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Complete health documentation during childbirth can reduce complications and improve maternal and foetal outcomes. One such document is the partograph which allows health workers to record and follow the labour progress. However, the completion rates of partograph remain low in some hospitals. This study describes the implementation of a quality improvement project to increase the completion rate of partograph in a district hospital in Rwanda.

The project team tackled the root cause of partograph incompletion by implementing a labour monitoring guideline, assigning patients and duties to midwives and by providing support and supervision.

The intervention successfully increased overall partograph completion rates from 11 to 61 per cent, p < 0.001. This study also showed that completeness of the partograph was statistically associated with a decrease in foetal deaths and higher Apgar score with p < 0.001 for both.

This study describes the establishment of a quality improvement project following the strategic problem solving approach to increase the completion rate of partograph documentation. The intervention was simple, data-driven and cost-neutral. The team achieved its objectives by integrating staff input, obtaining commitment from the multidisciplinary team and applying leadership skills.

The results are useful for hospitals in limited resources settings wishing to improve overall partograph completion and improve foetal and maternal outcomes during labour, in an efficient and cost-neutral way.

A clinical pathway for patients with acute ischemic stroke was implemented in 2014 by one Italian teaching hospital multidisciplinary team. The purpose of this paper is to determine whether this clinical pathway had a positive effect on patient management by comparing performance data.

Volume, process and outcome indicators were analyzed in a pre-post retrospective observational study. Patients’ (admitted in 2013 and 2015) medical records with International Classification of Diseases, ICD-9 code 433.x (precerebral artery occlusion and stenosis), 434.x (cerebral artery occlusion) and 435.x (transient cerebral ischemia) and registered correctly according to hospital guidelines were included.

An increase context-sensitive in-patient numbers with more severe cerebrovascular events and an increase in patient transfers from the Stroke to Neurology Unit within three days (70 percent, p=0.25) were noted. Clinical pathway implementation led to an increase in patient flow from the Emergency Department to dedicated specialized wards such as the Stroke and Neurology Unit (23.7 percent, p<0.001). Results revealed no statistically significant decrease in readmission rates within 30 days (5.7 percent, p=0.85) and no statistically significant differences in 30-day mortality.

The pre-post retrospective observational study design was considered suitable to evaluate likely changes in patient flow after clinical pathway implementation, even though this design comes with limitations, describing only associations between exposure and outcome.

Clinical pathway implementation showed an overall positive effect on patient management and service efficiency owing to the standardized application in time-dependent protocols and multidisciplinary/integrated care implementation, which improved all phases in acute ischemic stroke care.

The purpose of this paper is to clarify the effects of the Iranian Hospital Accreditation Program (IHAP) on hospital processes from the viewpoint of the staff charged with establishing the program.

This qualitative study is based on the data collected in semi-structured interviews conducted in 2016, which involved eight questions. Interviews were held with 70 staff members at 14 hospitals. Managerial staff were purposively interviewed based on their familiarity and involvement with the program. The hospitals were divided into five groups, comprising public, private, charity, military and social service hospitals. A thematic analysis was carried out using the collected data.

Three themes emerged from the data, which together comprise a process management cycle: the establishment, implementation, and control phases of the program. For each phase, various positive trends, as well as hurdles for establishing the program, declared which were framed two sub-themes as positive effects and challenges.

The findings contribute to the body of evidence used by policy-makers and hospital managers to improve the change management processes related to the Iranian IHAP. Although positive changes in the process management cycles at Iranian hospitals were noted, successful implementation of the program demands a thorough assessment of the hospitals’ technical and financial needs (taking into account disparities between hospitals), and there is an urgent requirement for a plan to meet these needs.

The quality of asthma care may be affected if asthma management is overlooked, thus needing frequent clinical audits to identify areas for improvement. The purpose of this paper is to evaluate the quality of the process (e.g. documentation of asthma-specific information), the structure (e.g. availability of resources) and the outcome (e.g. proportion of patients prescribed with asthma medications) at a university-based primary care clinic. The associated clinical factors for non-documentation of asthma control at the last visit were also examined.

This retrospective study involved auditing medical records and the pharmacy data system of 433 adult patients with asthma to evaluate 18 quality indicators. The standard target for the indicators of process and structure was 80 percent and the standard target for the indicators of outcome was 100 percent.

All the indicators failed to reach the standard targets. Documentation of asthma-specific information and availability of resources were deficient. The non-documentation of asthma control was significantly associated with presence of acute complaint(s) unrelated to asthma, presence of other issues and number of the documented parameters for asthma control. Although the prescription rates of inhaled reliever and preventer were substandard, they were reasonably high compared to the targets.

In this study, evaluation of the quality of care was limited by absence of asthma register, use of paper-based medical records and restricted practice capacity. Besides, the asthma-specific assessments and management were only audited at one particular time. Furthermore, the findings of this study could not be generalised to other settings that used other methods of record keeping such as patient-held cards and electronic medical records. Future studies should sample asthma patients from a register, evaluate more reliable quality indicators (e.g. over-prescription of short-acting β-2 agonist and underuse of inhaled corticosteroid) and assess asthma management over a duration of time.

This study provides quality information on all aspects of asthma care (process, structure and outcome) which can be a basis for clinical improvement. It is hoped that the study could assist the stakeholders to plan strategies for improvement of the asthma care. A more strategic and reliable system of documentation is needed, such as the use of a simple template or structured form, which should not jeopardise the provision of personalised and comprehensive care. With complete documentation, thorough investigational audits can be continuously performed to determine the quality of asthma care.

This study could provide useful findings to guide healthcare providers in developing a more strategic model of asthma care that can ensure asthma patients to receive a personalised, comprehensive, holistic and continuous care. Through this approach, their physical and psychosocial well-being can be optimised.

Even though our healthcare has advanced, the quality of asthma care is still suboptimal which requires further improvement. However, it could be considered assuring due to high outcome levels of asthma care despite having limited resources and practice capacity.

This study aims to give an account of how stakeholders in one NHS Hospital Trust responded to the clinical governance initiative, the effects on quality improvement and the practical accomplishment of legitimacy.

Sociological new institutionalism theory was utilised to explain the political and ceremonial conformity that marked the clinical governance process. A case study was employed using ethnographic methods. The qualitative data were obtained by documentary analysis, observation of meetings and ward activity and 28 semi‐structured interviews. A grounded theory approach was adopted in the analysis of the interviews.

Errors and inconsistencies were found in Trust documentation and reporting systems were poor. In practice clinical governance was inadequately understood and the corporate goals not shared. Nevertheless, during the same period the Trust obtained recognition for having appropriate structures and systems in place resulting in external legitimacy.

The results only relate to the Trust considered but the study has identified that, although the organization responded to isomorphic governmental pressures in the production of appropriate institutional documentation, the impact of clinical governance to improve the quality in practice was found to be inconsistent.

The Trust promoted and endorsed clinical governance success but the lack of organizational processes and knowledge management equally promoted its failure by denying the resources to implement the desired actions.

Whilst the study identified that clinical governance had been a “ceremonial success”, it is argued that the practical accomplishment in the improvement of quality of care for patients will remain a paper exercise until organizational and practice issues are addressed.

Maintaining good standards of clinical documentation remains a problem in the health service despite continued and consistent advice from protection organisations and professional bodies over many years. This article discusses some of the issues that arise from poor quality note keeping and the need for improvement and the establishment of basic minimum standards for all health records. Requirements are now being placed on NHS bodies to ensure that effective and robust systems are in place to ensure that record management meets Controls Assurance Standards and CNST standards. This article stresses the need to put the current house in order before we lose any opportunities to influence those aspects of electronic systems where appropriate risk management should help reduce the potential for documentation error.

This paper describes the development and implementation of care pathways in two orthopaedic units in Scotland. Although originally developed as a tool of project management, care pathways have been promoted internationally as a response to concerns for patient safety, variability in care and increasing costs. Generally, care pathways can be seen as an example of clinician led rather than management led reform. However, it does reflect a wider shift towards process and away from hierarchical approaches to management. Within the UK care pathways have been promoted as a response to the modernisation initiative of the Labour Government. While the initiative was a success in both units it was more difficult to implement care pathways in a trauma rather than an elective unit. In conclusion, it is questionable whether care pathways are a universal response to the requirement for modernisation and service redesign in the NHS.

The purpose of this paper is to describe the quality improvement project to increase the medical record documentation completion rate in a district hospital in Rwanda. Despite the importance of medical records to support high quality and efficient care, incomplete documentation is common in many hospitals.

The pre- and post-intervention record completion rate in the maternity unit was assessed. Intervention included assigned nurse to specific patients, developed guideline, provided trainings and supervisions.

The documentation completion rate significantly increased from 25 per cent pre-intervention to 67 per cent post-intervention, p < 0.001. The completeness of seven out of the ten elements of medical records also significantly increased.

The quality improvement project created a cost-effective intervention that successfully improved the documentation completion rate. Ongoing monitoring should be continued to learn sustainability.

The results are useful for hospitals with similar settings to improve completion of nursing documentation and increase nursing accountability on patient care.

The purpose of this paper is to evaluate the clinical practice for management of opiate dependence in a general hospital in‐patient population based on agreed standards and changes of clinical practice after the introduction of a guideline.

A complete cycle of audit was carried out based on the agreed guideline, which was introduced after the first cycle. Data were obtained, using a standardized audit form, over two one‐year periods, by cross‐sectional analysis of case notes for patients identified as having been dispensed methadone whilst an in‐patient.

There were significant increases in: referral to the specialist service whilst an in‐patient (p=0.01); referral to the addiction services on discharge (p<0.001) and providing information about the addiction diagnosis to GP (p<0.001). However, there was no improvement in the documented history and examination related to aspects of addiction, some of which were consistently low. Of most concern were significant decreases in the history documented for opiate withdrawal symptoms and alcohol consumption.

The method used may not reflect actual clinical practice, only captures opiate‐dependent patients prescribed methadone and does not establish the extent of awareness of the new guideline.

The paper identifies a variation in clinical practice of management of patients with opiate dependence in the general hospital. Though there were some significant improvements, further improvement and continual evaluation are needed.

The paper identifies the need to study how co‐morbid opiate dependence is managed in the acute hospital setting.