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Background Each year 700,000 infants die due to intrapartum-related complications. Implementation of Helping Babies Breathe (HBB)-a simplified neonatal resuscitation protocol in low-resource clinical settings has shown to reduce intrapartum stillbirths and first-day neonatal mortality. However, there is a lack of evidence on the effect of different HBB implementation strategies to improve and sustain the clinical competency of health workers on bag-and-mask ventilation. This study was conducted to evaluate the impact of multi-faceted implementation strategy for HBB, as a quality improvement cycle (HBB-QIC), on the retention of neonatal resuscitation skills in a tertiary hospital of Nepal. Methods A time-series design was applied. The multi-faceted intervention for HBB-QIC included training, daily bag-and-mask skill checks, preparation for resuscitation before every birth, self-evaluation and peer review on neonatal resuscitation skills, and weekly review meetings. Knowledge and skills were assessed through questionnaires, skill checklists, and Objective Structured Clinical Examinations (OSCE) before implementation of the HBB-QIC, immediately after HBB training, and again at 6 months. Means were compared using paired t-tests, and associations between skill retention and HBB-QIC components were analyzed using logistic regression analysis. Results One hundred thirty seven health workers were enrolled in the study. Knowledge scores were higher immediately following the HBB training, 16.4 ± 1.4 compared to 12.8 ± 1.6 before (out of 17), and the knowledge was retained 6 months after the training (16.5 ± 1.1). Bag-and-mask skills improved immediately after the training and were retained 6 months after the training. The retention of bag-and-mask skills was associated with daily bag-and-mask skill checks, preparation for resuscitation before every birth, use of a self-evaluation checklist, and attendance at weekly review meetings. The implementation strategies with the highest association to skill retention were daily bag-and-mask skill checks (RR-5.1, 95% CI 1.9–13.5) and use of self-evaluation checklists after every delivery (RR-3.8, 95% CI 1.4–9.7). Conclusions Health workers who practiced bag-and-mask skills, prepared for resuscitation before every birth, used self-evaluation checklists, and attended weekly review meetings were more likely to retain their neonatal resuscitation skills. Further studies are required to evaluate HBB-QIC in primary care settings, where the number of deliveries is gradually increasing. Trial registration ISRCTN97846009 . Date of Registration- 15 August 2012.

The COVID-19 pandemic has posed challenges to the conduct of clinical trials. Strategies for overcoming common challenges to non-COVID-19 trial continuation have been reported, but this literature is limited to pharmacological intervention trials from high-income settings. The purpose of this paper is to expand the literature to include a low- and middle-income country perspective. We describe the challenges posed by COVID-19 for a randomised feasibility trial of a psychological intervention for adolescents in Cape Town, South Africa, and lessons learned when implementing strategies to facilitate trial continuation in this context. We used a Plan-Do-Study-Act cycle method to explore whether our adaptations were having the desired effect on trial accrual and retention. We found that stakeholder engagement, trial coordination and team communication need to be intensified while testing these procedural changes. We learned that strategies found to be effective in high-income countries required significant adaptation to our resource-constrained setting. The detailed documentation of extraneous influences, procedural changes and trial process information was essential to guiding decisions about which adaptations to retain. This information will be used to examine the potential impact of these changes on study outcomes. We hope that these reflections will be helpful to other trialists from low- and middle-income countries grappling with how to minimise the impact of public health emergencies on their research. Trial registration The trial is registered with the Pan African Clinical Trials Registry (PACTR20200352214510). Registered 28 February 2020.   https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9795 .

Background: Tuberculosis (TB) is a major global health challenge, and South Africa is one of the high-burden countries. A national TB infection control (TBIC) guideline has stipulated three areas of infection control at health facilities: work practice and administrative control, environmental control, and personal protection for health workers. Aim: The aim of this study was to identify the gaps and address the challenges in institutional TBIC. Setting: The district hospital and a primary health care clinic within the Mossel Bay sub-district in the Western Cape. Methods: According to the national TBIC draft guideline, a quality improvement cycle was used to evaluate and improve TBIC. Each facility had an existing infection and prevention control and occupational health and safety team, which were used as the audit teams. Results: A baseline assessment was followed by a set of interventions, which did not show a significant improvement in TBIC. The difference between the pre- and post-intervention TB screening rate was not statistically significant. An assessment of time interval between 101 patients presenting with TB symptoms and diagnosed with TB was 4 days at baseline and post-intervention. Most of the anticipated improvements were dependent on the health workers’ adherence to the local TBIC policies, which emerged as an unexpected finding. Conclusion: We found good managerial commitment reflected by the presence of various policies, guidelines, specific personnel and committees to deal with infection control in general. This study has created awareness about TBIC among staff and pointed out the complexity of health workers’ behaviour towards adhering to policies.

Background: Foot screening is an important part of diabetic care as it prevents significant morbidity, loss of function and mortality from diabetic foot complications. However, foot screening is often neglected.Aim: This project was aimed at educating health care workers (HCWs) in a primary health care clinic to increase diabetic foot screening practices. Setting: A primary health care clinic in the Western Cape province of South AfricaMethods: A quality improvement project was conducted. HCWs’ needs were assessed using a questionnaire. This was followed by focus group discussions with the HCWs, which were recorded, transcribed and assessed using a general inductive approach. An intervention was designed based on common themes. Staff members were trained on foot screening and patient information pamphlets and screening tools were made available to all clinic staff. Thirty-two consecutive diabetic patient folders were audited to compare screening in 2013 with that in 2014 after initiation of the quality improvement cycle.Results: HCWs’ confidence in conducting foot screening using the diabetic foot assessment questionnaire improved markedly after training. Diabetic foot screening practices increased from 9% in 2013 to 69% in 2014 after the first quality improvement cycle. A strengths, opportunities, aspirations and results (SOAR) analysis showed promise for continuing quality improvement cycles.Conclusion: The findings showed a significant improvement in the number of diabetic patients screened. Using strategic planning with appreciative intent based on SOAR, proved to be motivational and can be used in the planning of the next cycle.

Background Management of chronic disease, including diabetes, is a central focus of most Aboriginal Community Controlled Health Services (ACCHSs) in Australia. We have previously demonstrated that diabetes monitoring and outcomes can be improved and maintained over a 10-year period at Derby Aboriginal Health Service (DAHS). While continuous quality improvement (CQI) has been shown to improve service delivery rates and clinical outcome measures, the process of interpreting audit results and developing strategies for improvement is less well described. This paper describes the evaluation of care of patients with type 2 diabetes mellitus (T2DM) and features of effective CQI in ACCHSs in the remote Kimberley region of north Western Australia. Methods Retrospective audit of records for Aboriginal and Torres Strait Islander primary care patients aged ≥15 years with a confirmed diagnosis of T2DM at four Kimberley ACCHSs from 1 July 2011 to 30 June 2012. Interviews with health service staff and focus group discussions with patients post audit. Main outcome measures: diabetes care related activities, clinical outcome measures and factors influencing good diabetes related care and effective CQI. Results A total of 348 patients from the four ACCHSs were included in the study. Clinical care activities were generally high across three of the four health services (at least 71% of patients had cholesterol recorded, 89% blood pressure, 84% HbA 1c ). Patients from DAHS had lower median cholesterol levels (4.4 mmol/L) and the highest proportion of patients meeting clinical targets for HbA 1c (31% v 16% ACCHS-3; P  = 0.02). Features that facilitated good care included clearly defined staff roles for diabetes management, support and involvement of Aboriginal Health Workers, efficient recall systems, and well-coordinated allied health services. Effective CQI features included seamless and timely data collection, local ownership of the process, openness to admitting deficiencies and willingness to embrace change. Conclusions Well-designed health care delivery and CQI systems, with a strong sense of ownership over diabetes management led to increased service delivery rates and improved clinical outcome measures in ACCHSs. Locally run CQI processes may be more responsive to individual health services and more sustainable than externally driven systems.

The main topics treated in this conference volume are problems of deflation and quality change, the adequacy of the data used to construct the U.S. national accounts, and the broad theoretical evolution of the U.S. national income and product accounts. As these topics suggest, this volume represents a new stage in the study of national income and product accounts in that emphasis is placed on the information content of the system rather than on the structure of the accounts. This new emphasis is highlighted by the inclusion of a discussion among prominent users of the national accounts—Lawrence Klein, Otto Eckstein, Alan Greenspan, and Arthur Okun—that indicates the difficulties that confront those who utilize this information.

This chapter contains sections titled: Quality and Quality Improvement Six Sigma Quality Improvement The Six Sigma Roadmap and DMAIC The Role of Statistical Methods in Six Sigma Minitab and its Role in the Implementation of Statistical Methods Exercises and Follow‐Up Activities

Aims: Individuals with severe mental illness (SMI) face a significantly reduced life expectancy, primarily due to preventable physical health conditions. This project aimed to enhance the timeliness and comprehensiveness of physical health checks for inpatients in an acute psychiatric ward. An initial audit cycle identified gaps, prompting targeted interventions, with subsequent re-audit assessing their impact. Methods: The first audit cycle (March 2023) reviewed adherence to physical health assessments, including physical examinations, observations, height and weight measurements, ECGs, blood tests, and cardiometabolic checklist completion. Interventions implemented included daily reviews in the Multi-Disciplinary Team (MDT), integration into daily job lists, and master list documentation. These measures reduced delays in completing assessments. The second cycle (November 2023) involved 35 inpatients over four months. Interventions included the introduction of a whiteboard for task tracking, post-MDT reviews, staff reminders, and induction sessions emphasising physical health monitoring. Colour coding was introduced to enhance task visibility and efficiency. Specific patient needs, such as those with heart failure and left bundle branch block (LBBB) or end-stage renal disease (ESRD) requiring dialysis, were incorporated into tailored care plans. Results: The second cycle demonstrated that, overall, there were visible improvements in clinical practice. The whiteboard intervention significantly improved the timeliness and completion rates of physical health checks. Key findings included: Physical examinations: Success rates increased from 93% to 100%. BMI measurements: Reduced delays and increased completions. Physical observations: Maintained at 100% completion. Challenges included gender-based refusals for ECGs and reluctance from patients with eating disorders to undergo BMI measurements. These findings highlight the importance of personalised approaches to monitoring and addressing barriers to compliance. Conclusion: Implementing a whiteboard for tracking physical health checks demonstrated substantial improvements in timeliness and completion rates through simple, cost-effective interventions. Despite challenges, this project underscores the potential of structured systems to enhance physical healthcare for patients with SMI. Scaling and expanding these strategies hospital-wide may contribute to addressing health disparities and improving outcomes for this vulnerable population.

PurposeThe purpose of this paper is to provide a review of the history, trends and needs of continuous improvement (CI) and Industry 4.0. Four strategies are reviewed, namely, Lean, Six Sigma, Kaizen and Sustainability.Design/methodology/approachDigitalization and CI practices contribute to a major transformation in industrial practices. There exists a need to amalgamate Industry 4.0 technologies with CI strategies to ensure significant benefits. A systematic literature review methodology has been followed to review CI strategy and Industry 4.0 papers (n = 92).FindingsVarious frameworks of Industry 4.0, their advantages and disadvantages were explored. A conceptual framework integrating CI strategies and Industry 4.0 is being presented in this paper.Practical implicationsThe benefits and practical application of the developed framework has been presented.Originality/valueThe article is an attempt to review CI strategies with Industry 4.0. A conceptual framework for the integration is also being presented.

Humic acids (HA) are organic molecules that play essential roles in improving soil properties, plant growth, and agronomic parameters. The sources of HA include coal, lignite, soils, and organic materials. Humic acid-based products have been used in crop production in recent years to ensure the sustainability of agriculture production. Reviewed literature shows that HA can positively affect soil physical, chemical, and biological characteristics, including texture, structure, water holding capacity, cation exchange capacity, pH, soil carbon, enzymes, nitrogen cycling, and nutrient availability. This review highlights the relevance of HA on crop growth, plant hormone production, nutrient uptake and assimilation, yield, and protein synthesis. The effect of HA on soil properties and crops is influenced by the HA type, HA application rate, HA application mode, soil type, solubility, molecular size, and functional group. This review also identifies some knowledge gaps in HA studies. HA and its application rate have not been tested in field experiments under different crops in rotation, nitrogen fertilizer forms, sites and climatic conditions. Furthermore, HA chemical and molecular structures, their water and alkaline soluble fractions have not been tested under field experiments to evaluate their effects on crop yield, quality, and soil health. The relationship between soil-plant nutrient availability and plant nutrient uptake following HA application should also be further studied.