What Might Be Required for Inspections to Be Considered Fair? Comment on "What Lies Behind Successful Regulation? A Qualitative Evaluation of Pilot Implementation of Kenya's Health Facility Inspection Reforms".

Tama et al offer us an interesting analysis of a piloted regulatory reform that introduced a Joint Health Inspections (JHIs) system in three Kenyan counties. The study highlights key factors facilitating or hindering the implementation of the reform. In this commentary we reflect on the concept of fairness, which is one of the topics that is discussed in the study. We describe four important dimensions of fairness in the context of inspections: expectation clarity, consistency of assessment, consistency of enforcement, and fairness to patients. We argue that all four dimensions are important in the regulatory design, in order for the inspection to be perceived as fair.

Learning team-based quality improvement in a virtual setting: a qualitative study.

OBJECTIVE: The objective was to explore students' perceptions of learning quality improvement (QI) in a virtual setting and identify factors that promote or inhibit virtual learning. DESIGN: We used an exploratory case study design with focus group interviews. The data were analysed using a thematic analysis approach, with an analytical framework derived from activity theory and Bloom's revised taxonomy of six categories of cognitive processes of learning. SETTING: Postgraduate students participating in a virtual 1-day simulation module to learn QI at two universities in Norway. PARTICIPANTS: Four focus groups with a total of 12 participants. RESULTS: The students' descriptions of learning outcomes indicate that the learning activity involved a variety of cognitive activities, including higher-order cognitive processes. We identified three themes pertaining to the students' experiences of the virtual learning activity: learning through active participation, constructing a virtual learning opportunity and creating a virtual learning environment. The students described that participation and active engagement led to a greater understanding and an integration of theory and practical improvement skills. They reported that to engage in the virtual learning opportunity, it was necessary to create a learning environment where they felt psychologically safe. CONCLUSION: Our findings indicate that it is possible to facilitate collaborative learning integrating theoretical knowledge and practical skills in a virtual setting. Students experienced that engaging in the virtual learning activity contributed to the integration of theoretical knowledge and practical skills. Psychological safety seems to be important for students' engagement in the virtual learning activity. A virtual learning environment alters prior common norms for interaction based on physical presence, which in turn affect students feeling of psychological safety. Educators need to be aware of this and facilitate a virtual learning environment where students feel comfortable to engage.

Contextual factors of external inspections and mechanisms for improvement in healthcare organizations: A realist evaluation.

External inspections constitute a key element of healthcare regulation. Improved quality of care is one of the important goals of inspections but the mechanisms of how inspections might contribute to quality improvement are poorly understood. Drawing on interviews with healthcare professionals and managers and health record data from inspected organizations, we used a realist evaluation approach to explore how twelve inspections of healthcare providers in x= Norway influenced quality improvement. We found that for inspections to contribute to quality improvement, there must be contextual structures present supporting accountability and engaging staff in improvement work. When such structures are present, inspections can contribute to improvement by creating awareness of gaps between desired and current practices, which leads to readiness for change and stimulates intra-organizational reasoning around quality improvement. We discuss our findings using the theory of de- and recoupling, noting how regulators can identify decoupling between intended goals, management systems, practices, and patient outcomes. We further argue that regulators can contribute to a recoupling between these levels by having the capacity to track the providers' clinical performance over time. This will hold the organization accountable for implementing improvement measures and evaluate the effects of the measures on quality of care.

Correction: Early diagnosis of sepsis in emergency departments, time to treatment, and association with mortality: An observational study.

[This corrects the article DOI: 10.1371/journal.pone.0227652.].

Promoting leadership and quality improvement through external inspections of management of sepsis in Norwegian hospitals: a focus group study.

OBJECTIVE: Inspections and other forms of external assessment may contribute to positive changes in the health services, but the mechanisms of such change remain unclear. We did a study to explore how external inspections may foster clinical improvement in hospitals. DESIGN: Focus group study. SETTING: Statutory inspections of sepsis treatment in hospital emergency departments in Norway. PARTICIPANTS: Clinicians, managers and inspection teams involved with the inspections of sepsis treatment in emergency departments at four different hospitals. Twelve focus group interviews were carried out, with a total of 47 participants. RESULTS: Three themes emerged as central for understanding how the inspections could contribute to clinical improvement in the emergency departments: (1) increasing awareness about the need to improve the quality of care by providing data on clinical performance, (2) building acceptance for improvement through professional credibility and focus on clinical practice, and (3) fostering leadership commitment. CONCLUSION: Our findings suggest that the inspections have the potential to enhance hospital management and staff's understanding of complicated care processes and help strengthen the organisational commitment to bring about systemic quality improvements.

Effects of external inspections on sepsis detection and treatment: a stepped-wedge study with cluster-level randomisation.

OBJECTIVE: To evaluate the effects of external inspections on (1) hospital emergency departments' clinical processes for detecting and treating sepsis and (2) length of hospital stay and 30-day mortality. DESIGN: Incomplete cluster-randomised stepped-wedge design using data from patient records and patient registries. We compared care processes and patient outcomes before and after the intervention using regression analysis. SETTING: Nationwide inspections of sepsis care in emergency departments in Norwegian hospitals. PARTICIPANTS: 7407 patients presenting to hospital emergency departments with sepsis. INTERVENTION: External inspections of sepsis detection and treatment led by a public supervisory institution. MAIN OUTCOME MEASURES: Process measures for sepsis diagnostics and treatment, length of hospital stay and 30-day all-cause mortality. RESULTS: After the inspections, there were significant improvements in the proportions of patients examined by a physician within the time frame set in triage (OR 1.28, 95% CI 1.07 to 1.53), undergoing a complete set of vital measurements within 1 hour (OR 1.78, 95% CI 1.10 to 2.87), having lactate measured within 1 hour (OR 2.75, 95% CI 1.83 to 4.15), having an adequate observation regimen (OR 2.20, 95% CI 1.51 to 3.20) and receiving antibiotics within 1 hour (OR 2.16, 95% CI 1.83 to 2.55). There was also significant reduction in mortality and length of stay, but these findings were no longer significant when controlling for time. CONCLUSIONS: External inspections were associated with improvement of sepsis detection and treatment. These findings suggest that policy-makers and regulatory agencies should prioritise assessing the effects of their inspections and pay attention to the mechanisms by which the inspections might contribute to improve care for patients. TRIAL REGISTRATION: NCT02747121.

Early diagnosis of sepsis in emergency departments, time to treatment, and association with mortality: An observational study.

BACKGROUND: Early recognition of sepsis is critical for timely initiation of treatment. The first objective of this study was to assess the timeliness of diagnostic procedures for recognizing sepsis in emergency departments. We define diagnostic procedures as tests used to help diagnose the condition of patients. The second objective was to estimate associations between diagnostic procedures and time to antibiotic treatment, and to estimate associations between time to antibiotic treatment and mortality. METHODS: This observational study from 24 emergency departments in Norway included 1559 patients with infection and at least two systemic inflammatory response syndrome criteria. We estimated associations using linear and logistic regression analyses. RESULTS: Of the study patients, 72.9% (CI 70.7-75.1) had documented triage within 15 minutes of presentation to the emergency departments, 44.9% (42.4-47.4) were examined by a physician in accordance with the triage priority, 44.4% (41.4-46.9) were adequately observed through continual monitoring of signs while in the emergency department, and 25.4% (23.2-27.7) received antibiotics within 1 hour. Delay or non-completion of these key diagnostic procedures predicted a delay of more than 2.5 hours to antibiotic treatment. Patients who received antibiotics within 1 hour had an observed 30-day all-cause mortality of 13.6% (10.1-17.1), in the timespan 2 to 3 hours after admission 5.9% (2.8-9.1), and 4 hours or later after admission 10.5% (5.7-15.3). CONCLUSIONS: Key procedures for recognizing sepsis were delayed or not completed in a substantial proportion of patients admitted to the emergency department with sepsis. Delay or non-completion of key diagnostic procedures was associated with prolonged time to treatment with antibiotics. This suggests a need for systematic improvement in the initial management of patients admitted to emergency departments with sepsis.