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The purpose of this paper is to report on the implementation of the World Health Organization (WHO) trauma care checklist (TCC) (WHO, 2016) in an emergency department in a tertiary hospital in Nepal. This research was undertaken as part of a Hybrid International Emergency Medicine Fellowship programme (Subedi et al., 2020) across UK and Nepal, incorporating a two-year rotation through the UK National Health Service, via the Medical Training Initiative (MTI) (AoMRC, 2017). The WHO TCC can improve outcomes for trauma patients (Lashoher et al., 2016); however, significant barriers affect its implementation worldwide (Nolan et al., 2014; Wild et al., 2020). This article reports on the implementation, barriers and recommendations of WHO TCC implementation in the context of Nepal and argues for Transformational Leadership (TL) to support its implementation.

Explanatory mixed methods research (Creswell, 2014), comprising quasi-experimental research and a qualitative online survey, were selected methods for this research. A training module was designed and implemented for 10 doctors and 15 nurses from a total of 76 (33%) of clinicians to aid in the introduction of the WHO TCC in an emergency department in a hospital in Nepal. The quasi-experimental research involved a pre- and post-training survey aimed to assess participant’s knowledge of the WHO TCC before and after training and before the implementation of the WHO TCC in the emergency department. Post-training, 219 patients were reviewed after four weeks to identify if process measures had improved the quality of care to trauma patients. Subsequently six months later, a qualitative online survey was sent to all clinical staff in the department to identify barriers to implementation, with a response rate of 26 (n = 26) (34%) (20 doctors and 6 nurses). Descriptive statistics were used to evaluate quantitative data and the qualitative data were analysed using the five stepped approach of thematic analysis (Braun and Clarke, 2006).

The evaluation of the implementation of the WHO TCC showed an improvement in care for trauma patients in an emergency setting in a tertiary hospital in Nepal. There were improvements in the documentation in trauma management, showing the training had a direct impact on the quality of care of trauma patients. Notably, there was an improvement in cervical spine examination from 56.1% before training to 78.1%; chest examination 125 (57.07%) before training and 170 (77.62%) post-training; abdominal examination 121 (55.25%) before training and 169 (77.16%) post-training; gross motor examination 13 (5.93%) before training and 131 (59.82%) post-training; sensory examination 4 (1.82%) before training and 115 (52.51%) post-training; distal pulse examination 6 (2.73%) before training and 122 (55.7%) post-training. However, while the quality of documentation for trauma patients improved from the baseline of 56%, it only reached 78% when the percentage improvement target agreed for this research project was 90%. The 10 (n = 10) doctors and 15 (n = 15) nurses in the Emergency Department (ED) all improved their baseline knowledge from 72.2% to 87% (p = 0.00006), by 14.8% and 67% to 85%) (p = 0.006), respectively. Nurses started with lower scores (mean 67) in the baseline when compared to doctors, but they made significant gains in their learning post-training. The qualitative data reported barriers, such as the busyness of the department, with residents and medical officers, suggesting a shortened version of the checklist to support greater protocol compliance. Embedding this research within TL provided a steer for successful innovation and change, identifying action for sustaining change over time.

The study is a single-centre study that involved trauma patients in an emergency department in one hospital in Nepal. There is a lack of internationally recognised trauma training in Nepal and very few specialist trauma centres; hence, it was challenging to teach trauma to clinicians in a single 1-h session. High levels of transformation of health services are required in Nepal, but the sample for this research was small to test out and pilot the protocol to gain wider stakeholder buy in. The rapid turnover of doctors and nurses in the emergency department, creates an additional challenge but encouraging a multi-disciplinary approach through TL creates a greater chance of sustainability of the WHO TCC.

International protocols are required in Nepal to support the transformation of health care. This explanatory mixed methods research, which is part of an International Fellowship programme, provides evidence of direct improvements in the quality of patient care and demonstrates how TL can drive improvement in a low- to medium-income country.

The Nepal/UK Hybrid International Emergency Medicine Fellowships have an opportunity to implement changes to the health system in Nepal through research, by bringing international level standards and protocols to the hospital to improve the quality of care provided to patients.

To the best of the authors’ knowledge, this research paper is one of the first studies of its kind to demonstrate direct patient level improvements as an outcome of the two-year MTI scheme.

This paper aims to present a method for strategic planning and implementation processes in health care based on lean management.

Within the framework of the action research methodology, the authors present the ten steps of a kaizen project, which enable lean transformation over a period of time. The study is underpinned by a literature review of enablers and barriers and an implementation case in a tertiary care hospital.

Key points and possible contingency issues are presented for each of the steps, and a successful lean tools intervention is illustrated by examples of improvement projects of the surgical process. Conclusions of the implementation establish a roadmap for improvement projects in hospital environments based on lean management, thus bridging the existing gap between the large number of theoretical projects (much of the projects described are not sustainable over time as the hospital sector is very particular) that have failed to be implemented, or been paused mid-term, and the self-sustaining projects developed by improvement teams in the hospital.

The study details knowledge gleaned from a three-year project entailing various stages: forming improvement teams; training health-care professionals in lean management; drawing up a process map to identify value stream mapping improvement opportunities; implanting projects and verifying the results obtained; and finally, laying the cornerstones, which would make the project self-sustaining and open to long-term continuous improvement.

In the recent climate of consumerism and consumer focused care, health and social care needs to be more responsive than ever before. Consumer needs and preferences can be elicited with accepted validity and reliability only by strict methodological control, customerisation of the questionnaire and skilled interpretation. To construct, conduct, interpret and implement improved service provision, requires a trained work force and infrastructure. This article aims to appraise various aspects of consumer surveys and to assess their value as effective service improvement tools.

The customer is the sole reason organisations exist. Consumer surveys are used worldwide as service and quality of care improvement tools by all types of service providers including health service providers. The article critically appraises the value of consumer surveys as service improvement tools in health services tool and its future applications.

No one type of survey is the best or ideal. The key is the selection of the correct survey methodology, unique and customised for the particular type/aspect of care being evaluated. The method used should reflect the importance of the information required.

Methodological rigor is essential for the effectiveness of consumer surveys as service improvement tools. Unfortunately so far there is no universal consensus on superiority of one particular methodology over another or any benefit of one specific methodology in a given situation. More training and some dedicated resource allocation is required to develop consumer surveys. More research is needed to develop specific survey methodology and evaluation techniques for improved validity and reliability of the surveys as service improvement tools. Measurement of consumer preferences/priorities, evaluation of services and key performance scores, is not easy.

Consumer surveys seem impressive tools as they provide the customer a voice for change or modification. However, from a scientific point‐of‐view their credibility in service improvement in terms of reproducibility, reliability and validity, has remained debatable.

This artcile is a critical appraisal of the value of consumer surveys as a service improvement tool in health services – a lesson which needs to be learnt.

This paper aims to demonstrate the approach taken in Norfolk, UK, to engage patients and staff to develop and improve services by stimulating improvements in integrated working. The two year programme focused on making specific improvements that patients said they wanted to see by working with staff who volunteered to take part in the programme.

The “Integrating Care in Norfolk” pilot (ICN) was one of 16 national pilots. GPs from 32 practices worked with local community staff to redesign services to meet “patient pledges”. The impact of changes on patients, staff and services were evaluated locally using questionnaires and by analysing data combined in a performance dashboard. The ICN was subject to both national and local evaluations, which provided a basis for comparison.

The local evaluation showed that progress had been made towards meeting objectives, including patients and staff satisfaction and reducing unplanned admissions. GPs recorded improvements to joint working, and all staff concerned chose to continue the project beyond the pilot period.

The findings of the local evaluation contrasted with those of the national evaluation. The Norfolk study demonstrated the positive impact of integrating care on patients, staff and services. The national study concluded that there were minimal or negative impacts of integrating care, although the study amalgamated all 16 pilots, with very different clients, services and objectives.

The ICN was novel in the way that patients and staff were engaged. Patients were invited to set an agenda for change, and provided a mandate to staff from each organisation to redesign their services. This approach may provide a solution to sustainable integrated working. The ICN was evaluated locally as well as nationally as part of the DH ICP programme, enabling respective findings to be compared and validated.

Improvements were delivered in the care of patients on anti‐coagulants through a collaborative improvement methodology within one primary care organisation. Although a key clinical governance priority, the project was conducted in a low‐key manner with minimal support. Practice teams were encouraged to apply evidence through small‐scale testing of changes, using measurements to monitor improvement and to share what they learned amongst themselves. No specific model of care was pursued and instead the emphasis was on demonstrating an improvement at the practice level, by whatever means worked best. The methodology used was similar to that applied in major national and regional collaborative programmes. This project demonstrates how it can be simplified and implemented within one primary care organisation to deliver improvements in care as well as to support the building of teams and learning about measurement and quality improvement.

The purpose of this paper is to explore and examine attitudes and perceptions of leaders on application of quality improvement (QI) strategies in a palliative and hospice care organization.

This study employed qualitative research methodology where leaders working in a hospice and palliative care organization were invited to participate in 45–60-min-long semi-structured interview. Interviews were recorded and transcribed verbatim. Qualitative content analysis was utilized to analyze the data collected during participant interviews.

Seven leaders participated in the interviews. Five themes were developed from data analysis: patient-centered care; continuous QI; leadership involvement and commitment; communication as a foundation for QI; and perceived barriers. Data analysis suggests that use of QI approach in palliative and hospice care enhances the quality of care provided for patients, and can help improve patient satisfaction.

Because there is a paucity of research on implementation of QI strategies in hospice and palliative care settings, this research can have wide practical implications. This research can provide useful practical tips to leaders as they work on implementing QI projects in their organization.

This manuscript can be of value to leaders, administrators and academicians who are interested in applying QI principles to healthcare processes especially in palliative and hospice care settings. Ability to work with others, solid communication and involvement of employees from all levels can help in streamlining current systems of care.

The purpose of this paper is to describe and explain a clinician‐led improvement of a hip fracture care process in a university hospital, and to assess the results and factors helping and hindering change implementation.

The paper has a mixed methods case study design. Data collection was guided by a framework directing attention to the content and process of the change, its context and outcomes.

Using a multiprofessional project team, beneficial changes in the early parts of the care process were achieved, but inability to change surgical staff work practices meant that the original goal of operating patients within 24 hours was not reached. After three years, top management introduced a hospital‐wide process improvement programme, which “took over” the responsibility for improving hip fracture care.

A clear vision why change is needed and what needs to be done, which is well communicated by a respected clinical leader, can motivate personnel, but other influences are also needed to bring about change. Without a plan agreed and supported by top management, changes are likely to be limited to parts of the process and improvements to patient care may be minimal. These and other findings may be applicable to similar situations in other services.

This case study is an illustration of both the strengths and the weaknesses of a “bottom‐up, clinician‐champion‐led improvement initiative” in a complex university hospital.

The purpose of this paper is to describe staff experiences in an on-going improvement project regarding patients with ureteral stones.

A qualitative descriptive study based on eight group interviews and 48 narratives, was performed. Data were analysed using qualitative content analysis. Trustworthiness was ensured by using a well-documented improvement process method during six months.

The results formed three categories: an absent comprehensive view; complexity; and vulnerability within the organisation. A holistic perspective regarding urological care at the micro-, meso- and macro-levels is needed to improve planning and caring processes.

This study includes one team (six members, different health professionals) within the same urology department.

Results show that staff need information, such as guidelines and support throughout the improvement work to deliver high-quality care. Moreover, there is a need for evidence-based guidelines at national level to support improvement work.

Healthcare staff need to pay attention to all team member needs to improve urological care. Organisational and managerial aspect are needed to support clear and common goals regarding healthcare improvement work.

Urological improvement projects, generally, are lacking, which is why this study is important to improve nephrolithiasis patient care.

This paper aims to explore the perceptions of facilitators and barriers to their using electronic medical records (EMRs) for these functions and contributes baseline data about the use of EMRs for chronic disease management. The sub‐study reported here is a baseline process evaluation of EMRs and their current use, preliminary to a larger, pragmatic, randomized controlled trial. Its purpose is to understand how EMRs are currently being used by primary care physicians to facilitate chronic disease prevention and screening in their practices.

This is a qualitative case study where the lead physician at each of eight primary care clinics (four in Alberta, four in Ontario) participated in semi‐structured interviews. Data were analyzed using thematic content analysis.

Although EMRs are being used in a limited fashion for chronic disease prevention and screening, clinicians identified few current benefits. Participants noted some instances in which paper charts were preferred and that the lack of human and financial resources is inhibiting the use of chronic disease applications already incorporated in EMRs.

To understand fully how EMRs can best be used in the logistical management of chronic disease prevention and screening requires research efforts towards improvement of the data structures they contain.

Data extraction needs to be easier so that screening of patients, at risk or living with chronic disease, can be facilitated.

Evaluation of the benefits, for the content of care and care relationships, conferred by this new method of communicating, needs to be complemented by a parallel exploration of the risks.

The paper illustrates that with the tremendous investments in EMRs it is important to learn how changes in their design could facilitate improvements in patient care in this important area.

The purpose of this article to review the literature relating to improving paramedic care in an Australian context.

The paper presents changes and challenges that have occurred in the ambulance services in terms of improving care and measuring performance, exploring the literature on quality improvement initiatives and their application to pre‐hospital care.

While hospitals and health services have moved well down the quality improvement pathway, the application of these processes to pre‐hospital care has been a relatively recent phenomenon. Ambulance services have taken a variety of approaches to measuring and improving pre‐hospital care. This article questions the transferability of lessons learned in hospitals to ambulance services. Arguably, the quality improvement approach is dependent upon health control and funding models and where ambulance is categorised in terms of health or emergency services.

The quality improvement approach by Australian paramedics and ambulance services is in its infancy. This article provides insights into the quality improvement approach taken by ambulance staff in Australia compared to other countries, as well as highlighting useful information on the future direction and research into the area.