Quality and Safety in Health Care Journal

Patient work self-managing medicines: a skilled job at the sharp end of care

Maintaining the safety and continuity of medicines at care transitions is a long-standing healthcare challenge and a global priority.1 Medication errors at hospital discharge are common and harmful: a systematic review reported a median rate of medication error and unintentional medication discrepancies of approximately 50% of adult and elderly patients, and adverse drug events affected a fifth of all discharged adult and older patients.2 Older people are particularly at risk, and more susceptible to the impact of errors, yet approximately a third to two-thirds of medication-related harm experienced by older people after discharge is considered preventable.3 Problems can often arise from care fragmentation when two or more healthcare organisations operating distinct work systems are involved in the care transition.4 Between those systems the tasks, tools and technologies are misaligned, and the resulting processes cause error and confuse patients.5

In...

Patient-activated escalation in hospital: patients and their families are ready!

Sutton et al report in this edition of BMJ Quality and Safety the findings from a qualitative process evaluation of a pilot patient-activated escalation system in four surgical wards in three English hospitals.1 The study is part of a £2.5 million National Institute for Health and Care Research grant2 testing an escalation system with the name ‘Early 3S’ (See it Early, Speak up Early and Save lives Early). In the participating wards, the system was publicised to patients through leaflets and posters. In two sites, the responder to telephone calls for help from patients and family was a nurse on the actual ward team; in one of these sites the programme was discontinued after 2 months and in the second site most calls were not picked up by the responder. In the third site, a critical care outreach team received seven calls in 8 months but identified no...

Assessing patient work system factors for medication management during transition of care among older adults: an observational study

Objective

To develop and evaluate measures of patient work system factors in medication management that may be modifiable for improvement during the care transition from hospital to home among older adults.

Design, settings and participants

Measures were developed and evaluated in a multisite prospective observational study of older adults (≥65 years) discharged home from medical units of two US hospitals from August 2018 to July 2019.

Main measures

Patient work system factors for managing medications were assessed during hospital stays using six capacity indicators, four task indicators and three medication management practice indicators. Main outcomes were assessed at participants’ homes approximately a week after discharge for (1) Medication discrepancies between the medications taken at home and those listed in the medical record, and (2) Patient experiences with new medication regimens.

Results

274 of the 376 recruited participants completed home assessment (72.8%). Among capacity indicators, most older adults (80.6%) managed medications during transition without a caregiver, 41.2% expressed low self-efficacy in managing medications and 18.3% were not able to complete basic medication administration tasks. Among task indicators, more than half (57.7%) had more than 10 discharge medications and most (94.7%) had medication regimen changes. Having more than 10 discharge medications, more than two medication regimen changes and low self-efficacy in medication management increased the risk of feeling overwhelmed (OR 2.63, 95% CI 1.08 to 6.38, OR 3.16, 95% CI 1.29 to 7.74 and OR 2.56, 95% CI 1.25 to 5.26, respectively). Low transportation independence, not having a home caregiver, low medication administration skills and more than 10 discharge medications increased the risk of medication discrepancies (incidence rate ratio 1.39, 95% CI 1.01 to 1.91, incidence rate ratio 1.73, 95% CI 1.13 to 2.66, incidence rate ratio 1.99, 95% CI 1.37 to 2.89 and incidence rate ratio 1.91, 95% CI 1.24 to 2.93, respectively).

Conclusions

Patient work system factors could be assessed before discharge with indicators for increased risk of poor patient experience and medication discrepancies during older adults’ care transition from hospital to home.

Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study

Background

The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND).

Methods

The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory.

Results

We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms.

Conclusions

This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.

What do clinical practice guidelines say about deprescribing? A scoping review

Introduction

Deprescribing (medication dose reduction or cessation) is an integral component of appropriate prescribing. The extent to which deprescribing recommendations are included in clinical practice guidelines is unclear. This scoping review aimed to identify guidelines that contain deprescribing recommendations, qualitatively explore the content and format of deprescribing recommendations and estimate the proportion of guidelines that contain deprescribing recommendations.

Methods

Bibliographic databases and Google were searched for guidelines published in English from January 2012 to November 2022. Guideline registries were searched from January 2017 to February 2023. Two reviewers independently screened records from databases and Google for guidelines containing one or more deprescribing recommendations. A 10% sample of the guideline registries was screened to identify eligible guidelines and estimate the proportion of guidelines containing a deprescribing recommendation. Guideline and recommendation characteristics were extracted and language features of deprescribing recommendations including content, form, complexity and readability were examined using a conventional content analysis and the SHeLL Health Literacy Editor tool.

Results

80 guidelines containing 316 deprescribing recommendations were included. Deprescribing recommendations had substantial variability in their format and terminology. Most guidelines contained recommendations regarding for who (75%, n=60), what (99%, n=89) and when or why (91%, n=73) to deprescribe, however, fewer guidelines (58%, n=46) contained detailed guidance on how to deprescribe. Approximately 29% of guidelines identified from the registries sample (n=14/49) contained one or more deprescribing recommendations.

Conclusions

Deprescribing recommendations are increasingly being incorporated into guidelines, however, many guidelines do not contain clear and actionable recommendations on how to deprescribe which may limit effective implementation in clinical practice. A co-designed template or best practice guide, containing information on aspects of deprescribing recommendations that are essential or preferred by end-users should be developed and employed.

Trial registration number

osf.io/fbex4.

A realist review of medication optimisation of community dwelling service users with serious mental illness

Background

Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI.

Objective

Published literature and two stakeholder groups were employed to answer: What works for whom and in what circumstances to optimise medication use with people living with SMI in the community?

Methods

A five-stage realist review was co-conducted with a lived experience group of individuals living with SMI and a practitioner group caring for individuals with SMI. An initial programme theory was developed. A formal literature search was conducted across eight bibliographic databases, and literature were screened for relevance to programme theory refinement. In total 60 papers contributed to the review. 42 papers were from the original database search with 18 papers identified from additional database searches and citation searches conducted based on stakeholder recommendations.

Results

Our programme theory represents a continuum from a service user’s initial diagnosis of SMI to therapeutic alliance development with practitioners, followed by mutual exchange of information, shared decision-making and medication optimisation. Accompanying the programme theory are 11 context-mechanism-outcome configurations that propose evidence-informed contextual factors and mechanisms that either facilitate or impede medication optimisation. Two mid-range theories highlighted in this review are supported decision-making and trust formation.

Conclusions

Supported decision-making and trust are foundational to overcoming stigma and establishing ‘safety’ and comfort between service users and practitioners. Avenues for future research include the influence of stigma and equity across cultural and ethnic groups with individuals with SMI; and use of trained supports, such as peer support workers.

PROSPERO registration number

CRD42021280980.

The good, the bad and the ugly: What do we really do when we identify the best and the worst organisations?

Identifying high and poorly performing organisations is common practice in healthcare. Often this is done within a frequentist inferential framework where statistical techniques are used that acknowledge that observed performance is an imperfect measure of underlying quality. Various methods are employed for this purpose, but the influence of chance on the degree of misclassification is often underappreciated. Using simulations, we show that the distribution of underlying performance of organisations flagged as the worst performers, using current best practices, was highly dependent on the reliability of the performance measure. When reliability was low, flagged organisations were likely to have an underlying performance that was near the population average. Reliability needs to reach at least 0.7 for 50% of flagged organisations to be correctly flagged and 0.9 to nearly eliminate incorrectly flagging organisations close to the overall mean. We conclude that despite their widespread use, techniques for identifying the best and worst performing organisations do not necessarily identify truly good and bad performers and even with the best techniques, reliable data are required.

Sex, drugs and rock 'n roll: the only reasons for regulators to target individuals

Healthcare regulators are having trouble keeping up. There is always a lag between regulators getting on top of things and fast-paced changes in health systems. Care is continuously becoming more complex.1 Rapid technological shifts (eg, new-generation drugs, artificial intelligence (AI) and advances in genomics) are accelerating. This confers new opportunities for better care, but it also implies new risks which need to be regulated differently. Yet the current paradigm is largely predicated on regulators mainly inspecting and investigating harmful events in retrospect, responding after they occur.2 This is despite developments and innovations in proactive inspection methods, and more collaborative approaches.

Another problem is that regulators often argue for system-based approaches to adverse events, but then often act by sanctioning individuals—in part because this is what they are empowered to do. The regulatory logic is: assemble objective evidence and assess this against compliance to the standard...

Safety netting: time to stop relying on verbal interventions to manage diagnostic uncertainty?

‘Safety netting’ refers to a range of activities to manage clinical uncertainty during consultations. This can include uncertainty about diagnosis, how disease may progress or whether or not a treatment will work. It is frequently delivered along the lines of ‘come back and see me if this does not get better’, but can also include more specific advice and steps to monitor the patient through lists or codes in the patient record. The desired effect is for patients to seek medical attention again if needed and to be reassured if not. Ten years of safety netting research has established that safety netting is ubiquitous and inconsistently practised. It is invariably delivered with missing details about how quickly symptoms may resolve or reappear, and what the implication would be.1 Requests to ‘come back’ are often made without clear instructions for how and when to do so.1...

Beyond polypharmacy to the brave new world of minimum datasets and artificial intelligence: thumbing a nose to Henry

Dealing with uncertainty is an inherent part of scientific discovery. One of the ways in which scientists have tried to overcome uncertainty is through the concept of measurement—defined as the act or the process of finding the size, quantity or degree of something.1 Over centuries, standardised and consistent measurement systems have assumed fundamental importance in societies in parallel with the increasing dominance of the scientific paradigm. The 11th century proposal by Henry I of England to standardise the measurement of a yard as the distance from his nose to outstretched thumb2 may appear egotistical and humorous by modern standards. But the reader does not need to stray far outside of the scientific paradigm to appreciate the range of philosophical standpoints on the nature of measurement and the ongoing debate over the concept of measurable quantity.3 4 Examples of outcomes that cannot...

Integration and connection: the key to effectiveness of large-scale pharmacist-led medication reviews?

Our population is ageing and with increased age, comes more frequent presentation of people living with multiple long-term conditions (MLTCs), who are likely to experience polypharmacy and the risk that accompanies taking multiple medications. These risks disproportionately affect the most socioeconomically deprived people in our communities, including those from minority ethnic groups, among whom the incidence of MLTCs is higher1 and acquired at an earlier age.2 Polypharmacy increases the prevalence of errors relating to the medicines use process, defined as including prescribing, dispensing, administration and monitoring of medication. Estimates in England report around 237 million medication errors per annum with avoidable errors costing around £98 million each year resulting in 1700 deaths.3 In the USA, around 7 million people per year are affected by medication errors at a cost of around US$21 billion.4 While not all of these errors are clinically significant,...

Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study

Background

Safety-netting is intended to protect against harm from uncertainty in diagnosis/disease trajectory. Despite recommendations to communicate diagnostic uncertainty when safety-netting, this is not always done.

Aims

To explore how and why doctors safety-netted in response to several clinical scenarios, within the broader context of exploring how doctors communicate diagnostic uncertainty.

Methods

Doctors working in internal medical specialties (n=36) from five hospitals were given vignettes in a randomised order (all depicting different clinical scenarios involving diagnostic uncertainty). After reading each, they told an interviewer what they would tell a ‘typical patient’ in this situation. A follow-up semistructured interview explored reasons for their communication. Interviews were recorded, transcribed and coded. We examined how participants safety-netted using a content analysis approach, and why they safety-netting with thematic analysis of the semistructured follow-up interviews using thematic analysis.

Results

We observed n=78 instances of safety-netting (across 108 vignette encounters). We found significant variation in how participants safety-netted. Safety-netting was common (although not universal), but clinicians differed in the detail provided about symptoms to be alert for, and the action advised. Although many viewed safety-netting as an important tool for managing diagnostic uncertainty, diagnostic uncertainty was infrequently explicitly discussed; most advised patients to return if symptoms worsened or new ‘red flag’ symptoms developed, but they rarely linked this directly to the possibility of diagnostic error. Some participants expressed concerns that communicating diagnostic uncertainty when safety-netting may cause anxiety for patients or could drive inappropriate reattendance/over-investigation.

Conclusions

Participants safety-netted variously, even when presented with identical clinical information. Although safety-netting was seen as important in avoiding diagnostic error, concerns about worrying patients may have limited discussion about diagnostic uncertainty. Research is needed to determine whether communicating diagnostic uncertainty makes safety-netting more effective at preventing harm associated with diagnostic error, and whether it causes significant patient anxiety.

Longitudinal cohort study of discrepancies between prescribed and administered polypharmacy rates: implications for National Aged Care Quality Indicator Programs

Background

Polypharmacy is frequently used as a quality indicator for older adults in Residential Aged Care Facilities (RACFs) and is measured using a range of definitions. The impact of data source choice on polypharmacy rates and the implications for monitoring and benchmarking remain unclear. We aimed to determine polypharmacy rates (≥9 concurrent medicines) by using prescribed and administered data under various scenarios, leveraging electronic data from 30 RACFs.

Method

A longitudinal cohort study of 5662 residents in New South Wales, Australia. Both prescribed and administered polypharmacy rates were calculated biweekly from January 2019 to September 2022, providing 156 assessment times. 12 different polypharmacy rates were computed separately using prescribing and administration data and incorporating different combinations of items: medicines and non-medicinal products, any medicines and regular medicines across four scenarios: no, 1-week, 2-week and 4-week look-back periods. Generalised estimating equation models were employed to identify predictors of discrepancies between prescribed and administered polypharmacy.

Results

Polypharmacy rates among residents ranged from 33.9% using data on administered regular medicines with no look-back period to 63.5% using prescribed medicines and non-medicinal products with a 4-week look-back period. At each assessment time, the differences between prescribed and administered polypharmacy rates were consistently more than 10.0%, 4.5%, 3.5% and 3.0%, respectively, with no, 1-week, 2-week and 4-week look-back periods. Diabetic residents faced over two times the likelihood of polypharmacy discrepancies compared with counterparts, while dementia residents consistently showed reduced likelihood across all analyses.

Conclusion

We found notable discrepancies between polypharmacy rates for prescribed and administered medicines. We recommend a review of the guidance for calculating and interpreting polypharmacy for national quality indicator programmes to ensure consistent measurement and meaningful reporting.

Crowdsourcing a diagnosis? Exploring the accuracy of the size and type of group diagnosis: an experimental study

Background

The consultation process, where a clinician seeks an opinion from another clinician, is foundational in medicine. However, the effectiveness of group diagnosis has not been studied.

Objective

To compare individual diagnosis to group diagnosis on two dimensions: group size (n=3 or 6) and group process (interactive or artificial groups).

Methodology

Thirty-six internal or emergency medicine residents participated in the study. Initially, each resident worked through four written cases on their own, providing a primary diagnosis and a differential diagnosis. Next, participants formed into groups of three. Using a videoconferencing platform, they worked through four additional cases, collectively providing a single primary diagnosis and differential diagnosis. The process was repeated using a group of six with four new cases. Cases were all counterbalanced. Retrospectively, nominal (ie, artificial) groups were formed by aggregating individual participant data into subgroups of three and six and analytically computing scores. Presence of the correct diagnosis as primary diagnosis or included in the differential diagnosis, as well as the number of diagnoses mentioned, was calculated for all conditions. Means were compared using analysis of variance.

Results

For both authentic and nominal groups, the diagnostic accuracy of group diagnosis was superior to individual for both the primary diagnosis and differential diagnosis. However, there was no improvement in diagnostic accuracy when comparing a group of three to a group of six. Interactive and nominal groups were equivalent; however, this may be an artefact of the method used to combine data.

Conclusions

Group diagnosis improves diagnostic accuracy. However, a larger group is not necessarily superior to a smaller group. In this study, interactive group discussion does not result in improved diagnostic accuracy.

How therapeutic relationships develop in group-based telehealth and their perceived impact on processes and outcomes of a complex intervention: a qualitative study

Background

Therapeutic relationships are a key domain in healthcare delivery. While well-understood in in-person interventions, how therapeutic relationships develop in more complex contexts is unclear. This study aimed to understand (1) how therapeutic relationships are developed during the telehealth delivery of a group-based, complex intervention and (2) the perceived impact of these relationships on intervention processes, such as intervention delivery and engagement, and patient outcomes, such as patient safety and satisfaction.

Methods

This qualitative study, nested within a randomised controlled trial, used an interpretivist approach to explore the perceptions of 25 participants (18 patients with shoulder pain and 7 clinicians) regarding developing therapeutic relationships in a group-based, complex intervention delivered via telehealth. Semi-structured interviews were conducted within 4 weeks of the telehealth intervention period and then analysed through in-depth, inductive thematic analysis.

Results

We identified six themes: (1) ‘Patients trust clinicians who demonstrate credibility, promoting the development of therapeutic relationships’; (2) ‘Simple features and approaches shape the therapeutic relationship’, including small talk, time spent together and social observation; (3) ‘A sense of belonging and support fosters connections’, facilitated by clinicians providing individualised attention within the group; (4) ‘Developing therapeutic relationships can impact the delivery of core intervention components’, reflecting challenges clinicians faced; (5) ‘Therapeutic relationships can facilitate intervention engagement’, through enhanced patient understanding and confidence and (6) ‘Therapeutic relationships can contribute to patient safety and satisfaction’, with patients feeling more comfortable reporting intervention-related issues.

Conclusions

Therapeutic relationships were developed during group-based telehealth sessions through a set of factors that may require additional skills and effort compared with in-person interactions. While these relationships have a perceived positive impact on intervention engagement and patient outcomes, clinicians need to find a balance between building relationships and delivering the telehealth intervention with fidelity.

Trial registration number

ACTRN12621001650886.

Components of pharmacist-led medication reviews and their relationship to outcomes: a systematic review and narrative synthesis

Introduction

Pharmacist-led medication reviews are an established intervention to support patients prescribed multiple medicines or with complex medication regimes. For this systematic review, a medication review was defined as ‘a consultation between a pharmacist and a patient to review the patient’s total medicines use with a view to improve patient health outcomes and minimise medicines-related problems’. It is not known how varying approaches to medication reviews lead to different outcomes.

Aim

To explore the common themes associated with positive outcomes from pharmacist-led medication reviews.

Method

Randomised controlled trials of pharmacist-led medication reviews in adults aged 18 years and over were included. The search terms used in MEDLINE, EMBASE and Web of Science databases were "medication review", "pharmacist", "randomised controlled trial" and their synonyms, time filter 2015 to September 2023. Studies published before 2015 were identified from a previous systematic review. Risk of bias was assessed using the Cochrane risk of bias 2 tool. Descriptions of medication reviews’ components, implementation and outcomes were narratively synthesised to draw out common themes. Results are presented in tables.

Results

Sixty-eight papers describing 50 studies met the inclusion criteria. Common themes that emerged from synthesis include collaborative working which may help reduce medicines-related problems and the number of medicines prescribed; patient involvement in goal setting and action planning which may improve patients’ ability to take medicines as prescribed and help them achieve their treatment goals; additional support and follow-up, which may lead to improved blood pressure, diabetes control, quality of life and a reduction of medicines-related problems.

Conclusion

This systematic review identified common themes and components, for example, goal setting, action planning, additional support and follow-up, that may influence outcomes of pharmacist-led medication reviews. Researchers, health professionals and commissioners could use these for a comprehensive evaluation of medication review implementation.

PROSPERO registration number

CRD42020173907.

Why a sociotechnical framework is necessary to address diagnostic error

Diagnostic error: the problem

Failures in the diagnostic process are thought to affect at least 15% of patient encounters, cause 34% of adverse events in hospitals, are a leading cause in major malpractice claims and payouts and are recognised as a top priority in patient safety research.1–3 The National Academies of Science, Engineering and Medicine defines diagnostic error as a failure to establish an accurate and timely explanation of a patient’s medical problem and has been shown to contribute to the morbidity and mortality of an estimated 795 000 patients each year in the USA.1 Although diagnostic error has received significant research attention across multiple clinical settings over the last several decades, it continues to pose consequential challenges and requires improvement in systematic investigation and operational intervention.3 4 Additionally, few effective mitigation strategies have been designed for...

Aiming for equity in children with chronic conditions: introducing a new population health management system

The widely known United Nations sustainable development goals indicate that good quality healthcare should be available to all those who need it.1 Unfortunately, the availability of good care tends to vary inversely with the actual need for it. This is not a new issue and had already been dubbed ‘the inverse care law’ as far back as 1971.2 In response, those working in healthcare strived to make changes, aiming to provide equitable access to high-quality healthcare to all patients. Despite this, differences between groups persist. Even in populations with good healthcare coverage, certain subgroups attend screening less,3 experience lower availability of care4 and have ongoing unmet needs.5 To address this, the concept of health equity was introduced, with multiple recent landmark articles stressing its importance.6 7 BMJ Quality and Safety has also embraced this concept,...

Investigating a novel population health management system to increase access to healthcare for children: a nested cross-sectional study within a cluster randomised controlled trial

Background

Early intervention for unmet needs is essential to improve health. Clear inequalities in healthcare use and outcomes exist. The Children and Young People’s Health Partnership (CYPHP) model of care uses population health management methods to (1) identify and proactively reach children with asthma, eczema and constipation (tracer conditions); (2) engage these families, with CYPHP, by sending invitations to complete an online biopsychosocial Healthcheck Questionnaire; and (3) offer early intervention care to those children found to have unmet health needs. We aimed to understand this model’s effectiveness to improve equitable access to care.

Methods

We used primary care and CYPHP service-linked records and applied the same methods as the CYPHP’s population health management process to identify children aged <16 years with a tracer condition between 1 April 2018 and 30 August 2020, those who engaged by completing a Healthcheck and those who received early intervention care. We applied multiple imputation with multilevel logistic regression, clustered by general practitioner (GP) practice, to investigate the association of deprivation and ethnicity, with children’s engagement and receiving care.

Results

Among 129 412 children, registered with 70 GP practices, 15% (19 773) had a tracer condition and 24% (4719) engaged with CYPHP’s population health management system. Children in the most deprived, compared with least deprived communities, had 26% lower odds of engagement (OR 0.74; 95% CI 0.62 to 0.87). Children of Asian or black ethnicity had 31% lower odds of engaging, compared with white children (0.69 (0.59 to 0.81) and 0.69 (0.62 to 0.76), respectively). However, once engaged with the population health management system, black children had 43% higher odds of receiving care, compared with white children (1.43 (1.15 to 1.78)), and children from the most compared with least deprived communities had 50% higher odds of receiving care (1.50 (1.01 to 2.22)).

Conclusion

Detection of unmet needs is possible using population health management methods and increases access to care for children from priority populations with the highest needs. Further health system strengthening is needed to improve engagement and enhance proportionate universalist access to healthcare.

Trial registration number

ClinicalTrials.gov Registry (NCT03461848).

Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS, 2010-2023

Background

Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear.

Aim

To identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010–2023, and to conduct a structured quality assessment.

Methods

We drew on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance to inform the design and reporting of our study. We identified relevant programmes using multiple search strategies of grey literature, research databases and other sources. Programmes that met a prespecified definition of improvement programme, that focused on intrapartum care and that had a retrievable evaluation report were subject to structured assessment using selected features of programme quality.

Results

We identified 1434 records via databases and other sources. 14 major initiatives in English maternity services could not be quality assessed due to lack of a retrievable evaluation report. Quality assessment of the 15 improvement programmes meeting our criteria for assessment found highly variable quality and reporting. Programme specification was variable and mostly low quality. Only eight reported the evidence base for their interventions. Description of implementation support was poor and none reported customisation for challenged services. None reported reduction of inequalities as an explicit goal. Only seven made use of explicit patient and public involvement practices, and only six explicitly used published theories/models/frameworks to guide implementation. Programmes varied in their reporting of the planning, scope and design of evaluation, with weak designs evident.

Conclusions

Poor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes.

Pages