BMJ Open Quality

PurposeQuality improvement (QI) in healthcare is a cultural transformation process that requires long-term commitment from the executive board. As such, an overview of QI applications and their impact needs to be made routinely visible. We explored how routine reporting could be developed for QI governance. DesignWe developed a retrospective evaluation of QI projects in an NHS healthcare organisation. The evaluation was conducted as an online survey so that the data accrual process resembled routine reporting to help identify implementation challenges. A purposive sample of QI projects was identified to maximise contrast between projects that were or were not successful as determined by the resident QI team. To hone strategic focus in what should be reported, we also compared factors that might affect project outcomes. FindingsOut of 52 QI projects, 10 led to a change in routine practice ( adoption). Details of project outcomes were limited. Project team outcomes, indicative of capacity building, were not systematically documented. Service user involvement, quality of measurement plan, fidelity of plan-do-study-act (PDSA) cycles had a major impact on adoption. We discussed how routine visibility of these factors may aid QI governance. OriginalityDesigning a routine reporting framework is an iterative process involving continual dialogue with frontline staff and improvement specialists to navigate data accrual demands. We demonstrated how a retrospective evaluation, as in this study, can yield empirical insights to support dialogue around QI governance, thereby honing the implementation science of QI in a healthcare organisation.

Recent years have seen a rise in digital interventions to improve coordination between care homes and NHS services, supporting remote sharing of data on the health of care home residents. Such interventions were key components in the response to the COVID-19 pandemic. This paper presents findings from the qualitative component of an evaluation of an implementation of the HealthCall Digital Care Homes application, across sites in northern England. The implementation commenced prior to the pandemic and continued throughout. Semi-structured, qualitative interviews were held with stakeholders. Interviews were conducted remotely (October 2020 -June 2021). Data were analysed via a reflexive thematic analysis then mapped against Normalization Process Theory (NPT) constructs (coherence, collective action, cognitive participation, and reflexive monitoring) providing a framework to assess implementation success. Thirty-five participants were recruited: 16 care home staff, six NHS community nurses, five relatives of care home residents, four HealthCall team members, three care home residents, and one local authority commissioner. Despite facing challenges such as apprehension towards digital technology among care home staff, the application was viewed positively across stakeholder groups. The HealthCall team maintained formal and informal feedback loop with stakeholders. This resulted in revisions to the intervention and implementation. Appropriate training and problem solving from the HealthCall team and buy-in from care home and NHS staff were key to achieving success across NPT constructs. While this implementation appears broadly successful, establishing rapport and maintaining ongoing support requires significant time, financial backing, and the right individuals in place across stakeholder groups to drive implementation and intervention evolution. The digital literacy of care home staff requires encouragement to enhance their readiness for digital interventions. The COVID-19 pandemic has pushed this agenda forward. Problems with stability across the workforce within care homes need to be addressed to avoid skill loss and support embeddedness of digital interventions. What is known about this topic?O_LIImproving healthcare delivery in UK care homes is a health policy priority. C_LIO_LIDigital interventions designed to enhance the referral process between care homes and NHS services and improve the healthcare delivery in care homes have become increasingly common in the UK. The HealthCall Digital Care Homes application is one such intervention. C_LIO_LIThese interventions and their implementations require evaluation to ensure that they operate as intended, function coherently and are considered appropriate and legitimate to the care home setting. C_LI What this paper adds?O_LIThe HealthCall Digital Care Homes app is a feasible, appropriate and legitimate intervention for referral, triage and health care support for non-urgent health care needs of care home residents. C_LIO_LIThe ongoing involvement of end users in further developing the intervention, and the level of monitoring and support provided by the implementation team appears to be key to the implementations success. C_LIO_LIThe digital preparedness of UK care homes is limited. Ensuring that care homes are digitally enabled, with a digitally literate workforce, should be a policy and research priority. C_LI

IntroductionDigital transformation and integration of eHealth solutions into chronic pain management faces significant challenges that have not yet been met. To realize the potential of eHealth solutions there is a need to understand the challenges, needs and care processes of eHealth into specific contexts and specific purposes. The objective of this study was to explore challenges, barriers, support needs, and visions experienced by patients and general practitioners (GPs) in the context of an eHealth solution designed for chronic pain management in general practice. MethodsThe study used action-research as a methodological framework. We conducted two future workshops involving eight patients living with chronic pain and seven GPs with clinical experience in managing chronic pain. Through case vignettes and inspiration cards, these workshops stimulated discussions and shared knowledge construction. Data were analysed using reflexive thematic analysis, separated by the groups, and were synthesized via a matrix analysis. ResultsThe analysis revealed five content summary themes: Theme 1--patients experience of challenges in life with pain; Theme 2--challenges in treating patients with chronic pain; Theme 3--patients suggestions for the structure of the eHealth solution; Theme 4--GP suggestions for the structure of the eHealth solution; and Theme 5--differences and similarities: Visions for an eHealth solution. The analysis generated several touchpoints and tension within the patient-physician encounter. ConclusionIn conclusion, these themes provide distinct narratives, offering valuable insights into the design objectives. Our study represents a significant advancement in developing personalized and innovative eHealth solutions for general practice, addressing key clinical challenges. PerspectiveRealizing the potential of eHealth solutions, these findings highlight both contrasting and shared viewpoints on design objectives, providing crucial insight into end-user perspectives for effective pain management. Additionally, the study underscores the importance of supported self-management and clinical communication in understanding each patients overall presentation within the healthcare system.

ImportanceLearning Health Systems (LHS) have proven efficacy in catalysing healthcare improvement, but adoption and scale-up in complex healthcare systems remains challenging, with limited implementation guidance. ObjectiveTo measure alignment with LHS principles and guide LHS implementation, we aimed to codesign, refine and apply an LHS Maturity Matrix (LHS-MM) based on the Monash LHS framework. DesignIn this mixed methods study, our scoping review identified existing tools. We then applied the Double Diamond design and innovation model (discover, define, develop, deliver) in the development of the LHS-MM. Insights from engineering, prior tools, and the Monash LHS Framework were leveraged to adapt the LHS-MM. This was refined through codesign, and triangulation with evidence-based implementation frameworks. The LHS-MM was then delivered in a test case on stroke. ParticipantsCodesign was conducted with subject matter experts (n=18), and end users of the LHS-MM (n=11). SettingWbithin a high-income high quality national health system (Australia), across regional and urban settings. OutcomesA tool to measure implementation fidelity and alignment of healthcare system behaviours and processes with LHS principles, and guide organisations in effective LHS implementation for healthcare improvement. ResultsTools uncovered in the discover and define phase emerged from the scoping review included the Cincinnati Network Maturity Grid. We adapted this tool to align to the Monash LHS framework. Codesign elevated the tool to focus on assessing complex systems behaviours aligned to LHS principles, with modification of assessment criteria, rating scales and scenarios for use. The LHS-MM assesses system-level behaviours across eight components on a numerical, five-point scale (1-5), visualised as a radar chart. Components include stakeholder engagement, priority identification, evidence-based information, evidence synthesis and guidelines, data systems, benchmarking, implementation, and healthcare improvement. Finally, in the deliver phase, a test case in stroke care revealed ratings from 4/5 (Established) to 5/ 5 (Transformative). ConclusionThrough an iterative and evidence-informed codesign process, we have generated the Monash LHS-MM. Further research and government implementation is underway to operationalise the Monash LHS-MM to measure fidelity and guide LHS implementation, advancing the field both within and beyond the Australian healthcare system and globally. As an implementation guide and monitoring tool, it will be a pivotal ingredient inside implementation toolkits currently being developed worldwide, supporting LHSs to fulfil their promise and enable the next frontier of healthcare innovation.

BackgroundThe trauma-informed care programme at the Tees, Esk and Wear Valleys Foundation NHS Trust identified a need to evaluate the ongoing service-wide trauma-informed care implementation effort. An absence of staff, service user and system-related outcomes specific to trauma-informed care presented barriers to monitoring the adoption of trauma-informed approaches and progress over time across the Tees, Esk and Wear Valleys Foundation NHS Trust. This paper describes the co-production of a new self-assessment tool, Roots, a discussion-based framework that facilitates learning and improvement by reflecting on positive or negative examples of trauma-informed services. MethodsUsing secondary data obtained from an affiliated national trauma summit and instruments found in literature, domains and items were co-produced with the help of trauma-informed care leads, NHS staff and service users. The research design consisted of community-based co-production methods such as surveys, focus groups, and expert consultations. ResultsAdopting trauma-informed care requires enthusiasm and commitment from all members of the organisation. Services must adapt to meet the dynamic needs of staff and service users to ensure they remain trauma-informed; this must be done as a community. ConclusionsFollowing an extensive co-production process, the Roots framework was published open-access and accompanied by a user manual. Roots can provide both qualitative and quantitative insights on trauma-informed care implementation by provoking the sharing of experience across services.

IntroductionHealthcare organisations worldwide are expected to investigate or review incidents that unintentionally harm or could cause harm. Investigation findings are presented in a written report, which is arguably a proxy measure for the quality of investigations. The report is an important document to be read and acted upon. The aims of this study were: 1) to design a tool to support the writing and review of healthcare safety investigation reports, and 2) to validate the content of the tool. MethodsThe study was conducted in two phases. Phase 1: The initial content of the tool was developed using relevant published literature and building consensus with 23 specialist participants from the United Kingdom and Australia. Phase 2: Content validity of the tool was assessed for relevance and clarity in two e-Delphi survey rounds with users of the tool. Using a 4-point scale, a median of 3 or 4 and an interquartile range of less than or equal to 1.5 were used to determine consensus. ResultsPhase 1: A tool containing 8 areas of review with accompanying descriptors was developed. For each area of review, a 3-point ordinal rating scale along with a comments box for formative self-assessment were included. Phase 2: At the end of the round 1 survey, there was consensus on all but one area of review in the tool. By the end of round 2 survey, consensus was reached on all areas of review. No additional areas of review were added and none were removed. Some descriptors were amended to improve clarity. ConclusionWe co-designed and validated the content of a tool that can be used to inform the quality of safety investigation reports and learning in terms of a systems-based approach. The tool has multiple uses ranging from self-assessment for report writers to facilitating oversight of the quality of healthcare safety investigation reports. Future work could focus on building further evidence of the tools overall utility. What is already known on this topic- summarise the state of scientific knowledge on this subject before you did your study and why this study needed to be done O_LIThe standard of healthcare safety investigation and reports internationally is known to be variable and often lacks the use of a Human Factors informed "systems approach". C_LIO_LIA formal mechanism appears to be lacking to facilitate a review of, and provide feedback on, the standard of healthcare investigation reports, which arguably serves as a proxy for the overall quality of the investigation process. C_LI What this study adds- summarise what we now know as a result of this study that we did not know before O_LITo our knowledge, this is a first validated tool that has been developed to support self-assessment and oversight of written safety investigations reports and learning reviews. C_LIO_LIKey principles of a systems-based approach to healthcare safety investigations and learning reviews are incorporated into a single tool to guide self-assessment and improvement, where needed. C_LI How this study might affect research, practice or policy- summarise the implications of this study O_LIThe tool supports organisational quality assurance or oversight mechanisms for monitoring, evaluating and improving the standard of investigation reports. C_LIO_LIAs written report can act as a proxy measure for the quality of investigations, improving the standard of reports may inform the learning and associated action from healthcare safety investigations. C_LIO_LIFurther research and evaluation are necessary to provide greater evidence of the utility of the tool. C_LI

BackgroundA learning health system (LHS) is a framework within healthcare that continuously enables improvement by incorporating knowledge generation into practice, leveraging routine data to optimise patient outcomes. Organisational culture, encompassing workplace values and traditions, is crucial for LHSs, allowing for integration of various elements within the system and ensuring cohesive functionality. Without a supportive organisational culture, a LHS may face challenges in achieving positive results, even with well-functioning individual components. Despite its recognised importance in LHS literature, the impact of organisational culture on LHS success remains unclear. This review aims to bridge this research gap. ObjectivesThe scoping review will address the question: How does organisational culture influence the generation and application of knowledge within a LHS? MethodsThis scoping review will follow Joanna Briggs Institute scoping review guidelines. Studies examining organisational culture within LHSs will be included, whilst those examining organisational culture outside a LHS framework not. Screening will be conducted using Rayyan, with title and abstract screening, followed by full-text review. A calibration exercise will be undertaken to ascertain agreement of eligibility criteria, after which the second reviewer will independently screen 10% of the studies during the title and abstract screening. A third reviewer will resolve any disagreements. Data extraction will use a standardised data information sheet, and the selection process and results of chosen studies will be recorded using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) flow diagram. Findings will be presented through a narrative summary using thematic analysis. Ethics and DisseminationThis review does not require an ethics approval. This protocol is registered to Open Science Framework and is publicly available at https://doi.org/10.17605/OSF.IO/K4EC3.

BackgroundLeadership is a critical lever for supporting implementation of practice change ideas intended to improve care. We need evidence-based leadership programs to help front-line providers meaningfully implement practice change in complex care settings. Part of the SHIFT intervention, this paper describes and pilot tests a leadership program module (LeaderSHIFT) that provides training and implementation coaching to front-line leaders, as one of several integrated facilitated supports designed to help front-line care teams meaningfully enact practice change. MethodsThe LeaderSHIFT program module was developed based on empirical work, relevant facilitation and transformational leadership theories, and principles of stakeholder co-design and feasible engagement. A pilot implementation study was conducted that examined several of Proctors (2011) implementation outcomes. ResultsLeaderSHIFT includes four interactive workshops plus two one-on-one coaching sessions designed to develop capacity in four areas of implementation leadership: (1) Self-awareness, (2) Motivate and inspire, (3) Facilitate learning capacity, and (4) Support team-oriented processes. Pilot results suggest it can be successfully implemented (it was acceptable, adopted, appropriate, feasible). Fidelity (LeaderSHIFT role enactment) varied across pilot teams. ConclusionsWith a strong theoretical and empirical base, LeaderSHIFT highlights important, often overlooked, relational and socio-cultural aspects of successful implementation leadership. As such, the LeaderSHIFT program module has the potential to improve implementation of practice change interventions in nursing homes and other institutional care settings. Trial registrationRegistered at ClinicalTrials.gov (ID NCT03426072) on July 18, 2022. KEY MESSAGES REGARDING FEASIBILITYO_LIWhat uncertainties existed regarding the feasibility? O_LIWhile leadership is known to be a critical lever for implementation of evidence-informed practice change, there are few leadership training programs that have a relational focus designed to support broader team-based practice change initiatives; and uncertainty remains regarding implementability (feasibility, acceptability, appropriateness, fidelity) of this type of leadership module in complex care settings C_LI C_LIO_LIWhat are the key feasibility findings? O_LIThe LeaderSHIFT module performed well on several key implementation outcomes (module acceptability, feasibility, appropriateness). Fidelity to implementation leadership was successful for managers who were able to enact relational aspects of the role. C_LI C_LIO_LIWhat are the implications of the feasibility findings for the design of the main study? O_LIFindings confirmed the value of one-to-one coaching for enhancing leaders relational competencies and prompted training overlap for senior and front-line leaders to ensure there is a common understanding of respective roles in intervention implementation. C_LI C_LI

ObjectiveTo investigate the association between initial discharge planning and transfers of in-patient care with discharge delay. To identify operational changes which could expedite discharge within the Discharge to Assess (D2A) model. DesignRetrospective cohort study. SettingUniversity Hospital Southampton NHS Foundation Trust (UHSFT). ParticipantsAll adults ([≥]18 years) who registered a hospital spell in UHSFT between 1 January 2021 and 31 December 2022 (n = 258,051 spells). Individuals were followed from hospital admission through to discharge. Data includes demographics, comorbidities, operational information (ward changes, handovers) and discharge information (estimated discharge date, D2A pathway). Main outcome measuresThe primary outcome was discharge delay, defined as the number of days between the final estimated discharge date and the actual discharge date. Odds ratio analysis was used to assess the impact of initial discharge planning accuracy (D2A pathway), number of ward moves, and number of in-speciality handovers on the outcome, adjusting for demographic and patient complexity factors. ResultsOut of 65,491 spells, 10,619 had an initial planned pathway that did not match the final discharge pathway, with 7,790 of these spells (75.1%) recording a discharge delay. Conversely, 10,216 of 54,872 spells (18.6%) where the initial pathway matched the final pathway recorded a discharge delay (adjusted odds ratio 2.72 (95% CI 2.55 - 2.91)). Ward moves and in-specialty handovers were also associated with increased likelihood of discharge delay, with adjusted odds ratio 1.25 (1.23 - 1.28) per ward move and 1.17 (1.14 - 1.20) per in-specialty handover. ConclusionsThis study finds a strong association between inaccurate initial discharge plans and in-patient transfers of care with discharge delay, after controlling for patient complexity and acuity. This highlights the need to consider how initial plans, and in-patient transfers affect discharge planning. Given the lead-times for organising onward care, operational inefficiencies are most impactful for patients eventually discharged on pathways with higher planning complexity. Key messagesWhat is already known on this topic O_LISeveral factors are known to influence discharge delay including age, whether the spell was elective, and patient complexity. C_LIO_LIDischarge planning has been historically difficult to characterise. C_LI What this study adds O_LIA robust measurement of the accuracy of discharge planning. C_LIO_LIHighlights the importance of considering the impact of initial discharge plans on the planning process. C_LI How this study might affect research, practice or policy O_LIEncourage a higher level of consideration when suggesting an initial Discharge to Assess pathway to reduce errors in planning down the line. C_LIO_LIEnsure that relevant discharge information is communicated when patients are transferred between wards and care teams. C_LI

BackgroundSystem-level barriers inhibit empathy in healthcare, and this can harm patients and practitioners. The barriers include burnout-inducing administrative workloads, burdensome protocols, lack of wellbeing spaces, un-empathic leadership, and not emphasising empathy as an institutional value. A workshop aimed at enhancing empathic systems was successfully delivered in Canada but has not been tested in the UK National Health Service (NHS) setting. AimTo test the feasibility of an empathic systems workshop within the UK NHS setting. MethodsWe conducted an interprofessional group of an emergency department (ED). We used a modified nominal group technique to prioritise actions to enhance empathy in the ED system. Satisfaction with the workshop and confidence that the workshop would lead to change were measured on a 10-point Likert scale. ResultsTwenty-eight participants representing the following stakeholder groups attended the workshop: leaders, consultants, nurses, security, and porters. The group agreed to generating a better wellbeing action plan and implementing an effective secondary triage system. Seventy-three percent (73%) rated their satisfaction with the workshop as 8 or higher out of ten, and 63% reported being confident that the workshop would lead to positive change. LimitationsA doctors strike limited the range of stakeholders who were able to attend, and long-term follow up was not conducted. ConclusionsParticipants in a UK setting were satisfied with a previously developed system empathy workshop and reported being confident that it would lead to positive change. Participants were able to prioritise changes that would improve system empathy and were confident that the changes would be effective.

BackgroundDespite comprising over 70% of the global healthcare workforce, women remain significantly underrepresented in healthcare leadership. Structural and systemic barriers persist across academic medicine, health services, and professional organisations, limiting career progression and leadership opportunities for women. Existing efforts often focus on individual-level interventions, overlooking the broader organisational and systemic contexts that shape leadership pathways. Urgent, coordinated action is needed to address gender inequity through sustainable, evidence-informed systems change. MethodsThis protocol outlines the Organisation Change Management (OCM) workstream within the Australian Advancing Women in Healthcare Leadership (AWHL) initiative--a nationally implemented, multi-sector partnership. The initiative applies a mixed-methods, coproduction approach to implement and evaluate multi-level interventions aimed at advancing gender equity in healthcare leadership. Guided by the Consolidated Framework for Implementation Research, the Learning Health System framework, and the Reach, Effectiveness, Adoption, Implementation and Maintenance evaluation model, the study engages stakeholders across outer (policy, regulation, funding) and inner (organisational culture, leadership structures) settings to drive systemic and organisational changes to enhance gender equity in leadership. Data collection includes administrative datasets and policy documents, semi-structured interviews, and surveys across partner organisations. Findings will inform tailored interventions and an implementation toolkit, developed and evaluated through iterative stakeholder engagement. DiscussionThis is the first national initiative to apply a systems-level, coproduced approach to gender equity in healthcare leadership, engaging strategic partners including health services, professional colleges and associations, government, and women in the workforce. By leveraging implementation science and systems change methodologies, the initiative aims to accelerate sustainable organisational transformation. The protocol provides a replicable framework for advancing equity in healthcare leadership and beyond.

BackgroundReadiness for change (R4C) is an important antecedent of care practice change and is linked to a range of implementation and effectiveness outcomes. We describe the creation, piloting, and evaluation of R4C activities intended to help nursing home (NH) teams implement a quality improvement intervention. MethodsWe developed and operationalized a R4C module with activities conducted with NH leaders during intervention recruitment. An implementation pilot was conducted in three NHs and evaluated using a mixed methods process evaluation guided by Proctors (2011) implementation outcomes framework. ResultsR4C activities were feasible, acceptable, and delivered with fidelity. The approach promoted readiness among senior leaders, but not among front-line teams. Results also showed (1) R4C activities are closely tied to other variables (e.g., NH leadership facilitation) that influence implementation, and (2) core R4C components (i.e., change efficacy) can emerge during an intervention, pending teams perceived success DiscussionWe suggest conducting R4C activities with all of those involved across an organization who have a role to play in change implementation. Findings also reveal challenges associated with isolating the effects of pre-intervention R4C activities on intervention implementation and success. Pilot results will inform a larger-scale quality improvement study. Trial registrationRegistered at ClinicalTrials.gov (ID NCT03426072) on July 18, 2022. KEY MESSAGES REGARDING FEASIBILITYO_LIWhat uncertainties existed regarding the feasibility? O_LIWhile readiness for change has been identified as an important lever for implementation of evidence-informed practice change, there is little in the published literature regarding how to operationalize of R4C to promote uptake of practice change initiatives. There is also uncertainty regarding implementability (feasibility, acceptability, appropriateness, fidelity) of R4C activities in complex care settings C_LI C_LIO_LIWhat are the key feasibility findings? O_LIUp-front activities requiring a few hours of a facility leaders time, designed to gauge and also operationalize and promote readiness for change were both feasible and acceptable and were delivered with fidelity. Facility leaders showed less fidelity enacting the intervention support and communication roles targeted by the R4C activities. A broken telephone scenario existed where senior leaders did not convey to unit leaders what their project roles entailed. C_LI C_LIO_LIWhat are the implications of the feasibility findings for the design of the main study? O_LIOur results suggest that it is necessary to actively target R4C activities directly to all organizational members involved in the practice change initiative. Failure to promote linkages and role clarity across participants at different levels of an organization makes it likely that change actors will remain unsure of their role in the change initiative. The design of the main study ultimately included two additional R4C focused meetings (one to bring senior and team sponsors together, one to bring team sponsors and team members together) to promote greater role clarity and enhanced project preparation. C_LI C_LI

ObjectivesTo synthesise evidence about primary care clinicians treating patients in or adjacent to hospital emergency departments in the UK. Study designMixed methods narrative systematic review. MethodsEligible studies were in English and described primary care services (general practitioners, GPs, or nurse practitioners) that treat patients within or adjacent to hospital Emergency Departments (ED). Searches were conducted on Medline, EMBASE, Cochrane Library and CINAHL databases. The search included extraction from an international review updated from 2020 to October 2022, and grey literature from inception to October 2022. The methods were informed by consultation with members of the public. ResultsFrom 4189 studies screened, 20 met inclusion criteria. Four studies assessed typology and streaming of services. Seven studies reported patient and public involvement. Ten studies reported differences in clinical outcomes between primary care and emergency services, but not definitive benefit for either. Likewise, results were equivocal for economic evaluations. Diverse delivery formats complicate evaluation and may explain why clinicians had mixed opinions about the utility of such services. Patients were generally satisfied with the service they received, in either primary care or emergency services. ConclusionDiversity of implementation complicate conclusions that can be drawn. Existing evaluations provide little evidence that primary care services in or near emergency departments offers any system advantages for clinical outcomes, or cost savings. Process evaluation in future evaluations is essential to understand what aspects of primary care at emergency departments are likely to improve system and patient care. Implications for the profession and/or patient careThe systematic review assessed outcomes arising due to primary care clinicians providing treatment in or near Emergency Departments (ED) in the UK. There were no consistent benefits for having primary care clinicians in or near EDs. This research highlights the need for healthcare leaders and policy makers to provide more clarity in developing primary care services in or near EDs. It will have impact for leaders in healthcare to consider whether primary care clinicians in or near EDs are providing best value healthcare, or whether other models could provide patients appropriate NHS resources according to their health need. Patient and public involvementThree focus groups (with 13 public advisors) were conducted to understand patients priorities and perspectives for attending EDs with relatively minor health conditions. This helped to guide study design, data extraction and analysis of this review.

IntroductionThe PriDem programme developed a flexible, primary care-led intervention to improve post-diagnostic dementia support, involving Clinical Dementia Leads (CDLs) working with general practices to strengthen care systems. Programme theory was articulated in a logic model, to guide a feasibility implementation study, which demonstrated intervention feasibility, acceptability, and potential for systems-level change. The process of refining programme theory following feasibility testing can appear as a black box; rarely reported in detail. This paper presents a structured exemplar of theory refinement, addressing this recognised gap in implementation science. MethodsA deductive thematic analysis was conducted, using the logic model as a framework. We synthesised previously reported findings with new qualitative insights from feasibility interviews, fieldnotes, supervision records and researcher reflections. Confirmed, refined, and newly emergent theoretical components were identified and the logic model updated. ResultsMany original theory elements were confirmed, including improved review processes leading to enhanced care plan personalisation and staff training increasing confidence in care delivery. New mechanisms were identified, such as mapping local services as a relational tool and care planning templates as educational resources. Pre-implementation activities, such as specific CDL training and champion identification, emerged as critical to success. Role ambiguity and capacity concerns acted as negative mechanisms, impeding implementation. These insights informed a revised logic model to guide future scale-up. ConclusionsThis paper demonstrates the value of theory refinement following feasibility testing. By unpacking the black box of implementation, we offer a transparent model for optimising complex interventions in primary care-led dementia support. Trial registration numberISRCTN11677384

BACKGROUNDEmergency departments (EDs) are under ever-increasing pressure. The General Practitioner Streaming and Treatment (GPST) service implemented at a large ED in England UK aimed to identify and treat patients who attended an ED but who might effectively be managed in primary care to reduce pressure on ED services. METHODSPatients attending ED were met by a GP nurse practitioner who streamed them to the GPST service or usual ED care. Routinely collected electronic records, satisfaction questionnaires and interviews were used to evaluate patient outcomes, staff experiences, service outcomes and impacts on usual ED services. RESULTSApproximately 96% of GPST patients were seen by a clinician within one hour and all within 87 minutes. Routinely collected ED datasets indicate statistically significant reductions in patients streamed to usual ED care who had to wait > 4 hours for disposition (p=<0.005). Of 769 patients with GPST consultation (approximately 10% of all walk-in patients) 421 (55%) needed no further intervention by ED. The speed at which GPST patients were managed exceeded patients expectations and was a major determinant of their satisfaction. No staff expressed dissatisfaction, but some suggested possible improvements in patient eligibility criteria and built environment design features. CONCLUSIONSConcurrent provision of GPST correlated with shorter waits for ED attenders to receive health care. Patient and staff experiences of GPST were positive. A robust assessment of safety and health economic outcomes would be useful to refine eligibility criteria and cost effectiveness.

BackgroundChronic pain is common among older adults with frailty and its management often remains suboptimal, despite evidence for the benefits of biopsychosocial treatment approaches being found for other populations. The Pain in Older People with Frailty Study (POPPY) was a four-phase study that aimed to develop a service model for pain management for this population to enable them to better manage their pain and reduce its impact on their lives. The aim of Phase 3 of the POPPY study was to understand the views of those delivering and commissioning services relating to older adults engagement in services and how pain services could be maximised to meet their needs. MethodsWe used in-depth semi-structured interviews with healthcare professionals (HCPs) and commissioners to explore: 1) perceptions of opportunities and barriers to including and managing older adults in pain services within different contexts, and 2) how to maximise support for this population in community, primary care, secondary care, and tertiary pain services. A thematic approach was used to analyse the data. FindingsWe recruited participants from 9 pain and 2 generic community services in the north, southeast and west of England. Services were in community, primary care, secondary care, and tertiary settings. We interviewed 42 HCPs including clinicians, psychologists, allied health professionals, nurses, social prescribers, service managers, and health/wellbeing coaches. We also interviewed 2 service commissioners. Most participants recognised that older adults living with frailty and pain often shared characteristics relating to their physical health, life experience and social circumstances which shaped their engagement in pain services. Generally, participants perceived there to be reduced engagement in pain services among older adults with frailty. Factors that were likely to improve the management of pain in the older population both within pain and non-pain services were also identified. ConclusionsFor pain services to meet the needs of older adults with frailty, it is essential for them to be responsive to the specific needs of this population, adapting both the content and delivery of interventions accordingly. Trial registrationresearch registry7169/ IRAS project ID: 310174

BackgroundA substantial number of emergency department (ED) attendances from care homes could be classed as avoidable. HealthCall is a technology that aims to streamline residents care by recording their observations electronically. Observations are fed to remote clinical staff to triage referrals. This study assessed the effectiveness of the HealthCall technology to safely reduce unplanned secondary care usage and associated costs. MethodsThe study involved 118 care homes across the North East from 2018-2021. Routinely collected NHS secondary care data from County Durham and Darlington NHS Foundation Trust was linked with data from the HealthCall technology App. Four outcomes were modelled monthly using Generalised Linear Mixed Models: counts of emergency attendances, emergency admissions, emergency readmissions (28-days), and length of stay of emergency admissions. A similar approach was taken for costs. The impact ofHealthCall was tested on each outcome using the models. FindingsData from 8,702 residents was used in the analysis. Results show HealthCall reduces the number of emergency attendances by 11%[6%-15%], emergency admissions by 25% 20%-39%], readmissions reduced by 29%[24%-33%] and length of stay by 11%[3%-18%] (with an additional month-by-month decrease of 28%[24%-34%]). The cost analysis found a cost reduction of {pound}57 per resident in 2018, increasing to {pound}113 in 2021. InterpretationThe introduction of a digital technology, such as HealthCall, significantly reduces contacts with and costs resulting from unplanned secondary care usage by care home residents. FundingThis work was funded by Health Data Research UK, CFC0124.

BackgroundHealthcare organisations that have a research culture within their practice (e.g. evidenced based and evidence informed practice) report better outcomes for their service users. There are however reported barriers to embedding research into practice. This includes time, knowledge, motivation, ability, resources, and access to organisational support. Psychological Services within the NHS regularly embed evidence-based practice as part of the care provision for their service users. However, at present little is known of the extent, capacity, and research readiness of those that practice within this sector. AimTo understand capacity, engagement and research readiness within the psychological services team at an NHS trust within the UK. MethodsMixed methods pilot study using cross sectional survey. Collecting both quantitative and qualitative data. 35 people were recruited from a pool of 89 people who attended a psychological services webinar in April 2024. Quantitative data was analysed on a descriptive level; qualitative data was analysed using thematic analysis. Findings and discussionResults indicate the value in the use of a mixed method survey to assess research readiness and capacity to those within psychological services practice. Overall response rate was good (39%) with a 100% completion rate of all questions. Both the quantitative and qualitative data revealed that participants wish to engage in research but encounter barriers such as capacity and time. Respondents were also unsure on the level or organisational support for research engagement and activity, unsure on the pathways to secure research time (e.g. funding opportunities), and findings also illustrate issues around practitioner confidence in applying research skills. Our findings show the acceptability of assessing research readiness within psychological practice and highlight several areas of need for practitioners to facilitate full research engagement. These findings will now seed a larger more ambitious assessment of research readiness.

Background Advice and Guidance (A&G) enables primary care clinicians to seek specialist input, supporting decision making and avoiding unnecessary referrals. The use of A&G has significantly expanded, accelerated by COVID19 and contractual changes. While A&G is intended to streamline elective care, concerns persist regarding workload shift, variable responsiveness, and system usability. Despite growing policy emphasis, little is known about why clinicians choose to use A&G. Aim Explore the current use of A&G within primary care, focusing on decision making processes which underpin PCCs' decision to use A&G. Design and Setting Qualitative study set in English Primary Care Method Twenty semi structured video interviews were conducted with primary care clinicians purposively sampled for maximum variation. Topic guides were developed with PPIE input and refined iteratively. Data were analysed using reflexive thematic analysis within an interpretive description framework, with themes developed collaboratively and refined through discussion with researchers and PPIE contributors. Ethical approval was obtained (REC 333799). Results Four overarching themes encapsulate clinicians' decisions to use A&G: clinical presentation (acuity and complexity), navigating healthcare pathways, previous experiences of A&G, and using A&G to validate clinical decision making. Barriers included delayed responses and uncertainty about inequitable workload distribution. These factors shape how effectively A&G could be integrated into routine practice. Conclusion Primary care clinicians use A&G to support patient care and aid decision-making, but its effectiveness depends on timely, clinically helpful responses. Ensuring responses remain appropriate to primary care remit and capacity will be essential if A&G becomes the main route into elective care.

BackgroundHospital at home (HaH), either admission avoidance (AA) or early supported discharge (ESD), was increasingly implemented in Catalonia (7.7 M, Spain) for selected patients, achieving regional adoption within the 2011-2015 Health Plan. This study aimed to assess population-wide HaH outcomes over five years (2015-2019) in a consolidated regional HaH program and provide context-independent recommendations for service quality assurance. MethodsA mixed-methods approach was adopted, combining population-based retrospective analyses of registry information with qualitative research. AA and ESD were separately compared with conventional hospitalization groups using propensity score matching techniques. In the analysis, we evaluated the 12-month period before the acute episode, the admission, and use of healthcare resources at 30 and 90 days after discharge. A panel of experts discussed the results and provided recommendations for monitoring HaH services. ResultsThe adoption of AA steadily increased from 5,185 to 8,086 episodes/year (total episodes 31,901; mean age 73 (SD 17) years; 79% high-risk patients), whereas ESD remained stable over the study period, averaging 5,329 episodes per year (total episodes 26,646; mean age 68 (SD 16) years; 71% high-risk patients). Mortality rates were similar in HaH and conventional hospitalization within the episode (AA: 0.31% vs. 0.45%; ESD: 0.18% vs. 0.45%) and at 30-days (AA: 3.94% vs. 3.24%; ESD: 4.50% vs. 4.07%). Likewise, the frequency of patients requiring hospital re-admissions or ER visits 30 days after discharge was similar in HaH (AA and ESD) and the corresponding controls. The 27 healthcare providers assessed showed high variability in patients age, multimorbidity, severity of episodes, recurrences, and length of stay of AA episodes. Recommendations aiming at enhancing service delivery were produced. ConclusionsBesides confirming safety and value generation of AA, we found that this service is delivered in a case-mix of diferent scenarios, encouraging provider-profiled monitoring of the service, particularly for ESD modalities. Impact statementWe certify that this work is confirmatory of Admission Avoidance (AA) as a value-based service by analyzing, with a population-based approach, a five-year period after regional adoption of AA in Catalonia. The research indicates the need for implementing quality assurance programs after service adoption and provides clear insights on how shape quality monitoring. The current study outcomes add novel knowledge to previous reports in the field, such as: O_LILeff B, DeCherrie L v., Montalto M, Levine DM. A research agenda for hospital at home. J Am Geriatr Soc. 2022;70(4):1060-1069. doi:10.1111/JGS.17715 C_LIO_LILevine DM, Ouchi K, Blanchfield B, et al. Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial. Ann Intern Med. 2020;172(2):77-85. doi:10.7326/M19-0600 C_LIO_LIMontalto M, McElduff P, Hardy K. Home ward-bound: features of hospital in the home use by major Australian hospitals, 2011-2017. Med J Aust. 2020;213(1):22-27. doi:10.5694/mja2.50599 C_LIO_LIHecimovic A, Matijasevic V, Frost SA. Characteristics and outcomes of patients receiving Hospital at Home Services in the South-West of Sydney. BMC Health Services Research. 2020;20(1):1090. doi:10.1186/s12913-020-05941-9 C_LIO_LILEONG MQ ET AL. Comparison of Hospital-at-Home models: a systematic review of reviews. BMJ Open. 2021;11:43285. doi:10.1136/bmjopen-2020-043285 C_LI The current manuscript covers relevant knowledge gaps well-identified in the nine dimensions for future research in the field of hospital at home reported by Leff B et al, 2022. Moreover, the population-based approach of the research provides a valuable approach for quality assurance of the different service modalities. O_TEXTBOXKey PointsO_LILarge scale adoption of Admission Avoidance shows value generation in real-world settings C_LIO_LIImplementation of continuous quality assurance monitoring after service adoption is highly recommended. C_LI Why does this paper matter?The population-based approach of the study design allows identification of key elements for service improvement after consolidated regional adoption of Hospital at Home Key strengths of the research are: i) demonstration of healthcare value generation of AA in large scale adoption of the service; and ii) generation of insightful recommendations for enhanced service delivery and continuous quality monitoring. C_TEXTBOX