, discussions and interactive ranking exercises to assess measurements for QI and prioritise WHO quality domains for guidance development. Findings from both components were synthesised to generate key insights.</p><p><strong>Findings: </strong>Eleven IDIs were conducted and 26 experts participated at the workshop. QI efforts in LMIC EUs primarily focused on quality domains of effectiveness, timeliness, safety and occasionally patient-centredness. Key barriers to QI included high patient turnover, a lack of skilled staff, limited funds and resources and prioritising patient care quantity over quality. Facilitators included the availability of QI guidance, training, initiating small-scale projects, enhancing documentation and communication and supportive hospital management. Safety and effectiveness were considered the most feasible domains for QI, although all domains were considered important. Variability in how participants defined these domains highlighted the need for clear guidance on definitions, their relative importance and appropriate measures for each.</p><p><strong>Conclusions: </strong>EUs are complex, high-pressure environments managing time-critical health conditions and require development of specific tools and guidance for QI. Addressing the barriers and leveraging facilitators identified in this study can inform the development of effective QI strategies for LMIC EUs.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"15 3","pages":""},"PeriodicalIF":2.1,"publicationDate":"2026-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13448536/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148677069","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}