Promoting equity, diversity, and inclusion in surveys: insights from a patient-engaged study to assess long COVID health-care needs in Brazil.

BACKGROUND AND OBJECTIVE: Long COVID (LC) refers to persistent symptoms after acute COVID-19 infection, which may persist for months or years. LC affects millions of people globally, with substantial impacts on quality of life, employment, and social participation. Ensuring access to effective, patient-centered care for LC demands evidence, grounded in inclusive representation of those affected by the condition. Yet survey studies frequently under-represent people with the most disabling disease presentations and racially and socioeconomically marginalized groups. We aimed to describe a patient-engaged approach to developing a survey to inform public LC health care and to assess its implementation in terms of enabling participation by diverse LC patients in Brazil. METHODS: Survey development was iterative, achieved through an interdisciplinary collaboration among researchers including people living with LC, and grounded in 3 guiding principles: (1) evidence-based; (2) inclusive, intersectional, and patient-centered understanding of chronic illness and research participation; and (3) sensitivity to the context of health-care access. RESULTS: The product of our collaboration was a longitudinal survey using a questionnaire assessing: LC symptoms; their clinical and functional evolution; and impacts on quality of life, household income, health service access, utilization, and out-of-pocket expenses. We illustrate how we operationalized our 3 principles through survey content, instrument design, and administration. Six hundred fifty-one participants with diverse LC symptoms, demography, and socioeconomic status completed the survey. We successfully included participants experiencing disabling symptoms, Black and mixed race participants, and those with lower education and income. CONCLUSION: By centering patient experience, our novel, principles-based approach succeeded in promoting equity, diversity, and inclusion in LC survey research. These principles guiding patient-engaged collaboration have broad transferability. We encourage survey researchers working on chronic illness and in other contexts of marginalization and inequality to adopt them.

Using Participatory Implementation Science to Advance Health Equity.

Participatory approaches to implementation science (IS) offer an inclusive, collaborative, and iterative perspective on implementing and sustaining evidence-based interventions (EBIs) to advance health equity. This review provides guidance on the principles and practice of participatory IS, which enables academic researchers, community members, implementers, and other actors to collaboratively integrate practice-, community-, and research-based evidence into public health and health care services. With a foundational focus on supporting academics in coproducing knowledge and action, participatory IS seeks to improve health, reduce inequity, and create transformational change. The three main sections of this review provide (a) a rationale for participatory approaches to research in implementation science, (b) a framework for integrating participatory approaches in research utilizing IS theory and methods, and (c) critical considerations for optimizing the practice and impact of participatory IS. Ultimately, participatory approaches can move IS activities beyond efforts to make EBIs work within harmful systems toward transformative solutions that reshape these systems to center equity.

Business-nonprofit hybrid organizing: a dynamic approach to balancing benefits and costs.

Introduction: Efforts to address complex public health challenges can benefit from cross-sector collaboration, while also fostering growing business sector engagement in promoting health equity. What form business-nonprofit collaboration should take, however, is a difficult question for managers and leaders. Hybrid organizational forms, which combine for-profit and nonprofit elements within a single organization in unconventional ways, offer an innovative and potentially promising approach. Yet, while existing typologies of cross-sector collaboration have identified hybrid forms at one end of a continuum of possible forms of collaboration, these typologies do not differentiate the diversity such hybrid forms may take, and the costs and benefits of these innovative hybrid forms are poorly understood. This leaves managers interested in promoting public health through business-nonprofit hybrid organizing with limited guidance about how to maximize potential merits while mitigating drawbacks. Methods: We performed a qualitative comparative case study of three examples of business-nonprofit hybrid organizing. Data collection included 113 interviews with representatives from 42 organizations and observation of case study activities. We used thematic analysis within and across cases to characterize the form of hybrid organizing in each case and to examine benefits and costs of different forms for supporting initiatives. Results: We identified two hybrid, collaborative forms - Appended and Blended forms. Each form had benefits and costs, the significance of which shifted over time contingent on changing strategic priorities and operating environments. Benefits and costs of particular forms become more or less important for establishing and sustaining initiatives under different conditions, requiring a dynamic view. Discussion: No particular form of business-nonprofit hybrid organizing is inherently better than another. Optimizing hybrid organizing and ensuring resilient collaborations may mean allowing collaborative forms to evolve. Practitioners can manage tradeoffs between benefits and costs through an ongoing process of assessing the fit between a given collaborative form, strategic priorities, and relevant features of the operating environment. This dynamic view offers important insights for ensuring the resilience of business-nonprofit collaborative efforts to enhance public health.

Building resilient partnerships: How businesses and nonprofits create the capacity for responsiveness.

Increasingly, businesses are eager to partner with nonprofit organizations to benefit their communities. In spite of good intentions, differences between nonprofit and business organizations can limit the ability of potential partnerships to respond to a changing economic and public health landscape. Using a retrospective, multiple-case study, we sought to investigate the managerial behaviors that enabled businesses and nonprofits to be themselves together in sustainable partnerships. We recruited four nonprofit-business partnerships in the Boston area to serve as cases for our study. Each was designed to address social determinants of health. We thematically analyzed qualitative data from 113 semi-structured interviews, 9 focus groups and 29.5 h of direct observations to identify organizational capacities that build resilient partnerships. Although it is common to emphasize the similarities between partners, we found that it was the acknowledgement of difference that set partnerships up for success. This acknowledgement introduced substantial uncertainty that made managers uncomfortable. Organizations that built the internal capacity to be responsive to, but not control, one another were able to derive value from their unique assets.

Achieving partnership synergy: resource inputs, shared mission and interdependencies in Danish health promotion partnerships.

Intersectoral partnerships have the potential to co-produce 'synergistic' solutions to complex public health problems, exceeding what any single organization acting alone might achieve. Synergy requires shared decision-making and equitable co-construction by partners. However, many partnerships struggle to realize such synergistic potential. Building on the Bergen Model of Collaborative Functioning, this study offers insights for optimizing partnership synergy by examining interactions between 'inputs' to the partnership-shared mission, and partner resources. Specifically, we introduce the concept of 'dependency structure' to draw attention to how these input interactions shape the balance of power and hence the potential for shared decision-making and co-construction. Findings are based on qualitative data from 10 intersectoral, health promotion partnerships in Denmark, including 27 interviews, 10 focus groups, partnership documents and meeting observations. We identified eight distinct types of 'input resources', which were important in shaping the potential balance of power between partners in more or less productive ways. However, the dependency structure that materialized-and its synergistic potential-was contingent on how these inputs interacted with the partnership mission. Our findings suggest a well-developed shared mission serves three functions-(i) foregrounding a common purpose, (ii) aligning individual partner's self-interests and (iii) enabling action. The extent to which partnerships developed a shared mission serving all three functions influenced realization of a balanced dependency structure in which collaborators recognized their interdependencies, in turn promoting shared decision-making. To ensure the greatest potential for synergy, early and ongoing discursive processes to co-develop the partnership mission were particularly important.

Overlooked Potential of Business-Inclusive Networks to Amplify Anchoring Activity Impact.

Mobilizing anchor institutions to promote community health and wellbeing is gaining prominence as an approach to systems change. Anchors are often conceptualized as large, locally rooted, nonprofits that leverage their resources for local benefit. However, existing literature underemphasizes 2 opportunities to enhance the systemic impact of anchoring activity: (1) coordinated action by anchoring networks that include diverse, multi-level stakeholders-a hallmark of health promotion and (2) the potential contributions of the business sector to anchoring networks. Our perspective describes the significance of both for amplifying anchoring impact and identifies critical questions for enabling action.

How Can Implementation of a Large-Scale Patient Safety Program Strengthen Hospital Safety Culture? Lessons From a Qualitative Study of National Patient Safety Program Implementation in Two Public Hospitals in Brazil.

Large-scale (e.g., national) programs could strengthen safety culture, which is foundational to patient safety, yet we know little about how to optimize this potential. In 2013, Brazil's Ministry of Health launched the National Patient Safety Program, involving hospital-level safety teams and targeted safety protocols. We conducted in-depth qualitative case studies of National Patient Safety Program implementation in two hospitals, with different readiness, to understand how program implementation affected enabling, enacting, and elaborating processes that produce and sustain safety culture. For both hospitals, external mandates were insufficient for enabling hospital-level action. Internal enabling failures (e.g., little safety-relevant senior leadership) hindered enactment (e.g., safety teams unable to institute plans). Limited enactment and weak elaboration processes (e.g., bureaucratic monitoring) failed to institutionalize protocol use and undermined safety culture. Optimizing the safety culture impact of large-scale programs requires effective multi-level enabling and capitalizing on the productive potential of interacting national- and local-level influences.

The role of the informal and formal organisation in voice about concerns in healthcare: A qualitative interview study.

The importance of employee voice-speaking up and out about concerns-is widely recognised as fundamental to patient safety and quality of care. However, failures of voice continue to occur, often with disastrous consequences. In this article, we argue that the enduring sociological concepts of the informal organisation and formal organisation offer analytical purchase in understanding the causes of such problems and how they can be addressed. We report a qualitative study involving 165 interviews across three healthcare organisations in two high-income countries. Our analysis emphasises the interdependence of the formal and informal organisation. The formal organisation describes codified and formalised elements of structures, procedures and processes for the exercise of voice, but participants often found it frustrating, ambiguous, and poorly designed. The informal organisation-the informal practices, social connections, and methods for making decisions that are key to coordinating organisational activity-could facilitate voice through its capacity to help people to understand complex processes, make sense of their concerns, and frame them in ways likely to prompt an appropriate organisational response. Sometimes the informal organisation compensated for gaps, ambiguities and inconsistencies in formal policies and systems. At the same time, the informal organisation had a dark side, potentially subduing voice by creating informal hierarchies, prioritising social cohesion, and providing opportunities for retaliation. The formal and the informal organisation are not exclusive or independent: they interact with and mutually reinforce each other. Our findings have implications for efforts to improve culture and processes in relation to voice in healthcare organisations, pointing to the need to address deficits in the formal organisation, and to the potential of building on strengths in the informal organisation that are crucial in supporting voice.

Optimizing patient partnership in primary care improvement: A qualitative study.

BACKGROUND: The need to expand and better engage patients in primary care improvement persists. PURPOSE: Recognizing a continuum of forms of engagement, this study focused on identifying lessons for optimizing patient partnerships, wherein engagement is characterized by shared decision-making and practice improvement codesign. METHODOLOGY: Twenty-three semistructured interviews with providers and patients involved in improvement efforts in seven U.S. primary care practices in the Academic Innovations Collaborative (AIC). The AIC aimed to implement primary care improvement, emphasizing patient engagement in the process. Data were analyzed thematically. RESULTS: Sites varied in their achievement of patient partnerships, encountering material, technical, and sociocultural obstacles. Time was a challenge for all sites, as was engaging a diversity of patients. Technical training on improvement processes and shared learning "on the job" were important. External, organizational, and individual-level resources helped overcome sociocultural challenges: The AIC drove provider buy-in, a team-based improvement approach helped shift relationships from providers and recipients toward teammates, and individual qualities and behaviors that flattened hierarchies and strengthened interpersonal relationships further enhanced "teamness." A key factor influencing progress toward transformative partnerships was a strong shared learning journey, characterized by frequent interactions, proximity to improvement decision-making, and learning together from the "lived experience" of practice improvement. Teams came to value not only patients' knowledge but also changes wrought by working collaboratively over time. CONCLUSION: Establishing practice improvement partnerships remains challenging, but partnering with patients on improvement journeys offers distinctive gains for high-quality patient-centered care. PRACTICE IMPLICATIONS: Engaging diverse patient partners requires significant disruption to organizational norms and routines, and the trend toward team-based primary care offers a fertile context for patient partnerships. Material, technical, and sociocultural resources should be evaluated not only for whether they overcome specific challenges but also for how they enhance the shared learning journey.

A Mixed Methods Study of Change Processes Enabling Effective Transition to Team-Based Care.

Team-based care is considered central to achieving value in primary care, yet results of large-scale primary care transformation initiatives have been mixed. We explore how underlying change processes influence the effectiveness of transition to team-based care. We studied 12 academically affiliated primary care practices participating in a learning collaborative, using longitudinal staff survey data to measure progress toward team-based care and qualitative interviews with practice staff to understand practice transformation. Transformation efforts focused on team formation and capacity building for quality improvement. Using thematic analysis, we explored types of change processes undertaken and the relationship between change processes and effective team-based care. We identified three prototypical approaches to change: pursuing functional and cultural change processes, functional only, and cultural only. Practice sites prioritizing both change processes formed the most effective teams: simultaneous functional and cultural change spurred a mutually reinforcing virtuous cycle. We describe implications for research, practice, and policy.

Lessons for Local Policy Initiatives to Address Dietary Supplement Use Among Adolescents: A Qualitative Study of Stakeholders' Perceptions.

PURPOSE: Weight-loss and muscle-building dietary supplements can have adverse health consequences for youth. At a time, when the Food and Drug Administration is considering increasing oversight of dietary supplements, this study aimed to explore community stakeholders' perceptions about the use of and access to such supplements among adolescents and to identify challenges and opportunities to engage stakeholders with policy initiatives to curtail youth access to supplements at the local level. METHOD: We conducted 32 key informant semistructured interviews in four municipalities in Massachusetts with purposefully selected participants representing three categories of community stakeholders who could contribute to policy agenda setting at the local level: policy professionals, youth service providers, and young adults aged 18-25 years who used weight-loss or muscle-building supplements as minors. Interviews were audio-recorded, transcribed, deidentified, and analyzed using thematic analysis approach, facilitated by Dedoose software. RESULTS: Community stakeholders reported wide availability and easy access to dietary supplements. Most participants were unaware of health risks. Many stakeholders did not perceive the use of these products as an issue impacting youth in their communities. The challenges identified in engaging stakeholders were competing concerns on the policy agenda, limited capacity of stakeholders, and uncertainty about who is accountable for the problem. CONCLUSION: This study indicates the need for complementary, multipronged approaches at the municipal level to address the problem of weak regulation and easy access to potentially dangerous weight-loss and muscle-building supplements for youth.

An ethnographic study of improving data collection and completeness in large-scale data exercises.

Background: Large-scale data collection is an increasingly prominent and influential feature of efforts to improve healthcare delivery, yet securing the involvement of clinical centres and ensuring data comprehensiveness often proves problematic. We explore how improvements in both data submission and completion rates were achieved during a crucial period of the evolution of two large-scale data exercises. Methods:  As part of an evaluation of a quality improvement programme, we conducted an ethnographic study involving 90 interviews and 47 days of non-participant observation of two UK national clinical audits in a period before submission of data on adherence to clinical standards became mandatory. Results: Critical to the improvements in submission and completion rates in the two exercises were the efforts of clinical leaders to refigure "data work" as a professionalization strategy. Using a series of strategic manoeuvres, leaders constructed a cultural account that tied the fortunes of the healthcare professions to the submission of high-quality data, proposing that it would demonstrate responsibility, transparency, and alignment with the public interest. In so doing, clinical leadership deployed tactics that might have been seen as unwarranted managerial aggression had they been imposed by parties external to the profession. Many residual challenges were linked not to principled objection by clinicians, but to mundane problems and frustrations in obtaining, recording, and submitting data. The cultural framing of data work as a professional duty was important to resolving its status as an abject form of labour. Conclusions: Improving data quality in large-scale exercises is possible, but requires cooperation with clinical centres. Enabling professional leadership of data work may offer some significant advantages, but attention is also needed to mundane and highly consequential obstacles to participation in data collection.

Improving Employee Voice About Transgressive or Disruptive Behavior: A Case Study.

PURPOSE: Employee voice plays an important role in organizational intelligence about patient safety hazards and other influences on quality of patient care. The authors report a case study of an academic medical center that aimed to understand barriers to voice and make improvements in identifying and responding to transgressive or disruptive behaviors. METHOD: The case study focused on an improvement effort at Johns Hopkins Medicine that sought to improve employee voice using a two-phase approach of diagnosis and intervention. Confidential interviews with 67 individuals (20 senior leaders, 47 frontline personnel) were conducted during 2014 to diagnose causes of employee reluctance to give voice about behavioral concerns. A structured intervention program to encourage voice was implemented, 2014-2016, in response to the findings. RESULTS: The diagnostic interviews identified gaps between espoused policies of encouraging employee voice and what happened in practice. A culture of fear pervaded the organization that, together with widespread perceptions of futility, inhibited personnel from speaking up about concerns. The intervention phase involved four actions: sharing the interview findings; coordinating and formalizing mechanisms for identifying and dealing with disruptive behavior; training leaders in encouraging voice; and building capacity for difficult conversations. CONCLUSIONS: The problems of giving voice are widely known across the organizational literature but are difficult to address. This case study offers an approach that includes diagnostic and intervention phases that may be helpful in remaking norms, facilitating employee voice, and improving organizational response. It highlights specific actions that are available for other organizations to adapt and test.

Challenges to the improvement of obstetric care in maternity hospitals of a large Brazilian city: an exploratory qualitative approach on contextual issues.

BACKGROUND: Maternal morbidity and mortality are still serious public health concerns in Brazil, and access to quality obstetric care is one critical point of this problem. Despite efforts, obstetric care quality problems and sub-optimal/poor outcomes persist. The study aimed to identify contextual elements that would potentially affect the implementation of an obstetric care quality improvement intervention. METHODS: A qualitative study was conducted in three public maternity hospitals of a large Brazilian city, with high annual volume of births and buy-in from high-level managers. Individual interviews with doctors and nurses were conducted from July to October 2015. Semi-structured interviews sought to explore teamwork, coordination and communication, and leadership, being open to capture other contextual elements that could emerge. Interviews were recorded and transcribed, and the categories of analysis were identified and updated based on the constant comparative method. RESULTS: Twenty-seven interviews were carried out. Extra-organizational context concerning the dependence of the maternity hospitals on primary care units, responsible for antenatal care, and on other healthcare organizations' services emerged from interviews, but the main findings of the study centered on intra-organizational context with potential to affect healthcare quality and actions for its improvement, including material resources, work organization design, teamwork, coordination and communication, professional responsibility vis-à-vis the patient, and leadership. A major issue was the divergence of physicians' and nurses' perspectives on care quality, which in turn negatively affected their capacity to work together. CONCLUSION: Overall, the findings suggest that care on the maternity hospitals was fragmented and lacked continuity, putting at risk the quality. Redesigning work organization, promoting conditions for multi-professional teamwork, better communication and coordination, improving more systemic accountability/lines of authority, and investing in team members' technical competence, and fitness of organizational structures and processes are all imbricated actions that may contribute to obstetric care quality improvement.

Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns.

BACKGROUND: Healthcare organisations often fail to harvest and make use of the 'soft intelligence' about safety and quality concerns held by their own personnel. We aimed to examine the role of formal channels in encouraging or inhibiting employee voice about concerns. METHODS: Qualitative study involving personnel from three academic hospitals in two countries. Interviews were conducted with 165 participants from a wide range of occupational and professional backgrounds, including senior leaders and those from the sharp end of care. Data analysis was based on the constant comparative method. RESULTS: Leaders reported that they valued employee voice; they identified formal organisational channels as a key route for the expression of concerns by employees. Formal channels and processes were designed to ensure fairness, account for all available evidence and achieve appropriate resolution. When processed through these formal systems, concerns were destined to become evidenced, formal and tractable to organisational intervention. But the way these systems operated meant that some concerns were never voiced. Participants were anxious about having to process their suspicions and concerns into hard evidentiary facts, and they feared being drawn into official procedures designed to allocate consequence. Anxiety about evidence and process was particularly relevant when the intelligence was especially 'soft'-feelings or intuitions that were difficult to resolve into a coherent, compelling reconstruction of an incident or concern. Efforts to make soft intelligence hard thus risked creating 'forbidden knowledge': dangerous to know or share. CONCLUSIONS: The legal and bureaucratic considerations that govern formal channels for the voicing of concerns may, perversely, inhibit staff from speaking up. Leaders responsible for quality and safety should consider complementing formal mechanisms with alternative, informal opportunities for listening to concerns.

Factors Influencing Team Behaviors in Surgery: A Qualitative Study to Inform Teamwork Interventions.

BACKGROUND: Surgical excellence demands teamwork. Poor team behaviors negatively affect team performance and are associated with adverse events and worse outcomes. Interventions to improve surgical teamwork focusing on frontline team members' nontechnical skills have proliferated but shown mixed results. Literature on teamwork in organizations suggests that team behaviors are also contingent on psychosocial, cultural, and organizational factors. This study examined factors influencing surgical team behaviors to inform more contextually sensitive and effective approaches to optimizing surgical teamwork. METHODS: This qualitative study of cardiac surgical teams in a large United States teaching hospital included 34 semistructured interviews. Thematic network analysis was used to examine perceptions of ideal teamwork and factors influencing team behaviors in the operating room. RESULTS: Perceptions of ideal teamwork were largely shared, but team members held discrepant views of which team and leadership behaviors enhanced or undermined teamwork. Other factors affecting team behaviors were related to the local organizational culture, including management of staff behavior, variable case demands, and team members' technical competence, and fitness of organizational structures and processes to support teamwork. These factors affected perceptions of what constituted optimal interpersonal and team behaviors in the operating room. CONCLUSIONS: Team behaviors are contextually contingent and organizationally determined, and beliefs about optimal behaviors are not necessarily shared. Interventions to optimize surgical teamwork require establishing consensus regarding best practice, ability to adapt as circumstances require, and organizational commitment to addressing contextual factors that affect teams.

Effective Leadership of Surgical Teams: A Mixed Methods Study of Surgeon Behaviors and Functions.

BACKGROUND: The importance of effective team leadership for achieving surgical excellence is widely accepted, but we understand less about the behaviors that achieve this goal. We studied cardiac surgical teams to identify leadership behaviors that best support surgical teamwork. METHODS: We observed, surveyed, and interviewed cardiac surgical teams, including 7 surgeons and 116 team members, from September 2013 to April 2015. We documented 1,926 surgeon/team member interactions during 22 cases, coded them by behavior type and valence (ie, positive/negative/neutral), and characterized them by leadership function (conductor, elucidator, delegator, engagement facilitator, tone setter, being human, and safe space maker) to create a novel framework of surgical leadership derived from direct observation. We surveyed nonsurgeon team members about their perceptions of individual surgeon's leadership effectiveness on a 7-point Likert scale and correlated survey measures with individual surgeon profiles created by calculating percentage of behavior types, leader functions, and valence. RESULTS: Surgeon leadership was rated by nonsurgeons from 4.2 to 6.2 (mean, 5.4). Among the 33 types of behaviors observed, most interactions constituted elucidating (24%) and tone setting (20%). Overall, 66% of interactions (range, 43%-84%) were positive and 11% (range, 1%-45%) were negative. The percentage of positive and negative behaviors correlated strongly (r = 0.85 for positive and r = 0.75 for negative, p < 0.05) with nonsurgeon evaluations of leadership. Facilitating engagement related most positively (r = 0.80; p = 0.03), and negative forms of elucidating, ie, criticism, related most negatively (r = -0.81; p = 0.03). CONCLUSIONS: We identified 7 surgeon leadership functions and related behaviors that impact perceptions of leadership. These observations suggest actionable opportunities to improve team leadership behavior.

Optimising the community-based approach to healthcare improvement: Comparative case studies of the clinical community model in practice.

Community-based approaches to healthcare improvement are receiving increasing attention. Such approaches could offer an infrastructure for efficient knowledge-sharing and a potent means of influencing behaviours, but their potential is yet to be optimised. After briefly reviewing challenges to community-based approaches, we describe in detail the clinical community model. Through exploring clinical communities in practice, we seek to identify practical lessons for optimising this community-based approach to healthcare improvement. Through comparative case studies based on secondary analysis, we examine two contrasting examples of clinical communities in practice - the USA-based Michigan Keystone ICU programme, and the UK-based Improving Lung Cancer Outcomes Project. We focus on three main issues. First, both cases were successful in mobilising diverse communities: favourable starting conditions, core teams with personal credibility, reputable institutional backing and embeddedness in wider networks were important. Second, top-down input to organise regular meetings, minimise conflict and empower those at risk of marginalisation helped establish a strong sense of community and reciprocal ties, while intervention components and measures common to the whole community strengthened peer-norming effects. Third, to drive implementation, technical expertise and responsiveness from the core team were important, but so too were 'hard tactics' (e.g. strict limits on local customisation); these were more easily deployed where the intervention was standardised across the community and a strong evidence-base existed. Contrary to the idea of self-organising communities, our cases make clear that vertical and horizontal forces depend on each other synergistically for their effectiveness. We offer practical lessons for establishing an effective balance of horizontal and vertical influences, and for identifying the types of quality problems most amenable to community-based improvement.

Obstacles to implementation of an intervention to improve surgical services in an Ethiopian hospital: a qualitative study of an international health partnership project.

BACKGROUND: Access to safe surgical care represents a critical gap in healthcare delivery and development in many low- and middle-income countries, including Ethiopia. Quality improvement (QI) initiatives at hospital level may contribute to closing this gap. Many such quality improvement initiatives are carried out through international health partnerships. Better understanding of how to optimise quality improvement in low-income settings is needed, including through partnership-based approaches. Drawing on a process evaluation of an intervention to improve surgical services in an Ethiopian hospital, this paper offers lessons to help meet this need. METHODS: We conducted a qualitative process evaluation of a quality improvement project which aimed to improve access to surgical services in an Ethiopian referral hospital through better management. Data was collected longitudinally and included: 66 in-depth interviews with surgical staff and project team members; observation (135 h) in the surgery department and of project meetings; project-related documentation. Thematic analysis, guided by theoretical constructs, focused on identifying obstacles to implementation. RESULTS: The project largely failed to achieve its goals. Key barriers related to project design, partnership working and the implementation context, and included: confusion over project objectives and project and partner roles and responsibilities; logistical challenges concerning overseas visits; difficulties in communication; gaps between the time and authority team members had and that needed to implement and engage other staff; limited strategies for addressing adaptive-as opposed to technical-challenges; effects of hierarchy and resource scarcity on QI efforts. While many of the obstacles identified are common to diverse settings, our findings highlight ways in which some features of low-income country contexts amplify these common challenges. CONCLUSION: We identify lessons for optimising the design and planning of quality improvement interventions within such challenging healthcare contexts, with specific reference to international partnership-based approaches. These include: the need for a funded lead-in phase to clarify and agree goals, roles, mutual expectations and communication strategies; explicitly incorporating adaptive, as well as technical, solutions; transparent management of resources and opportunities; leadership which takes account of both formal and informal power structures; and articulating links between project goals and wider organisational interests.

What is the role of individual accountability in patient safety? A multi-site ethnographic study.

An enduring debate concerns how responsibility for patient safety should be distributed between organisational systems and individual professionals. Though rule-based, calculus-like approaches intended to support a 'just culture' have become popular, they perpetuate an asocial and atomised account. In this article, we use insights from practice theory--which sees organisational phenomena as accomplished in everyday actions, with individual agency and structural conditions as a mutually constitutive, dynamic duality--along with contributions from the political science and ethics literature as a starting point for analysis. Presenting ethnographic data from five hospitals, three in one high-income country and two in low-income countries, we offer an empirically informed, normative rethinking of the role of personal accountability, identifying the collective nature of the healthcare enterprise and the extent to which patient safety depends on contributions from many hands. We show that moral responsibility for actions and behaviours is an irreducible element of professional practice, but that individuals are not somehow 'outside' and separate from 'systems': they create, modify and are subject to the social forces that are an inescapable feature of any organisational system; each element acts on the other. Our work illustrates starkly the structuring effects of the broader institutional and socioeconomic context on opportunities to 'be good'. These findings imply that one of the key responsibilities of organisations and wider institutions in relation to patient safety is the fostering of the conditions of moral community.