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BackgroundQuality improvement collaboratives (QIC) have proliferated internationally, but there is little empirical evidence for their effectiveness.MethodWe searched Medline, Embase, CINAHL, PsycINFO and the Cochrane Library databases from January 1995 to December 2014. Studies were included if they met the criteria for a QIC intervention and the Cochrane Effective Practice and Organisation of Care (EPOC) minimum study design characteristics for inclusion in a review. We assessed study bias using the EPOC checklist and the quality of the reported intervention using a subset of SQUIRE 1.0 standards.ResultsOf the 220 studies meeting QIC criteria, 64 met EPOC study design standards for inclusion. There were 10 cluster randomised controlled trials, 24 controlled before-after studies and 30 interrupted time series studies. QICs encompassed a broad range of clinical settings, topics and populations ranging from neonates to the elderly. Few reports fully described QIC implementation and methods, intensity of activities, degree of site engagement and important contextual factors. By care setting, an improvement was reported for one or more of the study’s primary effect measures in 83% of the studies (32/39 (82%) hospital based, 17/20 (85%) ambulatory care, 3/4 nursing home and a sole ambulance QIC). Eight studies described persistence of the intervention effect 6 months to 2 years after the end of the collaborative. Collaboratives reporting success generally addressed relatively straightforward aspects of care, had a strong evidence base and noted a clear evidence-practice gap in an accepted clinical pathway or guideline.ConclusionsQICs have been adopted widely as an approach to shared learning and improvement in healthcare. Overall, the QICs included in this review reported significant improvements in targeted clinical processes and patient outcomes. These reports are encouraging, but most be interpreted cautiously since fewer than a third met established quality and reporting criteria, and publication bias is likely.

Freshwater ecosystems are under increasing threat of salinization due to human activity. Given the contributions of microbial communities to stream ecosystems, it is critical to understand how these communities are affected by the increasing presence of salt in the environment. We used an artificial stream system to investigate how salt concentrations representing the 95th- and 99th-percentile of concentrations observed in NE Ohio streams affect bacterial community succession and what implications this has on community-level functional capabilities. We hypothesized that the successional trajectory of community functionality (in the form of extracellular enzyme activity) and structure (via denitrification gene abundances and community 16S rRNA gene profiles) would be altered in response to increasing salt concentrations. We observed considerable structural changes in bacterial composition among treatments that corresponded with niche expansion by more salt-tolerant taxa. Increases in denitrification gene abundances and modifications to extracellular enzyme activity were also observed. These data suggest that continued salt pollution can dramatically affect community structure and has the potential to modify the functional contributions of the bacterial community to the ecosystem.

Atomic models for nucleic acids derived from X-ray diffraction data at low resolution provide much useful information, but the observed scattering intensities can be fit with models that can differ in structural detail. Tradtional geometric restraints favor models that have bond length and angle terms derived from small molecule crystal structures. Here we explore replacing these restraints with energy gradients derived from force fields, including recently developed integral equation models to account for the effects of water molecules and ions that are not part of the explicit model. We compare conventional and force-field based refinements for 22 RNA crystals, ranging in resolution from 1.1 to 3.6 Å. As expected, it can be important to account for solvent screening of charge–charge interactions, especially in the crowded environment of a nucleic acid crystal. The newly refined models can show improvements in torsion angles and hydrogen-bonding interactions, and can significantly reduce unfavorable atomic clashes, while maintaining or improving agreement with observed scattering intensities.

In this paper, we pay attention to the impact on staff of what was a new place, Ko Awatea, within a large New Zealand hospital. The place became a space from within which a particular mood arose. This paper seeks to capture that mood and its impact. Using a Heideggerian hermeneutic approach, the study reported on drew on data from interviews with 20 staff. Philosophical notions about the nature and mood of place/space are explored. As staff claimed this space, the mood that emerged was of liveliness, buzz and comfort. It became a space where people wanted to be, where they met others, where conversations unfolded, where thinking happened in new ways. Staff places tend to be sacrificed or poorly resourced in resource-tight environments. We argue that creating a space that feels home-like, where staff come, linger and engage in community is a priority for generating the mood and thinking of an organization. Such spaces do not happen by chance; it takes forethought and intentionality. The gift of such space is the thinking that is sparked and grown.

Fertilizer use has dramatically increased the availability of nitrate (NO3−) in aquatic systems. Microbe-mediated denitrification is one of the predominant means of NO3− removal from freshwaters, yet oxygenation (O2)-induced disruptions—e.g., extreme precipitation events—can occur, resulting in a disproportional increase in nitrous oxide (N2O) production and efflux as facultative anaerobic bacterial populations use of O2 as a terminal electron acceptor increases. We examined the effects of 12- and 24-h passive O2 exposure on previously anaerobic bacterial communities focusing on denitrification enzyme activity (DEA), N2O production, and bacterial community 16S rRNA and nitrous oxide reductase gene (nosZ) profiles after 12, 24, and 48 h of anaerobic recovery. Treatments experiencing 24-h O2 exposure had significantly higher DEA 12 h into anaerobic recovery than treatments undergoing 12-h O2 exposure. Initial N2O emissions were significantly lower in the 24-h O2 exposure treatments although by 24 h a dramatic spike (tenfold relative to the 12-h O2 exposure treatments) in N2O concentrations was observed. However, within 6 h (30-h anaerobic recovery) these differences were gone. Community nosZ profiles experiencing 24-h O2 exposure exhibited reduced diversity after 24-h recovery, which corresponded with an increase in N2O emissions. However, after 48 h of anaerobic recovery, nosZ diversity had recovered. These observations highlight the effects of short-term aerobic disruption on denitrification, as well as the effects on the denitrifier community profile. Together, these data suggest that recovery to ambient N cycling is exacerbated by disturbance length due to increased lag time and subsequent loss of denitrifier community diversity.

The increasing demand for genetic assessment for familial breast cancer has necessitated the development of cancer genetics services. However, little is known about the factors motivating the client population likely to approach these services. A cross sectional questionnaire survey of 1000 women with a family history of breast cancer was conducted to identify self-reported reasons for attending a familial breast cancer clinic and possible differences in the characteristics of women who were attending for diverse reasons. Before attendance at clinic, 833 women completed a baseline questionnaire (83% response rate). Women who gave personal risk (n=188), awareness of a family history (n=120), risk to family members (n=84), reassurance (n=69), genetic testing (n=65), breast screening (n=46), or prevention (n=39) as their main reason for attending were compared on demographic and medical variables, and on psychological variables including general anxiety, cancer worry, perceived risk, and attitudes towards prophylactic surgery and genetic testing. Important differences in the psychological characteristics of these groups were found, which were unrelated to reported family history. In particular, women who primarily wanted genetic testing felt extremely vulnerable to developing breast cancer, were more likely to be considering prophylactic surgery, and perceived fewer limitations of testing. Those who primarily wanted reassurance were highly anxious about the disease. We recommend that cancer genetics services take into consideration the informational and psychological needs and concerns of their client group.

BackgroundMethodsIt draws on a series of 20 interviews with key protagonists and employs a Bakhtinian approach to narrative analysis, which explores the interplay between individual accounts and larger sociocultural themes.ResultsConclusionsIt concludes that the success in managing the complexity of this project can largely be attributed to a systems leader approach that draws on the power of an agile network to be replenished and redeployed against rapidly evolving strategic objectives. This effectively constitutes a parallel operating structure, which is devoted to the design and implementation of strategy based on a continual assessment of the organisation and serves to strengthen rather than supersede established hierarchical structures of authority.

Objectives To report on selected findings from an evaluation of two consecutive quality improvement campaigns that adapted the Breakthrough Series Collaborative model to the broad topic of reducing demand for hospital care and reflect on lessons learned from their adaption of the model for subsequent collaborative improvement efforts. Methods We conducted a series of semi-structured interviews with Campaign sponsors and Collaborative team leaders as part of the broader realist evaluation of the two Campaigns. In addition, follow-up semi-structured interviews with Campaign sponsors and implementers were undertaken three years after the evaluation concluded (ex post evaluation interviews) to understand which adaptions to the Breakthrough Series Collaborative model had been the most influential. Results The interviews explored two features that differentiated the Campaigns from other Breakthrough Series Collaboratives. Firstly, the Campaigns enabled a diverse range of improvement solutions to be tested which had implications for the collaborative nature of the learning collaboratives. Secondly, two sequential Campaigns were implemented that incorporated common elements and provided the opportunity for the transfer of knowledge from one Campaign to the next. Conclusions Given widespread pressure to transform health care into a learning system, this paper provides a practical example of using cumulative insights to encourage the sustainability of collaborative improvement efforts. These insights centre on the gains from spreading improvement methodology throughout the organization and learning how to select and support successful collaborative teams.

Purpose The purpose of this paper is to investigate the contextual factors contributing to the sustainability of healthcare quality improvement (QI) initiatives. Design/methodology/approach Themes from semi-structured interviews with international healthcare leaders are compared with Kaplan and Provost et al.’s (2012) model for understanding success in quality (MUSIQ). Critical success factors within these themes are shown in detail. Findings The interviews provide a rich source of information on critical success factors. The themes largely correspond with MUSIQ, reinforcing its robustness. An important factor emerging from the interviews was the importance of engagement with patients and families in QI, and this needs consideration in seeking to understand context in QI. Research limitations/implications Interview participants represent a limited set of western countries and health systems. Their experiences may not hold true in other settings. Practical implications The detail on critical success factors provides QI practitioners with guidance on designing and implementing sustainable initiatives. Originality/value Including consideration of contextual factors for engagement with patients and families in frameworks for context in QI appears to be an original idea that will add value to such frameworks. Researchers in patient engagement are starting to address contextual factors and connections should be made with this work.

In this paper, we pay attention to the impact on staff of what was a new place, Ko Awatea, within a large New Zealand hospital. The place became a space from within which a particular mood arose. This paper seeks to capture that mood and its impact. Using a Heideggerian hermeneutic approach, the study reported on drew on data from interviews with 20 staff. Philosophical notions about the nature and mood of place/space are explored. As staff claimed this space, the mood that emerged was of liveliness, buzz and comfort. It became a space where people wanted to be, where they met others, where conversations unfolded, where thinking happened in new ways. Staff places tend to be sacrificed or poorly resourced in resource-tight environments. We argue that creating a space that feels home-like, where staff come, linger and engage in community is a priority for generating the mood and thinking of an organization. Such spaces do not happen by chance; it takes forethought and intentionality. The gift of such space is the thinking that is sparked and grown.