School of Health Nursing Midwifery

Define Quality Improvement and consider the elements associated with it in relation to health and social care.

Quality Improvement (QI), in the context of health and social care services, could be recognized to be the framework through which systematic improvement could be performed in delivering appropriate care to the patients. The entire systematic process is primarily formulated to measure, analyze and control the various elements which constitute the entire process (Johnson and Sollecito, 2018). Additionally, seeking healthcare dissertation help can provide valuable insights into effective QI methodologies, enhancing the overall understanding of best practices in patient care.

The QI framework constituent elements entail the investment of persistent efforts by the health and social care service providers to attain predictable, suitable and stabilized outcomes in terms of service delivery. This could be better explained as the effort towards curtailment of variation of the care delivery processes and achievement of outcome improvement involving both the patients and the care organizations (Renedo, et al., 2015).

The core constituent elements of QI could be identified as focus on the efficacy of the care delivery systems, the recognition errors, emphasis on teamwork, attaching of value to peer reviews, reduction of the per capita healthcare expenditure and improvement of patient experiences through the utilization of errors as opportunities for learning experience development. Achievement of QI efficacy involves the sustained commitment of the entire working architecture and human resource capital of respective care delivery organizations, including the higher management echelons (Dixon-Woods and Martin, 2016).

Critically explore the factors that have led to a greater international emphasis on quality measurement and improvement in health and social care.

The previous decades have witnessed the expansion of global health contingencies and associated priorities (Srinivas and Raju, 2017). Such contingencies have culminated in the utilization of QI based approaches for redressing such problems in the health and social care services. The prevalence of Anti-Microbial Resistance (AMR) has proven to be the most intractable emerging healthcare issue (Vindrola-Padros, et al., 2017).

To this effect, significant emphasis has been concentrated on the improvement of healthcare services through which the AMR could be tackled. In this context, the development of the dual process of effective quality control and care planning could be perceived to be able to address this problem related to AMR. The prime objective of such QI mechanisms implemented globally could be considered to be the enhancement of effectiveness in supervising the healthcare facilities through which the health hazard posed by AMR could be successfully managed.

This format of QI based approach has been effective regarding the development of credible control and supervisory mechanisms through which the administrative initiatives in addressing AMR related problems could be brought to success (D'Lima, et al., 2016). Some instances of such administrative mechanisms could be stated as implementing stringent schedules for monitoring, administering antibiotic consumption prescriptions which could benefit the patients as per their health conditions since such antibiotic administering schedules are calibrated and well balanced and, development of task checklists through which healthcare efficiency management could be optimized at the levels of individual practitioners as well as care facilities.

Adherence to the International Health Regulation (IHR) of the WHO by different countries is premised upon the efficacy achieved in public healthcare system surveillance (Carinci, et al., 2015). Such healthcare surveillance could be implemented at the national and sub-national levels so that threat reporting mechanisms at such levels and the global level could be optimized.

Resource limitations in most of the countries generally constrain them from achieving such efficiency. The reason is that such countries, mostly situated in Sub-Saharan Africa and at some sections of Southern America and Asia, are confronted with various problems (Carvalho, Jun, and Mitchell, 2017). Some of these problems are recognizable in the form of the dearth of equipment and improper systems of early warning of possible pandemics and improperly qualified and trained healthcare professionals.

One of the direct outcomes of such constraints could be understood as the Ebola outbreak of 2014-15 due to the deficient health surveillance implementation systems at the small villages of Guinea in West Africa (Gadolin and Andersson, 2017). Apart from this, the outbreak of Zika virus in the Southern American countries has also brought forth the realization that dependence on individual national and localized disease surveillance and security are paramount in terms of prevention of such epidemics of infectious ailments. The emphasis has to be on the enhancement of measures of access of individuals to available healthcare facilities and effective disease prevention technologies. Delivery of proper and essential care services (such as affordable medications and vaccines to the affected populace) in tandem with the protection from differential risks has to be considered.

The considerable intensification of international migration propensities, with an approximation of 250 million personnel (including the 21 million international refugees, 40 million internally displaced personnel and 3% asylum-seeking personnel globally), has been another factor of concern for the health operational agencies at the international levels to emphasize on the application of comprehensive QI (Momani, Hirzallah and Mumani, 2017). The Sustainable Development Goals, under the purview of Universal Health Care principles, could remain to be unfulfilled since, the majority of such migrant populations, does not have the means to accessing effective healthcare services at the host nations (Barnard et al., 2016).

In this context, according to, the significance of QI application could become apparent concerning the healthcare service impartation domains related to equitable service delivery which have, so far been the neglected ones in terms of international health improvement initiatives (Melo, 2016). Such considerations involve the entire spectrum of health and social care services including preventive treatment, affordable medication and services, palliative and rehabilitative services and promotion of general health consciousness (Renedo, et al., 2015). Such services could be facilitated through the application of effective mechanisms of service control and quality enhancement planning with the objective of achievement of mitigation of all of the risks which could be generated through inequities in service delivery within the migrant populations.

Consider how globalisation affects the organisation you work in as it tries to achieve quality.

Various challenges are experienced by the healthcare organization in the process of achievement of necessary quality in service delivery. The most significant challenge is the expansion of in-patient facilities. Another of such challenges is the maintaining of an effective balance between patients and medically qualified operational care staff. The overcoming of this challenge could ensure that QI based betterment of medical services, for diseases such as AMR, could become successful.

The most significant ones are the necessity of enhancement of in-patient facilities and to maintain the balance since these are fundamental to the improvement of quality under the purview of QI. The primary concern is the resource crunch which affects the organization. The resources are mostly identifiable as financial, human resources and material resources. These are vital for the implementation of the practices of QI to enhance the existing quality up to the globalized standards which could be acknowledged by the Joint Commission International (JCI) which is the body of accreditation of the Joint Commission on the Accreditation of Healthcare Organisations, IIME and the World Federation for Medical Education (Harolds, 2015). The gross expenditure necessary to elevate the existing services as per the globally acknowledged standards has been prohibitive and this has contributed to the care distribution problems. The outcome has been that the patients within the UK are increasingly lodging complaints about having to pay considerably greater costs for even essential services. In the UK, such a scenario contributes to the increase in the medical insurance expenditures for the patients since they have to pay greater premiums.

The implication of globalization on the UK airline industry, pertaining to the health management of passengers, could be acknowledged as greater emphasis on the management of safety of the passengers as the global flight hours had doubled within the previous decade for the UK commercial aviation industry (from approximate measure of 25 million in 2010 to 54 million during 2019) and the fatality numbers have also declined from 450 to 250 on a per annum basis (Patankar and Brown, 2019). This could be compared to the healthcare industry where the avoidable mortality has been on the decline statistically. The current estimates suggest that since 2016, the rate has declined from 228.7 mortalities to 224.7 on a per population basis of 100000 till 2017 (Kavanagh, Saman, Bartel and Westerman, 2017).

Figure 1: Impact of globalised patient safety implications on the UK airline industry

Part 2 Brief description of the area for quality improvement

The reduction of undesirable complications occurring from the Health Care–Associated Infections (HAIs) has been selected for the purpose of quality improvement for the corresponding section of the research. The escalation of HAIs has been considered as one of the prime causalities of concern for the global clinical care perspectives (Renedo et al., 2015). HAIs, formerly known as Nosocomial Infection (NI), are formally referred to as the infections which are directly associated with the admission of patients within any acute-care hospital. However, this terminology also encompasses the unanticipated infections which are acquired by patients in the continuum of clinical healthcare administrative settings involving ambulatory, home, surgery and long terms based hospital cares. Patient mortality and morbidity rates from such HAIs are significant and the associated complications are prolonging the durations which have to be spent at hospitals/care centers with the generation of additional expenditure concerning the therapeutic and diagnostic interventions. The ECDPC (European Centre for Disease Prevention and Control) has reported 7.1% of average prevalence rate of HAIs within the European countries with a follow-up estimation of approximate 4131000 patients becoming affected by the HAIs from 4 544 100 incidents of care associated intervention on a per annum basis. On the other hand, at USA the estimated rate of incidence of HAIs was 4.5% in 2016-17 which has corresponded to 9.3 cases of HAIs per 1000 patients and this has amounted to 1.7 million patients affected with HAIs (approximate measure) throughout the country(Lucas and Nacer, 2015). The research of Brach et al., (2012) has brought forth the fact that previous studies in patient safety management have revealed the HAIs, adverse drug administration events and complications caused by inappropriate surgical methods have been responsible for the most frequent health hazards and adverse conditions to the safety of patients within the hospital/clinical care settings. On the basis of such studies, the Institute of Medicine had formulated the estimates which outlined that an approximate measure of 2 million patients on a per annum basis within the UK becomes affected by HAIs and the number of mortality is as high as 90000 (approximate) on average yearly basis. The additional incurrence of cost involving patient care on a per year basis regarding such cases is £4.5–5.7 billion (Pomey, et al., 2015).

Adler and Stead (2015) have researched about the different evidence based strategies of infection control and have outlined that an increasing trend in the Intensive Care Unit based healthcare services towards prevention of infections has been observed. However, the national infection surveillance and control mechanism of the UK has outlined that the increase in the microorganism based AMR cases has been alarming as well (Matziou, et al., 2014). The changing of trends have been suggestive of increasing acuity of inpatient illness, inadequate ratios of staffing concerning nurse to patients, paucity of systems resources and other complications. The subsequent demands on the resources and workers of the healthcare industry of UK have ensured improper quality infusion into the process of reduction of preventable HAIs. Thus, HAIs could be considered to be undesirable outcomes and since the majority of these are preventable, these could be conceptualized as indicators of patient care quality and major patient safety issues could be resolved in this manner( (Davis and Boykins, 2014) .

Such observations are required to be evaluated at the backdrop of the current orientation of UK healthcare industry towards greater inclination of shifting medical treatment based care services to the outpatient settings and thus, the numbers of patients getting admitted into the hospitals or care homes have been on a decline. This has brought the disturbing realisation that in spite of the duration of inpatient admissions getting steadily decreased, the HAI frequency has been on the increase. Reed and Card (2016) have observed that the application of Quality Improvement perspectives to properly regulate the extent of HAIs is firmly influenced by the fact that underestimation of the extent of HAIs has been caused by the comparatively shorter hospital stays than that of the periods of incubation of the infectious microorganisms which could signify the developing infections. In such case, the symptoms could manifest days after the patients get discharged from the care centers. Coulter et al., (2014) have determined that 12% to 84% infections contracted at the surgical sites become apparent only after the discharge of the patients since the average duration of emergence of the proper symptoms of infection is at least 21 days after the surgery could have been performed. Another complication which has arisen out of the deficiency of proper quality in identification of HAIs has been the inadequately networked reporting systems in non-acute care facilities where most of the patients receive post surgery care after their tenure at the hospitals/clinical care centers could come to an end. This poses primary complications regarding the documenting of the origin of suspected infections (Kaplan, et al., 2010).

Comparison in two quality improvement methodologies

Continuous Quality Improvement (CQI) indicates the approach of quality management and improvement which could build upon the methods of conventional quality assurance of healthcare sectors through emphasizing on the organisational attributes and the systems in existence (Hernández-Padilla, et al., 2019). The methods are identifiable as are Root Cause Analysis and PDSA (Plan, Do, Study, Act) models. These are common CQI approaches which could be utilised by the general healthcare entities for the purpose of improvement of benchmarking standardisation of control mechanisms of HAIs at a particular healthcare facility (Kwon, et al., 2016). Concerning the context of management of HAIs control mechanisms within the working architecture of an actual healthcare organisation, the selection of the Wellington Hospital has been performed which is currently situated at St John's Wood, North London. The comparison of the two selected procedures regarding Quality Improvement (QI) have been based on the objective of development of an annualised cycle of learning which could contribute to the improvement of clinical systems for the reduction of incidence and subsequent impact of HAIs at the selected independent hospital of UK. This hospital is also integral to the HCA international Hospital Group. The offered services at this hospital include neurosurgery, rehabilitative care, Gynecology, Orthopedics, cardiac services, liver surgery and HPB medication services, Oncology and various other disciplines( (Van Rossum, et al., 2016).

The utilized method of PDSA (Plan, Do, Study and Act) model has been developed on the analysis of a particular duration of 2 years based (2015-2016 and 2018-2019) evaluations of HAIs occurrence sessions within the Wellington Hospital by the IPCTs (Infection Prevention and Control Teams). The PDSA cycle involved the implementation of a strategic approach for the changing of currently observed practices pertaining to HAI prevention through the formulation of a particular framework of operations management which could involve multiplicity of ideas regarding reduction of probability of contraction of infection by patients during their care reception tenure at the concerned hospital.

Planning phase based preparation

This phase ensured the consideration and addressing of every prerequisite such as human and financial resources, necessary infrastructure and coordination based activities and delineation of responsibility accordance to particular personnel which included the in-house staff as well. Special emphasis of according of responsibility was placed on sensitisation of senior managerial personnel towards acknowledging the criticality of the problem and the requirement towards implementation of QI based approached within the PDSA framework. Furthermore, the planning baseline assessment involve an exploratory study design to evaluate the current situation within the Hospital care scenario concerning the probability of incidence of infection contraction by patients during care settings inadvertently. This involved the utilisation of an assessment tool which has been based on IPCAF (Infection Prevention and Control Assessment Framework) and HHSAF (Hand Hygiene Self-assessment Framework) as well as systems performed to develop better observation amongst the clinical staff at the Wellington Hospital. The outcomes from such baseline assessment had been utilised to develop the follow-up action phase perspectives so that a multimodal strategy of Quality Improvement could be put into effect.

Doing based on multimodal thinking processing

This process involved procurement of supplies and ensuring of accessibility of updated information regarding the procedures which could be evaluated under IPCAF and HHSAF tools. These could be further explained as availability of water and quality of ergonomic elements such as manual handling of patients after surgeries could be completed and placement of particular support equipment such as Central Venous Catheters (CVCs) and tray sets which are required to be autoclaved properly for removal of pathogens and microbes.

Studying

This procedure involved the perusal and analysis of documented information, documenting of instructions issued orally and assessing the data related to practical and interactive training services which are currently conducted at the Wellington Hospital such as bedside operations simulation training. One particular focus of the study phase involved the analysis of the hygiene awareness of the nursing staff and doctors who had been in charge of placement management and maintenance of CVCs so as to ensure prevention of BSIs (Blood Stream Infections). Finally, the study phase culminated through the summarization of critical practices which were grouped in bundles of best practices.

Acting

This phase involved the utilisation of reminders by the IPCTs in the form of implementation of differential advocacy awareness tools and promotion of methods which highlighted the necessity to act on instructional cues to improve care team based hygiene and sanitary conditions management quality. This method of communication was performed across the work units and intensive/critical care disciplines. Special emphasis was provided to the application of developed strategy for the prevention of occurrence of BSIs during the surgery sessions and promotional brochures and leaflets were developed so as to reinforce the identified best practices.

Root Cause analysis method application through utilisation of CEDs (Cause and Effect Diagrams)

The utilisation of the Root Cause Analysis was centered around the CEDs with the purpose of ensuring the tangible support development from the senior managerial staff of the hospital through the process of relevant decision formulation and promotion of adaptive approaches to strengthen the IPC culture at the hospital settings. The primary aims had been maintaining quality of patient safety through empowering the care specialists so that infection prevention intervention could be qualitatively enhanced. One specific example had been the prolonged discussions pertaining the BSI rates which were performed at the executive level meetings.

Figure 2: Root Cause Analysis CEDs

In this context, the HAIs prevention and IPC process based quality improvement involved a 3 phase based approach. At the initial phase, the prevalent problem and the medical procedures which required to be improved were identified and the mechanisms of infection prevention and control were decided upon. The second phase involved the documentation of the main factors which were most significant causalities of the HAIs for patients at the Wellington Hospital within the above mentioned framework so that each of the factors could be grouped within particular categories so that major branches could be formulated for the purpose of referential contexts. At the final phase, details of the casual factors were added by the IPCTs on each of the major sections of the diagrammatic framework. The identified reasons have been understaffing and impropriety in hand hygiene maintenance, time demands, insufficient application of biohazard protective medical equipment amongst doctors and nursing staff, improper hand washing behaviors and dearth of professional stringency in monitoring compliance.

Part 3 Critical reflection on the process of change management through factors which facilitate the process and the quality culture creation associated challenges

The process of change management within the Wellington Hospital involved the institution of appropriate hand hygiene practices with the cross-departmental ubiquitous practices of glove utilisation for the care specialists and post-surgical care service providers. The purpose has been the contribution to patient safety and subsequent reduction of HAIs. The benefit of it has been highlighted to be the relative cost effectiveness of the practice in comparison to the treatment costs which could incur in cases of HAIs. The practices were formulated on the basis of the standards specified by the JCIC (Joint Commission of Infection Control). Such change practices also involved the review of HAI sentinel events encompassing the ambulatory care, home care, disinfecting laboratory equipment, hand and surgical equipment hygiene promotion initiatives, behavioural care perspectives regarding infection prevention and environmental cleanliness factors.

Take a deeper dive into School of Health Nursing Midwifery with our additional resources.

Bonvehí and Temporiti (2018) have observed that infectious outbreaks caused by respiratory means within the closed setting of any healthcare facility such as Wellington Hospital could become the prime cause of morbidity for patients. Patients or care personnel suffering from respiratory illnesses could transmit viruses/pathogens through spreading of droplets of cough, sneezing or saliva which could come to settle on the surface of such instillations. The healthy personnel, including patients, could become contaminated/affected through the transmission of such pathogens which occurs through direct contact between the self-inoculating mucous membranes or through physical touching in between the contaminated surfaces and the patients/personnel of the hospital. The quality of IPC management to preclude such eventualities, has been the core element of such efforts of change management and such initiatives have involved post visual alerts issued in appropriate languages at every entrance of the outpatients facilities to instruct both patients and their escorts of the danger from aerosol dissemination and direct contact based pathogen transmission as well as detailed information provisioning through the care personnel about the symptoms of respiratory and other formats of infections when the patients could be registered for the first time in the hospital.

Factors of quality culture improvement

The focal points of care QI based care practice changes have been the differential clinical procedures through which the diverse and extensive population of pathogenic microorganisms arising within the surrounding environment of a patient, during and after the surgeries could have been completed, could be prevented from infecting the patient under consideration through intact or injured skin and infected wounds. Points of concern are IPC procedures through which the bed sheets, furniture/equipment situated at the proximity of the beds and gowns/apparels prescribed for the patients could be disinfected. Prioritisation has been accorded to prevention of contamination from pathogen colonized patients such as personnel infected with Clostridium difficile, MRSA, VRE and others.

Continue your exploration of Self-Assessment for Success with our related content.

Furthermore, the process involved the care quality improvement culture development on the particulars of direct components of IPC which involved the development of not only a culture of patient safety management, however, also the system of effective administrative support to ensure proper resources and incentives to the developed procedures. The procedures involved development of the hospital policies to institutionalize training of IPC teams with critical responsibilities of infection prevention within the ICUs, ITUs and ICCUs so that HAIs could be prevented and AMR could be combated at the patient care level. The specifics of changed quality culture involved implementation of defined objectives and annual work plans which have been based on National Institute for Health and Care Excellence (NICE) recommendations.

Patients and health care staff should consistently practice the following:

Challenges infection prevention culture development at the Wellington Hospital

The initial challenge had been persuading the staff and patients to utilise tissues consistently so that respiratory secretions could be restricted and the pathogen contaminated aerosol could not become a major source of infectious outbreak for the vulnerable personnel, both the patients and care staff alike. The sensitization of the staff and patients about the necessity to utilise tissues was relatively forthcoming in terms of success, however, the challenging aspect involved the persuasion of the personnel to dispose the tissues after their initial application in the waste receptacle nearest to them. This challenge was confounded by the less than satisfactory indication of acceptance of the critical IPC prevention practice of performing hand hygiene after coming into contact with contaminated objects and respiratory secretions generated by infectious disease affected patients.

Another challenge concerned the general utilisation of hypochlorite based sterilants and sanitisers at the housekeeping staff of the Wellington Hospital since this was not registered the Antimicrobials Division, Office of Pesticides Program, NHS. Thus, new chemical germicides for the disinfection and cleaning of medical equipment were required which added to the cost overheads of the hospital and thus, it was not a matter of astonishment that this measure did not garner spontaneous support from the hospital authorities. The final significant challenge became variation of circulating viruses which had added to the existing difficulties in properly defining the improvement necessities regarding the QI based approaches within the patient care scenario.

Dig deeper into Schizophrenia Stigma: Challenges and Solutions with our selection of articles.

References

Adler, N.E. and Stead, W.W., (2015) Patients in context—EHR capture of social and behavioural determinants of health. Obstetrical & Gynecological Survey, 70(6), pp.388-390.

Barnard, C., Woods, D., Noskin, G., Kricke, G. and Cella, D., (2016). Patient Perspectives on Healthcare Quality: Implications for Measurement and Improvement. An Innovative RAPPORTS Model of Patient-Centered Quality, p.92.

Brach, C., Keller, D., Hernandez, L.M., Baur, C., Parker, R., Dreyer, B., Schyve, P., Lemerise, A.J. and Schillinger, D., 2012. Ten attributes of health literate health care organizations. NAM Perspectives.

Carinci, F., Van Gool, K., Mainz, J., Veillard, J., Pichora, E.C., Januel, J.M., Arispe, I., Kim, S.M., Klazinga, N.S., OECD Health Care Quality Indicators Expert Group and Haelterman, M., (2015). Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators. International Journal for Quality in Health Care, 27(2), pp.137-146.

Carvalho, F., Jun, G.T. and Mitchell, V., (2017). Participatory design for behaviour change: An integrative approach to healthcare quality improvement.

Coulter, A., Locock, L., Ziebland, S., and Calabrese, J., (2014) Collecting data on patient experience is not enough: they must be used to improve care. BMJ, 348, p.g2225.

Daly, J., Hill, M.N. and Jackson, D., (2015). Leadership and healthcare change management in . J. Daly, J., S. Speedy, & D. Jackson (Eds.). Leadership & Nursing, pp.81-90.

Davis Boykins, A., 2014. Core communication competencies in patient-cantered care. ABNF Journal, 25(2).

Dixon-Woods, M. and Martin, G.P., (2016). Does quality improvement improve quality?. Future Hospital Journal, 3(3), pp.191-194.

D'Lima, D., Bottle, A., Benn, J. and Thibaut, B., (2016). Effective use of feedback for professional behaviour change and quality improvement in healthcare. European Health Psychologist, 18(S), p.964.

Gadolin, C. and Andersson, T., (2017). Healthcare quality improvement work: a professional employee perspective. International journal of health care quality assurance, 30(5), pp.410-423.

Goulding, L., Parke, H., Maharaj, R., Loveridge, R., McLoone, A., Hadfield, S., Helme, E., Hopkins, P. and Sandall, J., (2015). Improving critical care discharge summaries: a collaborative quality improvement project using PDSA. BMJ Open Quality, 4(1), pp.u203938-w3268.

Graban, M., (2018). Lean hospitals: improving quality, patient safety, and employee engagement. Productivity Press.

Harolds, J., (2015). Quality and safety in health care, Part I: Five pioneers in quality. Clinical nuclear medicine, 40(8), pp.660-662.

Haux, R., Hein, A., Kolb, G., Künemund, H., Eichelberg, M., Appell, J.E., Appelrath, H.J., Bartsch, C., Bauer, J.M., Becker, M. and Bente, P., (2014). Information and communication technologies for promoting and sustaining the quality of life, health and self-sufficiency in aging societies–outcomes of the Lower Saxony Research Network Design of Environments for Ageing (GAL). Informatics for Health and Social Care, 39(3-4), pp.166-187.

Hernández-Padilla, J.M., Cortés-Rodríguez, A.E., Granero-Molina, J., Fernández-Sola, C., Correa-Casado, M., Fernández-Medina, I.M. and López-Rodríguez, M.M., 2019. Design and Psychometric Evaluation of the ‘Clinical Communication Self-Efficacy Toolkit’. International journal of environmental research and public health, 16(22), p.4534.

Johnson, J.K. and Sollecito, W.A., (2018). McLaughlin &Kaluzny's Continuous Quality Improvement in Health Care.Jones & Bartlett Learning.

Kaplan, H.C., Brady, P.W., Dritz, M.C., Hooper, D.K., Linam, W.M., Froehle, C.M. and Margolis, P., (2010). The influence of context on quality improvement success in health care: a systematic review of the literature. The Milbank Quarterly, 88(4), pp.500-559.

Kwon, I.W.G., Kim, S.H. and Martin, D.G., (2016). Healthcare supply chain management; strategic areas for quality and financial improvement. Technological Forecasting and Social Change, 113, pp.422-428.

Lucas, B. and Nacer, H., (2015). The habits of an improver: thinking about learning for improvement in healthcare.

Matziou, V., Vlahioti, E., Perdikaris, P., Matziou, T., Megapanou, E. and Petsios, K., (2014). Physician and nursing perceptions concerning interprofessional communication and collaboration. Journal of Interprofessional Care, 28(6), pp.526-533.

Melo, S., (2016). The impact of accreditation on healthcare quality improvement: a qualitative case study. Journal of health organization and management, 30(8), pp.1242-1258.

Momani, A., Hirzallah, M.A. and Mumani, A., (2017). Improving Employees' Safety Awareness in Healthcare Organizations Using the DMAIC Quality Improvement Approach. The Journal for Healthcare Quality (JHQ), 39(1), pp.54-63.

Pomey, M.P., Hihat, H., Khalifa, M., Lebel, P., Néron, A. and Dumez, V., (2015). Patient partnership in quality improvement of healthcare services: Patients’ inputs and challenges faced. Patient Experience Journal, 2(1), pp.29-42.

Reed, J.E. and Card, A.J., (2016). The problem with plan-do-study-act cycles. BMJ Qual Saf, 25(3), pp.147-152.

Renedo, A., Marston, C.A., Spyridonidis, D. and Barlow, J., (2015). Patient and Public Involvement in Healthcare Quality Improvement: How organizations can help patients and professionals to collaborate. Public Management Review, 17(1), pp.17-34.

Renedo, A., Marston, C.A., Spyridonidis, D. and Barlow, J., (2015). Patient and Public Involvement in Healthcare Quality Improvement: How organizations can help patients and professionals to collaborate. Public Management Review, 17(1), pp.17-34.

Srinivas, T.V. and Raju, T.V., (2017). Quality Improvement in Healthcare-A Diagnostic Study. DHARANA-Bhavan's International Journal of Business, 10(2), pp.42-51.

Van Rossum, L., Aij, K.H., Simons, F.E., van der Eng, N. and ten Have, W.D., (2016). Lean healthcare from a change management perspective: the role of leadership and workforce flexibility in an operating theatre. Journal of Health Organization and Management, 30(3), pp.475-493.

Vindrola-Padros, C., Pape, T., Utley, M. and Fulop, N.J., (2017). The role of embedded research in quality improvement: a narrative review. BMJ QualSaf, 26(1), pp.70-80.

Hawkins, F.H., 2017. Human factors in flight. Routledge.

Patankar, M.S. and Brown, J.P., (2019), August. Adapting systems thinking and safety reporting in high-consequence industries to healthcare. In Seminars in perinatology. WB Saunders.

Kavanagh, K.T., Saman, D.M., Bartel, R. and Westerman, K., (2017). Estimating hospital-related deaths due to medical error: a perspective from patient advocates. Journal of patient safety, 13(1), pp.1-5.

Bonvehí, P.E. and Temporiti, E.R., (2018). Transmission and Control of Respiratory Viral Infections in the Healthcare Setting. Current Treatment Options in Infectious Diseases, 10(2), pp.182-196.