BMJ Open Quality

BackgroundPatient safety remains a global priority, yet adverse events persist due to gaps in communication, information, training and safety culture. Rapid response systems standardise observation models are widely used to recognise deterioration and guide escalation and response for ward patients in hospitals. A notable gap concerns the role of planning for further care, can improve hospital resource prioritisation as healthcare professionals respond to patients deterioration in daily practice. Engaging healthcare professionals as key stakeholders to ensure relevance, we identified unanswered research questions on hospital patient safety and rapid response systems and prioritised the top ten research needs. Aim and methodsWe conducted a hospital-tailored, modified James Lind Alliance Priority Setting Partnership (JLA PSP) with healthcare professionals as key stakeholders to identify and prioritise rapid response system related patient safety research needs and evidence uncertainties. The modified JLA process included five stages: (1) establish the Priority Setting Partnership; (2) identify uncertainties; (3) summarise and refine submissions with evidence checks. (4) priority setting; and (5) verify and finalise a top ten list, with evidence checks and project-group oversight throughout. ResultsA modified JLA PSP resulted in the stakeholders co-producing a list of research priorities. The top three priorities addressed implementation strategies, intervention effectiveness, and optimising hospital patient safety through clinical protocols and rapid response system activation thresholds. Additional priorities addressed ethical, educational, and organisational factors, highlighting evidence gaps which recognised and responded to patient deterioration and the need for safer transitions across levels of hospital care. The modified JLA PSP was feasible for co-producing a clinically relevant, practice-oriented research agenda. ConclusionsA transparent, systematic, stakeholder-driven process generated hospital patient safety research priorities for rapid response systems that reflect stakeholder needs and target key evidence gaps guiding future research and strengthening patient safety practice in hospitals and, in primary care.

BackgroundPatient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are increasingly used to integrate patient perspectives into healthcare delivery, yet their routine implementation in general internal medicine (GIM) remains limited. This study evaluated participation rates and the acceptability, appropriateness, and feasibility of collecting PROMs and PREMs among GIM patients and study nurses across five Swiss university hospitals. MethodsWe conducted a sequential mixed-methods study embedded in a larger multicenter trial involving inpatients with two or more chronic conditions, hospitalized for acute illness and study nurses from GIM divisions. Inpatients completed three generic PROMs (paper or digital) at day 3, discharge, and 10 and 30 days post-discharge: the ESAS-r (Edmonton Symptom Assessment System revised), the EQ-5D-5L (European Quality of Life 5 Dimensions 5 Level), and the Distress Thermometer. A customized PREM assessing perceived quality of care was collected at discharge only. Patients and study nurses rated acceptability, appropriateness, and feasibility using Weiners implementation outcome measures. Study nurses recommendations for clinical integration were explored subsequentially in a focus group. Quantitative data were analyzed using descriptive analyses, while qualitative data were analyzed thematically. ResultsAmong 1,773 eligible GIM inpatients, 59% (median age 72 years, IQR 63-81) agreed to participate in PROM and PREM collection. Overall, patients rated all the PROMs as highly acceptable, appropriate, and feasible. Study nurses rated the ESAS-r and the EQ-5D-5L accordingly but expressed a moderate rating for the Distress Thermometer and the PREM primarily for their ease of use. Focus group findings emphasized staff training, digital integration into electronic medical records, reduced questionnaire burden, and hierarchical support as key implementation facilitators. ConclusionOur study demonstrates that PROM and PREM collection in Swiss University Hospital Settings was considered acceptable, appropriate, and feasible by patients and study nurses in a multicentric GIM inpatient setting. Routine implementation warrants specific strategies. SUMMARY TABLEO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIPROMs and PREMs are widely used in many medical specialties to incorporate patient perspectives and evaluate the quality and value of care. C_LIO_LIRoutine use of patient-reported measures in acutely ill GIM inpatients living with multimorbidity remains limited. C_LIO_LIImplementation often faces barriers related to workload, workflows, and digital infrastructure. C_LI What this study addsO_LITwo-thirds of acutely ill GIM inpatients in Swiss University Hospitals living with multimorbidity are willing to participate in PROM and PREM collection. C_LI How this study might affect research, practice or policyO_LIStaff training, digitalization, and hierarchical support are key facilitators, and embedding tools into electronic medical records with fewer measures may improve adoption in GIM. C_LI

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.

Background Continuous Quality Improvement (CQI) is a core strategy for strengthening health systems, yet documentation and monitoring of CQI activities remain fragmented in many low- and middle-income country (LMIC) settings. In Jamaica, CQI has been institutionalized across priority programs, but it largely relies on paper-based tools and basic digital platforms that limit timely learning and oversight. To address these gaps, Jamaicas Ministry of Health and Wellness (MOHW), in collaboration with the Caribbean Training and Education Centre for Health (C-TECH), adapted a web-based CQI application using a participatory, human-centered design approach. Methods We conducted a formative, convergent mixed-methods evaluation across 24 healthcare facilities to assess early-stage implementation of the CQI app. Guided by the Implementation Outcomes Framework, we examined acceptability, adoption, appropriateness, and feasibility. Quantitative data were collected through a structured survey of healthcare workers (n=43), and qualitative data were gathered through five focus group discussions (n=33) and three key informant interviews with CQI leads. Survey data were summarized descriptively, and qualitative data were analyzed using rapid qualitative analysis. Findings were integrated using joint displays. Results Survey findings indicated moderate to high perceived acceptability and appropriateness of the CQI app, with 70% of participants reporting that it saved time and 67% noting that it aligned with facility goals. However, 19% reported never using it. Qualitative findings highlighted the apps value for improving CQI documentation, visualizing trends, and supporting supervisory oversight. Key barriers to sustained adoption included inconsistent internet connectivity, limited follow-up training, unclear team roles, and challenges integrating app use into routine workflows. Leadership engagement and alignment with existing CQI structures emerged as critical enablers. Conclusion This formative evaluation suggests that a digitally enabled CQI platform can strengthen documentation and oversight of quality improvement activities in resource-constrained health systems when embedded within supportive organizational and infrastructural contexts. Addressing foundational system readiness, including leadership engagement, capacity-building, and workflow integration, will be essential to realizing the CQI apps potential in Jamaica and similar LMIC settings.

Background Therapeutic empathy improves patient and practitioner outcomes, yet existing measures are often lengthy, conceptually inconsistent, and cannot be easily compared across respondent groups. Brief, universal measures (usable by patients, practitioners, students, and observers) are lacking. We therefore developed a universal single-item scale and conducted psychometric testing of the patient-reported version. Methods Following best-practice, we used a three-phase approach: (1) item development; (2) pre-testing the scale by obtaining expert panel feedback (n=9) and conducting cognitive interviews with stakeholders (n=35); and (3) scale validation in an international patient sample (n=521) assessing convergent, discriminant, and known-groups validity. Validation involved assessing correlations with the Consultation and Relational Empathy (CARE) measure and clinical neutrality measure, and by assessing differences in scores by patient ethnicity. Results We developed two versions (pictorial and text-based) of each scale. Expert feedback and cognitive interviews confirmed content and face validity. Pictorial and text-based versions showed high convergent validity with the CARE measure (r=0.761 and r=0.838, both p<0.001), and discriminant validity with a clinical neutrality measure (r=0.131 and r=0.139, p=0.003 and p=0.001, respectively). Correlations with the CARE measure remained high (r>0.70) and statistically significant (p<0.001) across patient gender, ethnicity, and practitioner type. Ethnic minority patients rated practitioner empathy lower than White patients (pictorial p=0.057; text-based p=0.033), demonstrating known-groups validity. Patients rated doctors' empathy higher than other healthcare practitioners' (p=0.001 for both pictorial and text-based); there were no significant differences in empathy scores by patient gender. Conclusions We developed the first universal single-item therapeutic empathy measure and demonstrated validity for the patient-reported versions. The scale is brief, accessible, and applicable to clinical practice, education, and research. Further research should validate practitioner-, student-, and observer-reported versions, and assess predictive and cross-cultural validity. This robust tool can support patient-reported routine measurement of therapeutic empathy and contribute to improving patient and practitioner outcomes.

BackgroundAlthough virtual consultations are increasingly used in healthcare, mode affects attendance patterns remains limited, particularly across demographic groups. Within NHS secondary care, telephone consultations have been the most widely adopted form of telephone care; however, few studies have examined non-attendance (commonly termed Did Not Attend [DNA]) patterns specifically for telephone consultations and fewer still have explored how patient characteristics influence attendance differently across consultation modes. Understanding these patterns is essential for equitable service planning. ObjectiveTo compare non-attendance rates between telephone and in-person secondary care consultations among adults with type 2 diabetes (T2D), and to identify patient characteristics associated with non-attendance under each mode. MethodsData from 853,693 secondary care consultations (January 2020-August 2024) for 45,618 patients with T2D in Northwest London were analysed. Telephone consultations in this dataset consisted exclusively of telephone consultations; we therefore refer to them as telephone consultations throughout. Patient-level consultations were aggregated into patient-mode strata for regression modelling. Zero-inflated Negative Binomial regression assessed factors associated with missed consultation rates by mode (in-person or telephone). Propensity-score balance diagnostics (inverse probability of treatment weighting) were conducted to assess measured confounding by mode assignment. Specialty-stratified non-attendance rates were examined across 34 major specialties. ResultsIn-person consultations had higher unadjusted non-attendance rates than telephone consultations (9.1% vs 7.2%, p<0.001). This pattern was consistent for both first consultations (9.3% vs 6.2%, p<0.001) and follow-up consultations (9.0% vs 7.50%, p<0.001). For in-person consultations, higher non-attendance was associated with younger age (18-39: 12.2%, 40-59: 11.1% vs 60-79: 9.9%, p<0.001), Black or Black British ethnicity (18.9% vs White: 7.6%, p<0.001), and greater deprivation (most deprived IMD1: 10.3% vs least deprived IMD5: 7.0%, p<0.001). For telephone consultations, higher non-attendance was associated with male gender (7.3% vs female: 7.0%, p<0.01), younger age (18-39: 11.3%, 40-59: 9.5% vs 60-79: 6.1%, 80+: 5.6%, p<0.001), and greater socioeconomic deprivation (most deprived: 8.3% vs least deprived: 4.7%, p<0.001). Interaction analyses revealed that demographic disparities were amplified for telephone relative to in-person consultations. Specialty-stratified analysis showed that in-person non-attendance exceeded telephone non-attendance in the majority of high-volume specialties. ConclusionsIn-person consultations had higher non-attendance rates than telephone consultations. Various demographic factors influenced non-attendance rates, with younger age and greater socioeconomic deprivation consistently associated with non-attendance for both in-person and telephone consultations. These findings suggest that a personalised, equity-informed approach to consultation mode selection is needed. Findings apply to telephone consultations and may not generalise to video-based modalities.

IntroductionInterventions are urgently needed for young people waiting for Child and Adolescent Mental Health Services (CAMHS) in England. Long waits can worsen mental health, increase distress for young people and families, and place additional pressure on already stretched services. Social prescribing, a referral system for connecting individuals with resources in the community via one-to-one support from a link worker, has not been routinely implemented or evaluated for young people on CAMHS waitlists. It remains unclear whether, and under what conditions, social prescribing can be implemented successfully within CAMHS. MethodsWe conducted semi-structured interviews with 23 staff and link workers involved in implementing social prescribing at 11 CAMHS sites across England as part of a large hybrid type II implementation-effectiveness study. We used a framework analysis approach, deriving the coding from the updated Consolidated Framework for Implementation Research (CFIR). ResultsBarriers and facilitators mapped to 12 CFIR constructs, generating 26 themes. Key areas included: the challenges of implementing a non-medical intervention in a clinical environment; the advantage of social prescribing compared to little waitlist support; the need for flexibility in mode, duration, and frequency of sessions; the importance of community assets, funding and external partnerships for delivery; and the capacity, skills, and professional experience of link workers and staff. Barriers within CAMHS related to limited resources and partial understanding of the intervention, as well as difficulties in integrating link workers and providing supervision. Successful implementation depended on tailoring the intervention to the needs and preferences of young people and parents. Alternative social prescribing pathways were proposed, with schools being recommended as a promising setting for preventive delivery or post-treatment transitions for young people. ConclusionYouth social prescribing for young people on CAMHS waitlists is feasible but requires careful implementation. Successful delivery depends on the capacity of link workers and supportive organisational structures in CAMHS. Alternative pathways, including delivery outside the waitlist through schools may facilitate its implementation and impact.

Acute myocardial infarction (AMI) is an increasing cause of morbidity and mortality in Sub-Saharan Africa (SSA) but is often underdiagnosed and undertreated. To address this gap, the Multicomponent Intervention to Improve Myocardial Infarction Care (MIMIC) was developed and implemented in the emergency department (ED) of a regional referral center in northern Tanzania. We conducted in-depth interviews with 20 key stakeholders (physicians, nurses, administrators, and patients) who participated in MIMIC during the first year of implementation. Purposive sampling was used to recruit a broad range of participants. Interviews were guided by a semi-structured interview guide informed by the Theoretical Framework of Acceptability (TFA). Interview transcripts were thematically analyzed by a team of coders using an inductive, grounded theory approach guided by the seven TFA domains. Nineteen major themes emerged across all TFA domains. Overall, participants described MIMIC as highly acceptable, minimally burdensome, and well-aligned with professional and ethical values. Perceived effectiveness was most emphasized, with staff citing improvements in AMI recognition, ECG and troponin testing, and use of evidence-based therapies. All components were highlighted as effective and easily integrated into existing workflows. Patients valued the educational pamphlet for improving knowledge and self-efficacy, though staff expressed concerns about distributing it during acute care, contributing to inconsistent delivery. Champions were viewed as key in promoting adherence and sustaining implementation of the intervention. MIMIC was widely acceptable in all seven TFA domains among ED providers and patients, with perceived effectiveness driving positive attitudes across stakeholder groups. Use of a co-design approach in MIMIC development likely contributed to high intervention acceptability. Patient education strategies may require adaptation to improve fidelity. These findings suggest that continued implementation and future adaptation of MIMIC may be feasible.

Objectives: Endometriosis affects approximately 10% of reproductive age women worldwide, yet care pathways remain fragmented and treatments have limitations. This study aimed to identify and categorize key stakeholders in endometriosis care in Ireland, assess their influence and interest in the digital health initiative, and identify drivers and barriers affecting uptake of innovative approaches to care. Methods: A virtual stakeholder mapping workshop was conducted with participants from healthcare, policy, education, technology, academia, and patient communities. Using a structured MS Teams Whiteboard, participants generated a stakeholder list, positioned stakeholders on an Influence-Interest Matrix, and provided qualitative insights on factors enabling or constraining engagement with digital health innovation. Results: Stakeholders were distributed across all four quadrants of the matrix. High-interest/high-influence stakeholders included the HSE, specialist centres, general practitioners, and the Endometriosis Association of Ireland. High-interest/low-influence groups comprised patients, families, and online communities, while policymakers, hospital managers, and the education sector were identified as high-influence but low-interest actors. Key drivers included strong patient advocacy, institutional support such as engagement from the HSE, and growing awareness of digital health tools. Major barriers encompassed prolonged diagnostic delays, resource constraints, gaps in clinical knowledge, technology anxiety, and challenges sustaining engagement. Conclusions: Stakeholder mapping provided an evidence-informed foundation for the VendoR project, revealing engagement gaps and leverage points critical for improving endometriosis care innovation. The findings highlight the need for intentional, well-resourced strategies that elevate patient voices, address systemic barriers, and ensure balanced representation, supporting the co-design, co-creation, and co-production of digital health interventions for sustainable, patient-centred care.

Introduction. Practice coaching is increasingly used to strengthen quality improvement (QI) capacity in primary healthcare (PHC) systems in low and middle income countries (LMICs), yet the causal pathways through which it shifts provider behaviour, and the systemic conditions that enable or constrain those pathways, remain under theorised. Using a theory based qualitative evaluation, we examined how and why a practice coaching intervention influenced QI in cervical cancer screening (CCS) and antenatal care (ANC) within Honduras decentralised PHC system during the third phase of the Salud Mesoamerica Initiative (SMI). Methods. We conducted a within case explanatory case study. A programme theory was reconstructed before data collection and iteratively refined against evidence. Data comprised semi structured interviews with 11 midlevel managers, 6 PHC team medical leads, and 2 regional managers, complemented by direct observation and document review. We applied combined deductive and inductive coding, thematic analysis, and pattern matching, and reporting per COREQ. Results. We identified four causal patterns that refined the initial programme theory. Three were activated pathways: (1) novel professional identity among participating managers; (2) collective efficacy and data driven learning, sustained through verifiable progress on observable indicators, strong for CCS but null for ANC, where outcomes were less attributable to teams actions; and (3) relational coordination, psychological safety, and trust, which provided the interpersonal basis for the first two. A fourth, unanticipated pattern showed structural misalignment between coaching enabling, learning based logic and the directive, punitive logic of Honduras performance based contracting environment, confining gains to localised enabling bubbles. Conclusion. Coaching can activate meaningful QI pathways in LMIC primary care, but sustained, equitable impact requires deliberate alignment between coaching learning oriented principles and the institutional performance management architecture, and matching of coaching investment to clinical processes with observable, attributable outcomes.

Background A mode of birth decision aid (DA) can provide information and support discussions about the potential risks and benefits (outcomes) associated with planning a vaginal or caesarean birth. Evidence shows that DAs can enhance patient knowledge, reduce decisional conflict, minimise inconsistencies in decision-making support, especially in maternity settings, and promote informed decision making. Despite these benefits, DAs specific to mode of birth are currently lacking in routine antenatal care. This paper outlines the process we followed to reach consensus on which outcomes of planned mode of birth should be included in a mode of birth DA. Methods Outcome identification and selection occurred in three phases. Phase 1 involved compiling a long list of outcomes from systematic reviews, the NICE Caesarean Birth Guidance and qualitative interviews with stakeholders. In Phase 2, this list was refined via a 2 round Delphi survey to prioritise outcomes considered important. An outcome reached consensus if [&ge;]70% of all participants, or 70% of women/partners rated it as critically important (7-9), and <15% rated it as not important (1-3). Phase 3 involved two stakeholder consensus meetings to finalise the outcome list. Results Seventy-one outcomes were identified. Following two Delphi rounds and consensus meetings, 54 outcomes were rated as critically important. Seventeen outcomes were consistently rated as not critical across both the survey and consensus phases, meaning that [&ge;]70% of participants in each phase did not consider them essential for informing women during pregnancy. Of these, 8 were retained due to NICE recommendations and ultimately, 9 outcomes were excluded. The final list included 44 maternal and 18 child outcomes. Maternal outcomes related to assistance with birth, complications at the time of birth, issues during recovery, pelvic floor, psychological issues, sexual function, and future pregnancy. Child outcomes related to morbidity and death, disease, obesity, issues with cognitive development and physical development. Conclusions Sixty-two priority outcomes were identified for inclusion in a planned mode of birth DA.

Safety net healthcare delivery organizations (SNOs) serve vulnerable populations but face persistent challenges in adopting new technologies, including AI. While systematic barriers to technology adoption in SNOs are well documented, little is known about how AI is implemented in these settings. This study explored real-world AI adoption in SNOs, focusing on identifying barriers encountered across the AI lifecycle and strategies used to overcome them. Five SNOs in the U.S. participated in a 12-month technical assistance program, the Practice Network, to implement AI tools of their choosing. Observed barriers and mitigation strategies were documented throughout program activities and, at the conclusion of the program, reviewed and refined with participants using a participatory research approach to ensure findings reflected lived experiences and organizational contexts. Key barriers emerged during the Integration and Lifecycle Management phases and included gaps in AI performance evaluation and impact assessments, communication with patients about AI use, foundational AI education, financial resources for purchasing and maintaining AI tools, and AI governance structures. Effective strategies for addressing these barriers were primarily supported through centralized expertise, structured guidance, and peer learning. These findings provide granular, actionable insights for SNO leaders, offering guidance for anticipating barriers and proactively planning mitigation strategies. By including SNO perspectives, the study also contributes to the broader health AI ecosystem and underscores the importance of participatory, collaborative approaches to support safe, effective, and ethical AI adoption in resource-constrained settings. Author SummarySafety net organizations (SNOs) are healthcare systems that primarily serve low-income and underinsured patients. While interest in artificial intelligence (AI) in healthcare has grown rapidly, little is known about how these organizations experience AI adoption in practice. In this study, we partnered with five SNOs over a 12-month program to document the challenges they encountered when implementing AI tools and the strategies they used to address them. We worked closely with SNO staff throughout the process to ensure our findings reflected their lived experiences with AI implementation. We found that the most common challenges arose when organizations tried to integrate AI into daily operations and monitor and maintain those tools over time. Specific barriers included difficulty evaluating whether AI was performing as expected, limited guidance on communicating with patients about AI use, a lack of resources for staff training, limited financial resources, and the absence of formal governance structures. Successful strategies for overcoming these challenges drew on shared knowledge and structured support provided by the program, as well as learning from peer organizations. These findings offer practical guidance for SNO leaders planning or managing AI adoption, and contribute to a broader conversation about what is required to implement AI safely and effectively in healthcare settings that serve the most medically and socially vulnerable patients.

Primary healthcare (PHC) managers are central to the functioning of South Africas healthcare system, yet many assume leadership roles without formal management training. To address this gap, the Aurum Institute developed the Management Development Programme (MDP), a structured leadership and management training intervention aimed at strengthening PHC management competencies. This study evaluated the impact of the MDP on leadership practices, organisational readiness for change, and workplace stress among PHC managers in the Western Cape Province. A non-randomised matched cluster trial was conducted across 20 PHC facilities. Intervention facilities were purposively selected based on participation in the MDP, while matched control facilities were randomly selected. Data were collected using structured and semi-structured surveys administered to facility managers and clinic staff. Leadership competency was assessed using the Leadership Practices Inventory (LPI), which measures five dimensions of exemplary leadership: Model the Way, Inspire a Shared Vision, Challenge the Process, Enable Others to Act, and Encourage the Heart. Organisational readiness for change was measured using Kotters 8-Step Framework, while workplace stress was assessed using a 13-item version of the Brief Job Stress Questionnaire focusing on Job Meaning, Environmental Quality, Autonomy, and Control. Intervention effects were estimated using generalised linear models adjusted for manager age, years in role, matched-pair fixed effects, and cluster-robust standard errors. Outcomes were reported as adjusted risk differences with 95% confidence intervals and two-sided p-values. A total of 20 facility managers (median age 51 years; IQR 42-55; 90% female) and 105 clinic staff members (median age 42 years; IQR 35-50) participated in the study. Managers in both intervention and control facilities reported consistently high self-rated leadership competency scores across all LPI domains, with no statistically significant differences between groups. Similarly, clinic staff rated managers highly across the standard LPI domains, and no significant differences were observed between intervention and control facilities. Despite the absence of significant differences in overall leadership competency scores, staff in intervention facilities reported significantly stronger relational and communication practices among managers compared with staff in control facilities (72.7% vs. 64.0%; adjusted risk difference 22.0%, 95% CI 6.1-37.8; p=.007). After adjustment for age and tenure imbalances, intervention facilities also demonstrated significantly higher scores for institutionalised capability and learning culture (adjusted risk difference 21.3%, 95% CI 0.6-42.0; p=.043). Managers who participated in the MDP further reported stronger perceptions of district support, including improved internal leadership and cultural readiness (adjusted risk difference 22.1%, 95% CI 14.0-30.3; p<.001) and greater district leadership and resource availability (adjusted risk difference 28.1%, 95% CI 15.6-40.6; p<.001). No statistically significant differences were observed in workplace stress across any domain. Although the MDP did not produce measurable short-term improvements in managers self-rated leadership competencies or standard LPI domains as assessed by staff, it was associated with important gains in relational leadership practices, organisational readiness for change, and perceived district support. These findings suggest that structured management training programmes may strengthen critical organisational and interpersonal foundations necessary for sustained performance improvement within PHC settings.

Background: Strong management capacity is essential for effective primary healthcare (PHC) service delivery and health system strengthening [1]. The AURUM Management Development Programme (MDP) was implemented to strengthen district and PHC leadership in the Western Cape province of South Africa. This study explored the contextual barriers and enabling conditions influencing the scalability of the programme within district health systems. Methods: This study employed a qualitative exploratory design to investigate barriers and enablers associated with scaling the MDP. In-depth interviews were conducted with purposively selected district health managers from three Western Cape districts. Interviews were audio-recorded, transcribed verbatim, and analysed thematically using NVivo 14. The study explored perceptions regarding programme adaptability, district readiness, implementation challenges, and enabling conditions for sustainability and scale-up. Results: Twenty participants (7 males and 13 females) from the Cape Winelands, Garden Route, and Cape Town Metro district health offices were interviewed. The MDP was viewed as relevant, practical, and adaptable to district health system contexts. District readiness for implementation emerged as an important determinant of perceived programme success. High readiness was characterised by clear team roles, strong management structures, decentralised decision-making, digital tool utilisation, ongoing mentorship systems, and prior exposure to PHC reforms such as the Ideal Clinic Realisation and Maintenance (ICRM) programme. Lower readiness was associated with staff shortages, operational pressures, limited leadership support, and partially functional health systems. Key enabling factors included integration with existing training structures, visible improvements in service delivery, mentorship support, and active engagement from district leadership. Conclusion: The MDP demonstrates potential for scalability within South Africas public health system. However, successful scale-up depends on district-level readiness, supportive leadership structures, integration into existing training and management systems, and sustained mentorship and implementation support.

Background Pancreatic Ductal Adenocarcinoma will be the 2nd-most common cause of cancer mortality by 2030. It is associated with rapid deterioration, severe symptoms, and significant quality-of-life concerns. Using input from patients, family caregivers (FCGs), and provider stakeholders, we designed an intervention, PAL-CHW-PDAC, delivered by a community health worker that involves proactive symptom monitoring and management, care navigation, and disease education. Methods We conducted a pilot randomized controlled trial of 60 patients with newly diagnosed PDAC (within 2 weeks of diagnosis) and their caregivers at Loma Linda University Health from 09/2025 to 05/2026. Patients were randomized 1:1 to receive the PAL-CHW-PDAC intervention (6 CHW visits over 3 months) or an attention control. The control comparator involved receiving standard handouts and videos on pancreatic cancer, along with check-in visits with research staff. The primary outcome was symptom burden, defined using the NCCN/FACT Hepatobiliary Symptom Index. Secondary outcomes included quality of life (QoL) measured by the FACT-Hep and psychological distress (measured by the NCCN-Distress Thermometer). Caregiver outcomes included burden, preparedness, quality of life, and psychological distress. Results: 60 out of 74 eligible (81%) were enrolled. The median age was 71, 60% of patients were Hispanic. 68% of patients presented with metastatic PDAC, 23% with borderline resectable disease and 9% with resectable PDAC. There was a trend towards improved symptom burden at 12 weeks (mean increase of 5.3 points vs. decrease of 3.2 points; p=0.093) with the intervention compared to the attention control. The intervention group also had improved psychological distress at 12 weeks (3.31 vs. 5.95, p=0.01), caregiver psychological distress (3.26 vs. 6.86, p<0.001) and caregiver preparedness (2.92 vs. 2.11) at 12 weeks. Telehealth utilization for symptom-focused visits improved with the intervention (82%) compared to the control. (14%, p=0.01) Hospice utilization also improved with the intervention (41% vs 7%, p-0.12). Conclusions: A pilot RCT of the PAL-CHW-PDAC intervention demonstrated preliminary efficacy with a trend towards improved symptom burden, psychological distress, and caregiver psychological distress and preparedness. A larger definitive clinical trial is needed to understand the impact of this promising intervention. ClinicalTrials.gov number, NCT07591571

IntroductionObstetric litigation is the largest single category of NHS clinical negligence by cost. The last systematic analysis of NHS obstetric litigation data was published in 2012 [1]. Despite major national safety programmes, annual costs have continued to escalate. This study aims to update the analysis and consider ethical and resource implications. MethodsFOI claims data were obtained from NHS Resolution for 2015/16-2024/25, supplemented by cerebral palsy and brain damage (CP/BD) data for the most recent six years. Activity-weighted HRG unit costs for 2024/25 and 2023/24 were used to compare planned vaginal birth (PVB) and planned caesarean section (PCS) pathway costs, incorporating indemnity attribution by cause-code proportion. The consent architecture was reviewed against Montgomery v Lanarkshire Health Board [2015] UKSC 11. ResultsOver the period, 11,881 claims were notified (approximately one per 500 England NHS births); 7,216 were settled, with total damages of {pound}5,974 million, rising approximately 85% in real terms. Four intrapartum monitoring failure codes and seven labour-exclusive delivery complication codes together accounted for {pound}2,776 million paid (55.9% of all obstetric damages). CP/BD claims represented 16.6% of volume but 77.7% of obstetric damages over 2019/20-2024/25, at an average of {pound}3.58 million per claim. Activity-weighted HRG analysis at 2024/25 tariff showed PCS at {pound}6,202 versus PVB at {pound}6,339 per birth. ConclusionsObstetric litigation costs continue to escalate, driven overwhelmingly by labour-attributable harm. NHS England data show, for the first time, PCS tariff costs below PVB. Including indemnity under the primary eleven-code attribution, total system cost excess of PVB reaches approximately {pound}1,032-{pound}3,082 per birth (2024/25 cash to actuarial basis). Consent architecture for planned mode of delivery raises a potential inconsistency with Montgomery. Key messagesO_ST_ABSWhat is already known on this topicC_ST_ABSObstetric litigation is the largest single category of NHS clinical negligence by cost, driven overwhelmingly by intrapartum harm, yet no systematic analysis of cause-code data has been published since 2012. What this study addsTen years of NHS Resolution FOI data show that eleven labour-exclusive cause codes account for 55.9% of obstetric damages; NHS England tariff data show, for the first time, that planned caesarean section ({pound}6,202) is less costly than the planned vaginal birth pathway ({pound}6,339), and when indemnity is included the total system cost excess of planned vaginal birth reaches {pound}1,032-{pound}3,082 per birth. How this study might affect research, practice or policyA formal comparative-risk consent process at booking, equivalent to that currently required for planned caesarean section under RCOG Consent Advice No. 14, should be considered standard for all women; NICE should update its economic analysis of mode of delivery to incorporate litigation costs; and NHS tariff methodology should be reviewed to ensure indemnity is allocated in proportion to the pathway-level mechanisms that generate it.

Introduction Antibiotic use drives antimicrobial resistance, and optimizing prescribing in skilled nursing facilities (SNFs) - which care for medically complex residents in congregate settings characterized by frequent care transitions and diagnostic uncertainty - presents unique challenges. Antimicrobial stewardship (AMS) in SNFs has therefore become a focus of quality improvement efforts by federal and state health agencies. We aimed to identify factors that facilitate and hinder AMS implementation in SNFs. Methods A qualitative study of AMS implementation was conducted in Southern Arizona SNFs randomly sampled to represent urban/suburban, border, and rural regions. Semi-structured interviews were conducted with administrators, clinicians, and nonclinical staff within participating facilities. Interview transcripts were analyzed using constant comparative analysis, with both directed and emergent coding, facilitated by NVivo 12 software. Findings From 04/13/2019 through 12/13/2019, 57 interviews were conducted with 9 administrators, 38 clinical providers, and 10 nonclinical staff across 6 urban/suburban, 2 border, and 2 rural facilities. Analysis identified two thematic categories: "influencer themes," which describe specific barriers and facilitators to AMS implementation, and "system themes," which characterize SNFs as complex adaptive systems shaped by interacting staff roles, care transition challenges, and differing perceptions of AMS practices within the same facility. Key facilitators included effective internal communication, ongoing AMS education, and clinician AMS champions. Primary barriers included poor interfacility communication during care transitions, limited access to diagnostic resources, enculturated prescribing norms, and tension between immediate infection control priorities and long-term AMS goals. Conclusions Findings suggest that AMS implementation in Arizona SNFs is best understood as a systems-level process emerging from interactions among staff roles, organizational workflows, and care transitions, rather than solely from individual prescribing decisions. Recognizing SNFs as complex adaptive systems highlights the importance of communication structures, local champions, and feedback mechanisms. It underscores the need for coordination strategies within and across SNFs to sustain AMS interventions.

PurposeHigh clinical workload is associated with worse patient and hospital outcomes and is a well-established driver of clinician burnout. Trainees may be particularly exposed, shouldering both clinical and educational responsibilities. Evidence-based work design offers a data-driven approach to healthcare work but relies on robust workload measurements. Trainee workload remains poorly characterized, as commonly used metrics (e.g., duty hours, patient census) overlook cognitive and contextual dimensions. This pilot evaluated the feasibility of combining survey-based and electronic health record (EHR) data to characterize internal medicine (IM) trainees workload. MethodsA pilot study was conducted including IM and Medicine-Pediatrics residents (postgraduate years 1-4) between March 31 and June 22, 2025. Participants completed daily surveys during a seven-day inpatient schedule assessing workload and work experience domains, including environment, professional fulfillment, psychological safety, autonomy, and rounding experience, using validated instruments where available. Concurrently, EHR data captured chart review, documentation, orders, and secure messaging activity. Associations between survey and EHR data were assessed. ResultsAmong 37 eligible residents, 28 (76%) participated in the pilot capturing 166 shifts. Trainees spent 4.4 {+/-} 1.6 (mean {+/-} SD) minutes completing daily surveys and 8.6 {+/-} 2.3 minutes completing the final survey. Trainees reported working 11.6 {+/-} 1.0 hours/day and a median census of 9.0 (IQR 6.0-11.0). NASA-TLX score was 50.8 {+/-} 12.6. Positive shift ratings were associated with lower NASA-TLX scores and perceived rounding length. First-to-last EHR login duration was 15 {+/-} 2 hours/day, and EHR data showed 204 {+/-} 46 active minutes/day. Login duration correlated with self-reported hours (r=0.43, p<0.0001), and notes signed correlated with self-reported team (r=0.19, p=0.013) and personal census (r=0.34, p<0.0001). ConclusionsIntegrating survey-based and EHR-derived workload measures provides multidimensional insight into trainee work. This novel approach supports scalable measurement and evidence-based work design interventions to improve trainee well-being, education, and clinical efficiency.

BackgroundHealth facility financial autonomy enables facilities to retain their revenue and use it to meet facility level needs and priorities to ensure responsiveness, accountability and efficiency. Public facilities need to develop public finance management (PFM) compliant budgets before spending this revenue. However, existing constraints such as lack of competencies and capacities among facility managers in developing budgets and limited political goodwill have influenced the existence of autonomy. This study presents a case study of Nakuru county which implemented an intervention to enhance the capacity of facility managers in developing, implementing and monitoring budgets. MethodsWe used a qualitative case study approach, with data collected through participant observations and document analysis. We utilized process evaluation in examining the motivations for the intervention, its implementation, early outcomes and the role of context in these outcomes. ResultsThe emergence of the intervention was guided by technical, legal and political motivations. The implementation was done in four phases. The first phase targeted the Level four (4) and five (5) facilities who had greater experience with revenue management and already had some level of autonomy, while the second phase built on the lessons learnt and targeted level three (3) and two (2) facilities. The last phase focused on institutionalization and continuous improvement of the standard budgeting process. Early findings showed improvements in budgeting practices in higher level facilities but minimal in level two (2) facilities with some contextual factors such as availability of management staff playing a role. ConclusionThe experience of Nakuru county in building budgeting capacity for facility financial autonomy demonstrates that sustained progress requires a multi-year, adaptive approach that combines training with standardized tools, institutional support, and routine performance monitoring. This journey offers valuable lessons for effective decentralization: tailor support by facility level, embed monitoring and accountability mechanisms, and foster strong leadership and partnerships to sustain gains and enable responsive, autonomous health service delivery.

BackgroundThe urgent care departments in Europe face a structural paradox: accelerating digitalisation is accompanied by a patient population that is disproportionately unable to engage with standard digital tools. An internal analysis at the Emergency Department (Akutafdelingen) of Nordsjaellands Hospital in Hillerod, Denmark found that 43% of emergency patients struggle with digital solutions -- a figure that reflects the predictable composition of acute care populations rather than any individual failing. ObjectiveThis paper presents the design, iterative development, and secondary validation of the ED Adaptive Interface (v5): a prototype adaptive patient terminal developed in response to this challenge. The system operationalises what the author terms impairment-first design -- a methodology that treats the most constrained patient experience as the primary design problem and derives the standard experience as a subset. The interface configures itself in under ten seconds via nurse-led setup, adapting across four axes of impairment: visual, motor, speech, and cognitive. SystemVersion 4 supports five accessibility modes, a heatmap pain assessment grid, a Privacy and Dignity panel, a live workflow tracker with care notifications, structured dual-category help requests, and plain-language medical term definitions across four languages. Version 5, reported here for the first time, introduces a Condition Worsening Escalation button, a Referral Pathway Display, a "Why Am I Waiting?" triage explainer, a Symptom Progression Log, MinSP/Yellow Card Scan simulation, expanded language support (seven languages: English, Danish, Arabic with full RTL layout, Turkish, Romanian, Polish, and Somali), and an expanded ten-item Communication Board. The entire system runs as a single 79-kilobyte HTML file with zero infrastructure requirements. MethodsTo base the design on patient-generated evidence, two independent social media threads were subjected to an inductive thematic analysis (Braun and Clarke, 2006) a primary corpus of 83 entries in the Facebook group: Foreigners in Denmark (collected March 2026) and a corroborating corpus in an international community group in the Aarhus region (collected April 2026). All identifiers in both datasets were fully anonymised under GDPR Article 89 research provisions prior to analysis. No participants were contacted. Generative AI tools were used to assist with drafting, writing, and prototype code development in the preparation of this manuscript; all scientific content, data collection, analysis, and conclusions are the sole responsibility of the authors. ResultsThe first discourse corpus produced five major themes in relation to the five general problem areas that the prototype was intended to cover: system navigation and triage literacy gaps (31 entries); language and cultural barriers (6 entries); communication failures during care (5 entries); staff overload and capacity constraints (8 entries); and pain and severity assessment failures (14 entries). The supportive dataset supported all five themes on its own and presented two new themes: the different treatment of international patients and medical gaslighting as a long-term trend of patient advocacy failure. One of the major structural discoveries the five most-liked comments were critical of the original poster being self-referring to the ED when she had in fact been explicitly triaged to receive 1813 telephone referral to the ED directly inspired the Referral Pathway Display and Why Am I Waiting? features in v5. ConclusionsThe convergence of design rationale and independent social evidence across all five problem categories suggests that impairment-first design is not a niche accessibility concern but a structural approach to healthcare interface quality. The prototype is ready for a structured clinical pilot using the System Usability Scale (SUS) and semi-structured staff interviews. The long-term roadmap includes full MinSP integration, hospital PMS connectivity, and clinical validation.