BMJ Open Quality

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

Executive SummaryThis study set out to evaluate the longer-term sustainability, effectiveness, and cost-effectiveness of the National PReCePT Programme (NPP) in England, and explore trends and MgSO4 guidance implementation practices in the devolved nations, Scotland and Wales. We found that the majority of improvement in MgSO4 use seemed to take place in the first year or two following the NPP. Benefits were largely sustained over the 4 years of follow-up, with an overall appearance of plateau in recent years. There was some indication of a slight declining trend in use coinciding with the COVID-19 pandemic, that continued to the end of 2022 (the end of the currently available data). Regional disparities in use of MgSO4 reduced since the NPP was launched. We estimated that the NPP was associated with around {pound}597,000 net monetary benefit (NMB) from a lifetime societal perspective, with an 89% probability of being cost-effective for babies with less than 30 weeks gestation. This NMB increased to {pound}4.2m when including babies up to 32 weeks gestation. By 2022, MgSO4 use in Wales had caught up with levels in England, with levels in Scotland not far behind. The NMB of implementing MgSO4 for babies up to 32 weeks gestation in the three nations has increased over time, generating approximately {pound}125m in England, {pound}8m in Scotland and {pound}5m in Wales in 2022. Consequently, the benefit forgone for not achieving optimal MgSO4 uptake has also reduced over time, although there remains considerable scope for improving performance in each nation. The improvements in implementing MgSO4 have generated health gains and cost savings associated with CP prevention. Investing additional resources in implementing MgSO4 further would be likely to be cost-effective in all three nations. Our analysis highlighted how devolved nation activities were (directly or indirectly) shaped by PReCePT methodology. Qualitative interviews with clinical leads involved in implementing MgSO4 in Scotland and Wales - where the NPP was not implemented - shed light on the separate but similar initiatives implemented there, explaining the increasing trends also observed in the devolved nations (e.g. the Maternity and Children Quality Improvement Collaborative (MCQIC) Preterm Perinatal Wellbeing Package (PPWP) in Scotland, improvement interventions mirroring PERIPrem in Wales, and British Association for Perinatal Medicine Toolkits in both nations). Challenges and enablers were linked to perinatal team relationships; local leadership with protected time and funding; access to national performance data; staff clarity and confidence on guidance and administration of treatment; opportunities for and commitment to co-creating meaning around the intervention; skills, competencies and resources available to adopters; and engagement in continuous improvement activities (e.g. audit and feedback, benchmarking and missed case reviews). Findings reiterate the need for local champions with backfill funding and protected time, and regional and national capacity building and support structures. These reflect findings from the corresponding interviews with English teams. The essential next step in this quality improvement journey is to better quantify, in this same population, the health and societal benefits associated with cases of cerebral palsy prevented from the improvements achieved in use of MgSO4.

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 adoption of remote methods of care has been accelerated by the COVID-19 pandemic, but concerns exist relating to the potential impact on health disparities. This evaluation explores the implementation of COVID-19 remote home monitoring services across England, focussing on patients experiences and engagement with the service. MethodsThe study was a rapid, multi-site, mixed methods evaluation. Data were collected between January and June 2021. We conducted qualitative interviews with staff service leads, and patients and carers receiving the service. We conducted quantitative surveys with staff delivering the service, and patients and carers receiving the service across 28 sites in England, UK. Qualitative data were analysed using thematic analysis and quantitative data were analysed using univariate and multivariate methods. FindingsMany sites designed their service to be inclusive to the needs of their local population. Strategies included widening eligibility criteria, prioritising vulnerable groups, and creating referral pathways. Many sites also adapted their services according to patient needs, including providing information in different languages or more accessible formats, offering translation services, offering non-digital options, or providing face-to-face assessments. Despite these adaptions, disparities were reported across patient groups (e.g. age, health status, ethnicity, level of education) in their experience of and engagement with the service. InterpretationServices must determine how best to design and implement remote monitoring services to be of value to all populations. National guidance should play a role in supporting services to best serve the needs of their populations, and patients and staff must play an active role in service design. FundingThis is independent research funded by the National Institute for Health Research, Health Services & Delivery Research programme (RSET Project no. 16/138/17; BRACE Project no. 16/138/31) and NHSEI. NJF is an NIHR Senior Investigator. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSEvidence shows COVID-19 has a disproportionate impact on certain population groups, such as ethnic minority groups, older adults and those with comorbidities. The rapid adoption and spread of remote home monitoring services in England must be accompanied by evaluations at a local level to monitor the impact on health disparities in local populations. Added value of this studyThis rapid mixed methods evaluation of COVID-19 home monitoring services adopted across 28 sites in England aimed to increase understanding of how services have been designed and delivered to address local population needs to increase accessibility to the service and facilitate engagement with the service. We add to the literature by identifying a range of local service adaptations which aim to increase reach and facilitate patient engagement, and consider their potential impact on health disparities. We found strategies included prioritising vulnerable groups, creating referral pathways, offering translation services, offering non-digital options, or providing face-to-face assessments. Despite efforts to adapt services to meet local needs, disparities across patient groups in their experience of, and engagement with, the service (related to age, health status, ethnicity, and level of education) were reported. Implications of the available evidenceAt both a national and local level, and particularly given the increasing use of remote home monitoring schemes, lessening health disparities must be a primary focus in the design and delivery of remote monitoring models for COVID-19 and other conditions. Future research should focus on how best to design and evaluate remote monitoring services, for a range of conditions, especially for patients residing in areas where significant health disparities persist, as well as addressing the effectiveness of any strategies on specific population groups.

BackgroundClinical decisions made early after stroke can make the difference between survival with disability or death. We aimed to develop, implement and evaluate a new Shared decision making (SDM) process for severe stroke into a regional 36 bedded stroke unit. MethodsWe developed the process through four coproduction workshops, attempted its implementation then its impact on death at 6 months, discharge destination and tube feeding. We also explored patients, families and staff views about SDM. ResultsEleven people (staff and people with lived experience of stroke) attended the first co-production workshop, eight the second, seven the third and six the fourth. The new SDM process incorporated Tailored Talks (a digital platform with information about stroke and its prognosis) and an implementation plan (including staff training). We implemented this process on 1st August 2022. Only 8/1020 patients received Tailored Talks (4 before and 4 after implementation). For the entire group there was no change tube feeding, discharge destination or death. The proportion of people with severe strokes dead at six months was higher before implementation. Twenty-one patients or family members provided views about SDM quality, but the sample size was too small to draw conclusions. Staff interviews suggested that insufficient time, lack of a human touch and inadequate leadership explained the lack of implementation. ConclusionOur co-produced SDM was not effectively implemented into a stroke unit and there was no change in the use of tube feeding or death in 1020 patients. Key pointsShared decision making after severe stroke is complex. A co-produced new process for shared decision making after severe stroke was not effectively implemented into clinical practice. There was no change in tube feeding, death or institutionalisation.

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

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.

BackgroundAvoidable hospital admissions in the UK have been a focal area for healthcare policy and research, often with a focus on prevention. This is particularly important as hospitalisation can negatively impact patients, especially frail older people, leading to further risk of morbidity and mortality. To reduce costs and enhance patient care, the focus has shifted toward improving community interventions to prevent admissions. Actions to address this issue include the expansion of new types of care, such, for example, virtual wards. However, evidence is lacking on how current initiatives are improving care and which factors lead to emergency admissions which could be avoided in the UK. The aim of this study is to examine and synthesise the current evidence of admissions avoidance in the UK, including understanding how different populations, chronic conditions and social determinants might affect the most the risk of avoidable admissions. From a health services perspective the aim is to understand which types of care and community interventions prevent avoidable admissions. DesignThe published evidence on admission avoidance is voluminous and so a hermeneutic review was undertaken. Results82 papers met the criteria. A dominant theme is the complexity of reducing emergency admissions, emphasising the impact of social determinants, particularly in deprived and older populations. Optimising service delivery, targeting care gaps, and improving care coordination are essential. Managing comorbidities, especially in conditions like ambulatory care-sensitive conditions such as COPD, diabetes, heart failure, cancer and preventing infections, can reduce admissions. Interventions vary in context, style and target with some, particularly those who provide care to high-risk patients and in deprived areas showing success in reducing emergency attendances and improving hospital resource use. ConclusionIn conclusion, preventing avoidable admissions is complex due to the broad range of factors that influence risk of admission, and the multifaceted interventions required, as no single solution fits all neither interventions evaluations are consistent. This complexity should be considered when introducing new services. While shifting care towards the community can offer benefits, this review suggests a more integrated approach--one that bridges acute, hospital, and community care--is necessary to effectively reduce emergency admissions. Key target areas which might offer further opportunities are those populations who are elderly, experience poverty and social deprivation and which have high risk of comorbidities such as ambulatory care-sensitive conditions.

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.

Communication with patients in language they understand leads to greater comprehension of treatment and diagnoses but can be time consuming for clinicians. Here we sought to investigate the utility of ChatGPT to translate clinic letters into language patients understood, without loss of clinical information. Twenty-three letters from a range of specialities were translated, resulting in no loss of clinical information. Subjective analysis from patient representatives revealed significantly increased understanding of treatment and diagnoses, increased satisfaction, and a significant decrease in the requirement to seek medical assistance in understanding their content when compared to original letters written to clinicians. Overall, we conclude that ChatGPT can be used to translate clinic letters into patient friendly language, and that these letters are preferred by patients.

ObjectiveTo compare the impact of the National PReCePT Programme (NPP) versus an enhanced Quality Improvement (QI) support programme in improving magnesium sulfate (MgSO4) uptake in English maternity units. DesignUnblinded cluster randomised controlled trial. SettingEngland, Academic Health Sciences Network (AHSN), 2018. ParticipantsMaternity units with [&ge;]10 preterm deliveries annually and MgSO4 uptake [&le;]70%. 40 maternity units (27 NPP, 13 enhanced support) were included (randomisation stratified by MgSO4 uptake). InterventionsNHS England commissioned the NPP to increase MgSO4 uptake in very preterm deliveries to reduce risk of cerebral palsy. NPP maternity units received PReCePT QI materials, regional support, and midwife backfill funding. Enhanced support units received this plus extra backfill funding and unit-level QI coaching. Outcome measuresMgSO4 uptake post-implementation was compared between groups using routine data and multivariable linear regression. Net monetary benefit was estimated, based on implementation costs, lifetime quality-adjusted life-years and societal costs. The implementation process was assessed through qualitative process evaluation. ResultsMgSO4 uptake increased in all units, with no evidence of difference between groups (0.84 percentage points lower uptake in the enhanced group, 95% Confidence Interval -5.03 to 3.35 percentage points). The probability of enhanced support being cost-effective was <30%. NPP midwives allocated more than their funded hours. Units varied in support required to successfully implement the intervention. Enhanced support units reported better understanding, engagement, and perinatal teamwork. ConclusionPReCePT improved MgSO4 uptake in all maternity units. Enhanced support did not further improve uptake but may improve teamwork, and more accurately represented the time needed for implementation. Targeted enhanced support, sustainability of improvements and the possible indirect benefits of stronger teamwork associated with enhanced support should be explored further. Trial registrationISRCTN 40938673 (https://www.isrctn.com/ISRCTN40938673) WHAT IS ALREADY KNOWN ON THIS TOPICO_LIDespite long-standing evidence that Magnesium Sulfate (MgSO4) confers fetal neuroprotection and reduces risk of cerebral palsy in very preterm babies, by 2017 only two-thirds of eligible women in England were receiving it, with wide regional variation. C_LIO_LIThe pilot PReCePT (Prevention of Cerebral Palsy in preterm labour) Quality Improvement (QI) study appeared to effectively accelerate uptake of MgSO4, and a version of this support model was rolled-out nationwide in 2018. C_LI WHAT THIS STUDY ADDSO_LIPReCePT improved MgSO4 uptake in all maternity units, and the full ( enhanced) support model did not appear to improve uptake beyond the achievements of the standard support model used in the National PReCePT Programme. However, enhanced support may be associated with improved perinatal team working, and the funding more accurately represented the staff time needed for implementation. C_LI HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICYO_LIPReCePT may serve as a blueprint for other improvement programs to accelerate uptake of evidence-based interventions, and future studies should consider the potential for indirect but far-reaching benefits to staff and patients. C_LI

ObjectiveTo identify key characteristics associated with a CQC positive and negative safety rating across London NHS organisations. DesignAdvanced data analytics and linear discriminant analysis. Data sourcesLinked CQC data with patient safety variables sources from 10 publicly available datasets. MethodsIterative cycles of data extraction, insight generation, and analysis refinement were done and involved regular meetings between the NHS London Patient Safety Leadership Forum and analytic team to optimise academic robustness alongside with translational impact. Ten datasets were selected based on data availability, usability, and relevance and included data from April 2018 to December 2019. Data pre-processing was conducted in R. Missing values were imputed using the median value while empty variables were removed. London NHS organisations were categorised based on their safety rating into two groups: those rated as inadequate or requires improvement (RI) and those rated as Good or outstanding (Good). Variable filtering reduced the number of variables from 1104 to 207. The top ten variables with the largest effect sizes associated with Good and RI organisations were selected for inspection. A Linear Discriminant Analysis (LDA) was trained using the 207 variables. Effect sizes and confidence intervals for each variable were calculated. Dunns and Kruskal-Wallis tests were used to identify significant differences between RI and Good organisations. ResultsTen variables for Good and RI NHS organisations were identified. Key variables for Good organisations included: Organisation response to address own concerns (answered by nurse/midwife) (Good organisation = 0.691, RI organisation = 0.618, P<.001); fair career progression (answered by medical/dental staff) (Good organisation = 0.905, RI organisation = 0.843, P<.001); existence of annual work appraisal (answered by medical/dental staff)) (Good organisation = 0.922, RI organisation = 0.873, P<.001); organisations response to patients concerns (Good organisation = 0.791, RI organisation = 0.717, P<.001); harassment, bullying or abuse from staff (answered by AHPHSSP) (Good organisation = 0.527, RI organisation = 0.454, P<.001); adequate materials supplies and equipment (answered by Other staff) (Good organisation = 0.663, RI organisation = 0.544, P<.001); organisation response to address own concerns (answered by medical/dental staff) (Good organisation = 0.634, RI organisation = 0.537, P<.001); staff engagement (answered by medical/dental staff) (Good organisation = 0.468, RI organisation = 0.376, P<.001); provision of clear feedback (answered by "other" staff) (Good organisation = 0.719, RI organisation = 0.650, P<.001); and collection of patient feedback (answered by wider healthcare team) (Good organisation = 0.888, RI organisation = 0.804, P<.001). ConclusionsOur study shows that healthcare providers that received positive safety inspections from regulators have significantly different characteristics in terms of staff perceptions of safety than those providers rated as inadequate or requiring improvement. Particularly, organisations rated as good or outstanding are associated with higher levels of organisational safety, staff engagement and capacities to collect and listen to patient experience feedback. This work exemplifies how a partnership between applied healthcare and academic research organisations can be used to address practical considerations in patient safety, resulting in a translational piece of work.

BackgroundAnticipatory injectable medications for symptom control are a key end-of-life care intervention. However, ensuring their safe and timely use in the community is a global challenge. The needs and priorities of stakeholders involved in processes for prescribing and administering these medications remain underexplored. We must understand these perspectives to design inclusive and adaptive systems. AimTo identify the needs and priorities of key stakeholders involved in community-based systems for using anticipatory injectable medications. DesignWe adopted a qualitative exploratory design, using an online survey between September and October 2024. Participants provided anonymised demographic information and completed up to four prompts capturing their stakeholder role, needs and priorities. Data were analysed using a combined inductive-deductive framework to produce synthesised shortlists of priorities and needs. Setting/participantsUK-based professional and public participants were recruited through social media, professional networks, charities, and public engagement events. ResultsIn total, 439 participants contributed 729 responses across various stakeholder groups. Findings revealed substantial diversity in stakeholder needs and priorities, both within and between groups. However, most stakeholder groups prioritised timely care, minimising of suffering, and wanted nationally consistent guidance for using injectable medications. Broader societal influences also shaped responses. ConclusionsOur findings highlight wide diversity in priorities and needs between stakeholders for using anticipatory injectable medications in the community. We propose that inclusive system design should include comprehensive assessment of key stakeholders needs and priorities, with the aim of providing better care. Our study demonstrates that stakeholder needs assessment offers a valuable framework to achieve this. What is already known about the topic?O_LIAnticipatory injectable medications are a widely used intervention in several countries to support timely end-of-life symptom control at home. C_LIO_LIThere are ongoing challenges with delays, inconsistent access, and variations in prescribing and governance across regions, indicating that system design influences both timeliness and safety. C_LIO_LIExisting research has primarily focused on the needs of individual professional groups, and no prior work has mapped the differing needs of all stakeholders involved in these systems. C_LI What this paper adds?O_LIOur study demonstrates that stakeholder groups have diverse needs but most share some core priorities -timely care, national consistency in practice guidance, and minimising suffering. C_LIO_LIWider societal factors and concerns shape stakeholder expectations of end-of-life medication systems. C_LIO_LIOur approach to stakeholder needs assessment reveals system requirements that consensus-based or single-perspective approaches often overlook. C_LI Implications for practice, theory, or policyO_LISystem improvements should be tailored to the specific needs of key stakeholder groups rather than assuming uniform priorities. C_LIO_LIStrong cross-stakeholder support exists for national, practical guidance on anticipatory prescribing, equipment, training, and governance. C_LIO_LIStakeholder needs assessment offers a useful method for designing safer, more responsive end-of-life medication systems. C_LI

Advancements in artificial intelligence (AI) are revolutionising the healthcare sector, but challenges exist in AI adoption and its long-term use. This umbrella review aimed to identify the facilitators and barriers of AI implementation within hospitals and was registered on PROSPERO. Five databases (MEDLINE, HMIC, CINAHL Plus, Web of Science and Cochrane Reviews) were searched in January 2025, 763 articles were screened, with 13 included. The inclusion criteria encompassed studies implementing AI that were conducted within the hospital setting. The quality of the data were assessed using the ROBIS checklist and data were extracted using the NASSS (Nonadoption, Abandonment, and challenges to the Scale-up, Spread, and Sustainability) framework, to demonstrate how AI implementation was affected by: whether the AI solution had been technologically validated to ensure generalisability across departments; evidence the AI solution brings measurable gains; a lack of trust or understanding among hospital staff; the budgets and resources available to onboard the AI solution, train staff, and maintain the solution; the need for national policies on funding and regulating AI solutions. These factors affected the adoption, spread, scalability and sustainability of AI implementation and could be considered in future implementation efforts. The study was funded by the NIHR (NIHR205439).

BackgroundMultiple long-term conditions (MLTC) are increasingly common and place significant strain on healthcare systems designed around single-organ conditions, often resulting in fragmented and reactive care for people living with MLTC. There is limited understanding of how health care professionals (HCPs) make decisions for and with individuals with MLTC at the point of hospital presentation. This study examined how HCPs in emergency and acute settings make decisions around pathways and places of care for people with MLTC, exploring the factors that shape clinical judgement, the challenges HCPs navigate in practice and structures that influence clinical decision-making. MethodsWe conducted semi-structured, individual interviews with 40 NHS professionals working in emergency departments (EDs) and acute assessment units across multiple regions, roles, and specialties. Participants included consultant physicians, resident doctors, senior nursing staff and allied health professionals. Interviews focused on how decisions were made around referrals, admissions, and care planning for people with MLTC. Data were analysed thematically using an inductive approach. ResultsFour themes were identified: A journey of uncertainty, Within and beyond limitations, Structures of care and Implementing relational care. Clinical decision-making is shaped by clinical uncertainty, limited resources, care approaches, and interpersonal relationships and communication. Fragmented services and single-disease pathways complicate care, but participants highlighted the value of continuity, communication, and relational approaches. Challenges include resource limitations, rigid pathways and limited community support. Key enablers of clinical decision-making include integrated care, ownership, and early conversations about priorities. ConclusionsClinical decision-making by HCPs in hospitals for patients with MLTC is complex and shaped by systemic misalignment, where clinical realities clash with health system structures. Improving clinical decision-making around referrals, admissions and care planning for people with MLTC will require adapting systems and training to reflect the realities of MLTC. Potentially beneficial adaptations include strengthening relational and multidisciplinary approaches and expanding intermediate care to reduce avoidable admissions.

BackgroundClinical research studies have made significant strides globally requiring clear processes to transition research interventions into clinical practice. Theoretically, implementation of novel interventions require clear methods as part of a fit-for-purpose (FFP) framework comprising of effective adaptation processes in conjunction with practice policies. Implementation science (IS) based operational research (OR) is vital in global health as it addresses the know-how-do gap using a real-world setting to achieve best practices to sustain healthcare. Despite this, limited OR is available to evaluate and validate implementation frameworks for complex clinical specialties such as oncology, diagnostic radiology (DR), nuclear medicine (NM) and interventional radiology (IR). This is the first study to systematically review implementation frameworks including its validity and applicability in healthcare. MethodWe searched 17 databases including PubMed, Medline/OvidSP, Science Direct, PROSPERO, PRISMA, PubMed Health, Embase, EBSCOhost, SciELO, TRIP, ProQuest, Academic search complete, Ageline, Cochrane, Web-of-Science and BIOSIS using a comprehensive search strategy and MeSH indexing to review publications from January 1st 1980 to 31st March 2019 in English. We selected 20 publications as per the inclusion/exclusion criteria developed under a review protocol registered with PROSPERO (CRDG42019124020). FindingsThere were no publications indicating a validated framework or a specific system used to implement evidence based interventions (EBIs) within oncology, IR, NM and DR although there were generalized implementation processes, adaptation models and policies. Furthermore, validation studies were not conducted against these frameworks to review their applicability and viability in healthcare especially in the UK. InterpretationIt is evident there is a research implementation gap in healthcare and further research is required to establish a fit for purpose framework to cover multiple blind spots using a real-world (RW) setting. Current evidence also suggests, alignment of academic theories to healthcare including its applicability to various clinical specialties is needed.

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

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

Introduction Patients with nephrolithiasis face challenges in making a high-quality, preference sensitive decision. Our prior work established feasibility and patient acceptance of a software-based decision aid (DA). The objectives for this study were to identify implementation strategies for the DA in routine care and determine whether DA implementation enhances decisional quality for patients. Methods New nephrolithiasis patients were recruited from the institution Medical Center from June 2018 to April 2024 to receive a software-based pre-visit DA that measured care preferences and used decision analysis to rank treatments. The RE-AIM framework and Plan-Do-Study-Act (PDSA) cycles were used to improve implementation outcomes. Patients completed survey instruments evaluating decisional conflict, shared decision-making, care satisfaction, and treatment choice following their provider visit. These metrics were compared in the DA cohort (n=81) to those in a usual care cohort (n=78) with Wilcoxon rank-sum and Chi-square (or Fishers exact) tests. Results Implementation data revealed sustained reach and progressive improvement in fidelity. The DA cohort reported higher decisional quality relative to controls (p=0.003) and reported greater support/advice to make a choice (p=0.005). The DA cohort more often discussed options with their doctor (87.5% vs 69.2%, p=0.005) and were more likely to be promoters of their provider (p<0.001) and health system (p=0.029). The DA cohort was less likely to have switched their treatment preference post-consultation (32.1% vs 71.8%, p<0.001) suggesting greater consistency in decision-making. Conclusions Software-based DAs in nephrolithiasis can mitigate decisional conflict, improve SDM, and improve patient satisfaction. Further work should explore broader implementation and long-term clinical outcomes.