A new approach to a wicked problem: development of a cross-sector community-centered learning network to tackle childhood food inequity.

Food insecurity is a complex societal problem that disproportionately impacts households with children and those led by minoritized populations, with negative impacts on health across the life course. System to Achieve Food Equity adapted the learning systems model, used to address similarly complex problems, to tackle food insecurity at a neighborhood level. SAFE, born out of the COVID-19 pandemic, leverages a family-centered, community-based, cross-sector network fundamentally aimed at changing the food system so that all children in Cincinnati have the food they need to thrive. Through the following principles, Community-Led Network, Co-Production with Community, Equitable Sustainability, Learning to Learn Together, Distributing Leadership and Power, and Shared Data and Governance, SAFE has grown to over 300 individuals and 100 organizations, funded 9 novel interventions, distributed over 270,000 meals, and created a collaborative of motivated like-minded stakeholders. Future work includes improved data collection and sharing, support for increased stakeholder engagement and greater distribution of leadership and power, advocacy for policy change, refining measurement tools of network maturity for community settings, and collaboration with other efforts that contribute to food security indirectly.

Integrating Patients Into Programmes to Address the Allergy Knowledge Practice Gap.

There is a wide gap between the first publication of new treatments with efficacy and their successful application in clinical practice. In many respects, the management of allergic diseases is a good exemplar of the knowledge/practice gap. It was assumed that systematic reviews and publication of guidelines would ensure timely delivery of effective care, but this has not proved to be the case. While there are many reasons to explain shortcomings in healthcare delivery, the lack of patient and carer involvement in the planning of research, evidence review, guideline development and guideline implementation is most compelling. To achieve adherence to evidence-based guidelines consistently across all levels of the health service requires the implementation of integrated care with clear pathways through which patients can navigate. Quality improvement methodology could be employed to plan and implement integrated care pathways (ICPs). There is evidence that ICPs achieve improved outcomes for acute hospital-based interventions, but less work has focussed on long-term conditions where more diverse agencies are involved. At all stages, stakeholder representation from the full range of healthcare professionals, patients, their families, social services, education, local government and employers must be involved. In this article we review the step-wise and iterative process by which knowledge is implemented into practice to improve patient experience and outcomes We argue how this process can benefit from the involvement of patients and their carers as equal partners, and we discuss how different initiatives have involved patients with allergic diseases. There currently is a gap in evidence that links patient involvement to improved outcomes. We recommend the use of the Core Outcome Sets (COS) and Patient Reported Experience Measures (PREMS) which have been developed for allergic diseases to monitor the effects of implementation research and the impact of patient and carer involvement on outcomes.

Exploring the implementation of an educational film within antenatal care to reduce the risk of cytomegalovirus infection in pregnancy: A qualitative study.

BACKGROUND: Congenital cytomegalovirus (CMV) infection is a leading cause of sensorineural hearing loss and neuro-disability in childhood. In the absence of a licensed vaccine, adoption of hygiene-based measures may reduce the risk of CMV infection in pregnancy, however these measures are not routinely discussed with pregnant women as part of National Health Service (NHS) antenatal care in the United Kingdom (UK). METHODS: An exploratory qualitative study was conducted, underpinned by Normalization Process Theory (NPT), to investigate how an educational intervention comprising of a short film about CMV may best be implemented, sustained, and enhanced in real-world routine antenatal care settings. Video, semi-structured interviews were conducted with participants who were recruited using a purposive sample that comprised of midwives providing antenatal care from three NHS hospitals (n = 15) and participants from professional colleges and from organisations or charities providing, or with an interest in, antenatal education or health information in the UK (n = 15). FINDINGS: Midwives were reluctant to include CMV as part of early pregnancy discussions about reducing the risk of other infections due to lack of time, knowledge and absence of guidance or policies relating to CMV in antenatal education. However, the educational intervention was perceived to be a useful tool to encourage conversations and empower women to manage risk by all stakeholders, which would overcome some identified barriers. Macro-level challenges such as screening policies and lack of official guidelines to legitimise dissemination were identified. DISCUSSION: Successful implementation of education about CMV as part of routine NHS care in the UK will require an increase in awareness and knowledge about CMV amongst midwives. NPT revealed that 'coherence' and 'cognitive participation' between service members are vital to imbed CMV education in routine practice. 'Collective action' and 'reflexive monitoring' is required to sustain service changes.

Reducing severe maternal morbidity for birthing persons with severe hypertension through a statewide quality improvement initiative.

BACKGROUND: Hypertensive disorders of pregnancy are a leading preventable cause of severe maternal morbidity and maternal mortality worldwide. OBJECTIVE: To assess the improvement in hospital care processes and patient outcomes associated with hypertensive disorders of pregnancy after introduction of a statewide Severe Maternal Hypertension Quality Improvement Initiative. STUDY DESIGN: A prospective cohort design comparing outcomes before and after introduction of the Illinois Perinatal Quality Collaborative statewide hypertension quality improvement initiative among 108 hospitals across Illinois. Participating hospitals recorded data for all cases of new-onset severe hypertension (>160 mm Hg systolic or >110 mm Hg diastolic) during pregnancy through 6 weeks postpartum from May 2016 to December 2017. Introduction of the statewide quality improvement initiative included implementation of severe maternal hypertension protocols, standardized patient education and discharge planning, rapid access to medications and standardized treatment order sets, and provider and nurse education. The main outcome measure was the reduction of severe maternal morbidity for pregnant/postpartum patients with severe hypertension. Key process measures include time to treatment of severe hypertension, frequency of provider/nurse debriefs, appropriate patient education, and early postpartum follow-up. RESULTS: Data were reported for 8073 cases of severe maternal hypertension. The frequency of patients with new-onset severe hypertension treated within 60 minutes increased from 41% baseline to 87% (P<.001) at the end of the initiative. The initiative was associated with increased proportion of patients receiving preeclampsia education at discharge (41% to 89%; P<.001), scheduling follow-up appointments within 10 days of discharge (68% to 83%; P<.001), and having a care team debrief after severe hypertension was diagnosed (17% to 59%; P<.001). Conversely, severe maternal morbidity was reduced from 11.5% baseline to 8.4% (P<.002) at the end of the study period. Illinois hospitals have achieved time to treatment goal regardless of hospital characteristics including geography, birth volume, and patient mix. CONCLUSION: Introduction of a statewide quality improvement effort was associated with improved time to treatment of severe hypertension and increased frequency of provider/nurse debriefs, appropriate patient education, and early postpartum follow-up scheduled at discharge, and reduced severe maternal morbidity.

What is quality in long covid care? Lessons from a national quality improvement collaborative and multi-site ethnography.

BACKGROUND: Long covid (post covid-19 condition) is a complex condition with diverse manifestations, uncertain prognosis and wide variation in current approaches to management. There have been calls for formal quality standards to reduce a so-called "postcode lottery" of care. The original aim of this study-to examine the nature of quality in long covid care and reduce unwarranted variation in services-evolved to focus on examining the reasons why standardizing care was so challenging in this condition. METHODS: In 2021-2023, we ran a quality improvement collaborative across 10 UK sites. The dataset reported here was mostly but not entirely qualitative. It included data on the origins and current context of each clinic, interviews with staff and patients, and ethnographic observations at 13 clinics (50 consultations) and 45 multidisciplinary team (MDT) meetings (244 patient cases). Data collection and analysis were informed by relevant lenses from clinical care (e.g. evidence-based guidelines), improvement science (e.g. quality improvement cycles) and philosophy of knowledge. RESULTS: Participating clinics made progress towards standardizing assessment and management in some topics; some variation remained but this could usually be explained. Clinics had different histories and path dependencies, occupied a different place in their healthcare ecosystem and served a varied caseload including a high proportion of patients with comorbidities. A key mechanism for achieving high-quality long covid care was when local MDTs deliberated on unusual, complex or challenging cases for which evidence-based guidelines provided no easy answers. In such cases, collective learning occurred through idiographic (case-based) reasoning, in which practitioners build lessons from the particular to the general. This contrasts with the nomothetic reasoning implicit in evidence-based guidelines, in which reasoning is assumed to go from the general (e.g. findings of clinical trials) to the particular (management of individual patients). CONCLUSION: Not all variation in long covid services is unwarranted. Largely because long covid's manifestations are so varied and comorbidities common, generic "evidence-based" standards require much individual adaptation. In this complex condition, quality improvement resources may be productively spent supporting MDTs to optimise their case-based learning through interdisciplinary discussion. Quality assessment of a long covid service should include review of a sample of individual cases to assess how guidelines have been interpreted and personalized to meet patients' unique needs. STUDY REGISTRATION: NCT05057260, ISRCTN15022307.

Disparities in Care for Low-Income Patients with Cirrhosis: Implementing an Innovative Outpatient Clinic for Refractory Ascites in a Safety Net Hospital.

BACKGROUND: Disparities in life-saving interventions for low-income patients with cirrhosis necessitate innovative models of care. AIM: To implement a novel generalist-led FLuid ASPiration (FLASP) clinic to reduce emergency department (ED) care for refractory ascites. SETTING: A large safety net hospital in Los Angeles. PARTICIPANTS: MediCal patients with paracentesis in the ED from 6/1/2020 to 1/31/2021 or in FLASP clinic or the ED from 3/1/2021 to 4/30/2022. PROGRAM DESCRIPTION: According to RE-AIM, adoption obtained administrative endorsement and oriented ED staff. Reach engaged ED staff and eligible patients with timely access to FLASP. Implementation trained FLASP clinicians in safer, guideline-based paracentesis, facilitated timely access, and offered patient education and support. PROGRAM EVALUATION: After FLASP clinic opened, significantly fewer ED visits were made by patients discharged after paracentesis [rate ratio (RR) of 0.33 (95% CI 0.28, 0.40, p < 0.0001)] but not if subsequently hospitalized (RR = 0.88, 95% CI 0.70, 1.11). Among 2685 paracenteses in 225 FLASP patients, complications were infrequent: 39 (1.5%) spontaneous bacterial peritonitis, 265 (9.9%) acute kidney injury, and 2 (< 0.001%) hypotension. FLASP patients rated satisfaction highly on a Likert-type question. DISCUSSION: Patients with refractory ascites in large safety net hospitals may benefit from an outpatient procedure clinic instead of ED care.

A Multisite Electronic Health Record Integrated Remote Monitoring Intervention for Hypertension Improvement: Protocol for a Randomized Pragmatic Comparative Effectiveness Trial.

BACKGROUND: Hypertension is a major contributor to various adverse health outcomes. Although previous studies have shown the benefits of home blood pressure (BP) monitoring over office-based measurements, there is limited evidence comparing the effectiveness of whether a BP monitor integrated into the electronic health record is superior to a nonintegrated BP monitor. OBJECTIVE: In this paper, we describe the protocol for a pragmatic multisite implementation of a quality improvement initiative directly comparing integrated to nonintegrated BP monitors for hypertension improvement. METHODS: We will conduct a randomized, comparative effectiveness trial at 3 large academic health centers across California. The 3 sites will enroll a total of 660 participants (approximately n=220 per site), with 330 in the integrated BP monitor arm and 330 in the nonintegrated BP control arm. The primary outcome of this study will be the absolute difference in systolic BP in mm Hg from enrollment to 6 months. Secondary outcome measures include binary measures of hypertension (controlled vs uncontrolled), hypertension-related health complications, hospitalizations, and death. The list of possible participants will be generated from a central data warehouse. Randomization will occur after enrollment in the study. Participants will use their assigned BP monitor and join site-specific hypertension interventions. Cross-site learning will occur at regular all-site meetings facilitated by the University of California, Los Angeles Value-Based Care Research Consortium. A pre- and poststudy questionnaire will be conducted to further evaluate participants' perspectives regarding their BP monitor. Linear mixed effects models will be used to compare the primary outcome measure between study arms. Mixed effects logistic regression models will be used to compare secondary outcome measures between study arms. RESULTS: The study will start enrolling participants in the second quarter of 2023 and will be completed by the first half of 2024. Results will be published by the end of 2024. CONCLUSIONS: This pragmatic trial will contribute to the growing field of chronic care management using remote monitoring by answering whether a hypertension intervention coupled with an electronic health record integrated home BP monitor improves patients' hypertension better than a hypertension intervention with a nonintegrated BP monitor. The outcomes of this study may help health system decision makers determine whether to invest in integrated BP monitors for vulnerable patient populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT05390502; clinicaltrials.gov/study/NCT05390502. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/45915.

Publishing quality improvement studies: learning to share and sharing to learn.

This editorial welcomes the decision of BJA Open to publish quality improvement (QI) studies. It summarises the current problems with conducting, evaluating, and publishing QI studies. It highlights existing guidance for prospective authors to follow regarding the reporting of QI interventions, their context(s), underlying theories, and evaluation. In so doing, we hope to encourage the publication of more QI studies of sufficient quality to facilitate learning or replication elsewhere.

Data quality in an HIV vaccine efficacy clinical trial in South Africa: through natural disasters and with discipline.

BACKGROUND: To produce quality data that informs valid clinical trial results and withstands regulatory inspection, trial sites should adhere to many complex and dynamic requirements. Understanding non-conformance to requirements informs the emerging field of improvement science. We describe protocol deviations in South Africa's largest HIV vaccine efficacy trial. METHODS: We analysed data from the HVTN 702 trial using mixed methods. We obtained descriptive statistics, from protocol deviation case report forms collected from 2016-2022, of deviation by participant, trial site, and time to site awareness. We thematically analysed text narratives of deviation descriptions, corrective and preventive actions, generating categories, codes and themes which emerged from the data. RESULTS: For 5407 enrollments, 4074 protocol deviations were reported (75 [95% CI: 73.0-77.6] deviations per 100 enrolments). There was a median of 1 protocol deviation per participant (IQR 1-2). Median time from deviation to site awareness was 31 days (IQR 0-146). The most common category of deviation type was omitted data and/or procedures (69%), and 54% of these omissions were stated to have arisen because of the national lockdown at the beginning of the COVID-19 pandemic. The ratio of protocol deviations to cumulative enrolments was highest in the year 2020 (0.34). Major themes of deviations were: COVID-19 and climate disasters giving rise to deviation trends, subroutines introducing an opportunity for deviation, and document fragmentation (such as requirements dispersed across multiple guidance documents) as an obstacle. Preventive action categories were: no preventive measures; discipline, training and/or awareness; quality review, checking and verifying and changing the process and/or implementation tools. Major themes of preventive actions were that systems-based actions are unusual, with people-based actions dominating, and that root cause analysis was rarely mentioned. CONCLUSIONS: In the age of infectious and climate disaster risks, trials may benefit from simple study designs and trial-related documents. To optimise protocol adherence, sponsors and sites should consider ongoing training, and routinely review deviation reports with a view to adjusting processes. These data quality lessons may inform future trial design, training and implementation. TRIAL REGISTRATION: HVTN 702 was registered with the South African National Clinical Trials Register (DOH-27-0916-5327) and ClinicalTrials.gov ( NCT02968849 ).

A problem-bound evaluation approach.

Traditional modes of evaluation can be constraining when seeking to improve persistent societal problems within complex systems. Frameworks that assume stability and predictability may not match the system dynamics within which a program resides. This paper seeks to further evaluators' understanding of how to improve problems in complex systems by offering a "problem-bound" evaluation approach. This model is grounded in theoretical concepts from complexity science, complex adaptive systems, systems thinking, and improvement science. As such, it provides an agile and flexible framework for continually learning from emergent findings related to the problem. By offering this model, we seek to contribute to the limited knowledge base on how to apply systems change theoretical ideas in evaluation practice, along with practical implications regarding the evaluator's role.

Quality Improvement Methodology.

Patient Safety and Quality Improvement as a formal discipline has become widely established, with hospitals and health systems dedicating significant resources to improvement science. Physicians have leadership potential in quality and safety due to their clinical expertise and influence with both patients and hospital leadership. Success in such a leadership role, however, requires knowledge of the fundamentals of how to navigate an improvement endeavor from inception through implementation, analysis, and sustainment. Herein, the authors introduce the formal process of improvement science, discuss basic principles of change management, and provide a summary of the elements of scholarly writing to facilitate dissemination of knowledge across institutions.

A cross-sectional study evaluating the relationship between followership type and burnout amongst critical care followers.

INTRODUCTION: Healthcare teams include both leaders and followers, with followers making up the majority of the healthcare team. There are five followership styles which have been described by Kelly (1992) based on critical thinking and active engagement. We aim to explore if a relationship exists between followership style and burnout, and also with job satisfaction of followers within the critical care setting. Additionally, we aim to quantify the distribution of followership types amongst followers within the critical care setting. METHODS: Participants were recruited in person at random to participate in a single centered, cross sectional, four-part survey to determine their followership type (Kelly followership type), burnout (Maslach Burnout Inventory) and job satisfaction (Brayfiled-Rothe Survey and Work and Meaning Inventory). Correlations between followership type and burnout as well as followership type and job satisfaction were then determined. RESULTS: A total of 64 participants (27 residents and 37 critical care nurses) took part in the study. There was a weak-moderate correlation between independent critical thinking and personal accomplishment (R = 0.297), and moderate correlation to meaningful work (R = 0.390), and job satisfaction (R = -0.300). Active engagement was moderately correlated with personal accomplishment (R = 0.302), meaningful work (R = 0.448) and job satisfaction (R = -0.418). Neither independent critical thinking nor active engagement showed significant correlation with depersonalization and emotional exhaustion subscales. Most participants were characterized into effective/exemplary followership type with no statistically significant differences between nurses and residents. CONCLUSION: This research shows that by creating an environment which promotes critical thinking and active engagement, nurses and residents may display less burnout, and enhanced job satisfaction.

A critical reflection on the use of improvement science approaches in public health.

OBJECTIVE: 'Improvement science' is used to describe specific quality improvement methods (including tests of change and statistical process control). The approach is spreading from clinical settings to population-wide interventions and is being extended from supporting the adoption of proven interventions to making generalisable claims about new interventions. The objective of this narrative review is to evaluate the strengths and risks of current improvement science practice, particularly in relation to how they might be used in population health. METHODS: A purposive sampling of published studies to identify how improvement science methods are being used and for what purpose. The setting was Scotland and studies that focused on health and wellbeing outcomes. RESULTS: We have identified a range of improvement science approaches which provide practitioners with accessible tools to assess small-scale changes in policy and practice. The strengths of such approaches are that they facilitate consistent implementation of interventions already known to be effective and motivate and empower staff to make local improvements. However, we also identified a number of potential risks. In particular, their use to assess the effectiveness of new interventions often seems to pay insufficient attention to random variation, measurement bias, confounding and ethical issues. CONCLUSIONS: The use of current improvement science methods to generate evidence of effectiveness for population-wide interventions is problematic and risks unjustified claims of effectiveness, inefficient resource use and harm to those not offered alternative effective interventions. Newer methodological approaches offer alternatives and should be more widely considered.

Using Iterative Experimentation to Accelerate Program Improvement: A Case Example.

BACKGROUND: This article offers a case example of how experimental evaluation methods can be coupled with principles of design-based implementation research (DBIR), improvement science (IS), and rapid-cycle evaluation (RCE) methods to provide relatively quick, low-cost, credible assessments of strategies designed to improve programs, policies, or practices. OBJECTIVES: This article demonstrates the feasibility and benefits of blending DBIR, IS, and RCE practices with embedded randomized controlled trials (RCTs) to improve the pace and efficiency of program improvement. RESEARCH DESIGN: This article describes a two-cycle experimental test of staff-designed strategies for improving a workforce development program. Youth enrolled in Year Up's Professional Training Corps (PTC) programs were randomly assigned to "improvement strategies" designed to boost academic success and persistence through the 6-month learning and development (L&D) phase of the program, when participants spend most of their program-related time in courses offered by partner colleges. SUBJECTS: The study sample includes 317 youth from three PTC program sites. MEASURES: The primary outcome measures are completion of the program's L&D phase and continued college enrollment beyond the L&D phase. RESULTS: The improvement strategies designed and tested during the study increased program retention through L&D by nearly 10 percentage points and increased college persistence following L&D by 13 percentage points. CONCLUSION: Blending DBIR, IS, and RCE principles with a multi-cycle RCT generated highly credible estimates of the efficacy of the tested improvement strategies within a relatively short period of time (18 months) at modest cost and with reportedly low burden for program staff.

Understanding the Role of External Facilitation to Drive Quality Improvement for Stroke Care in Hospitals.

The use of external facilitation within the context of multicomponent quality improvement interventions (mQI) is growing. We aimed to evaluate the influence of external facilitation for improving the quality of acute stroke care. Clinicians from hospitals participating in mQI (Queensland, Australia) as part of the Stroke123 study were supported by external facilitators in a single, on-site workshop to review hospital performance against eight clinical processes of care (PoCs) collected in the Australian Stroke Clinical Registry (AuSCR) and develop an action plan. Remote support (i.e., telephone/email) after the workshop was provided. As part of a process evaluation for Stroke123, we recorded the number and mode of contacts between clinicians and facilitators; type of support provided; and frequency of self-directed, hospital-level stroke registry data reviews. Analysis: We measured the association between amount/type of external facilitation, (i) development of action plans, and (ii) adherence to PoCs before and after the intervention using AuSCR data from 2010 to 2015. In total, 14/19 hospitals developed an action plan. There was no significant difference in amount or type of external facilitator support provided between hospitals that did, and did not, develop an action plan. There was no relationship between the amount of external facilitation and change in adherence to PoCs. Most (95%) hospitals accessed stroke registry performance data. In the Stroke123 study, the amount or type of external facilitation did not influence action plan development, and the amount of support did not influence the changes achieved in adherence to PoCs. Remote support may not add value for mQI.

Seven practices for pursuing equity through learning health systems: Notes from the field.

INTRODUCTION: Despite learning health systems' focus on improvement in health outcomes, inequities in outcomes remain deep and persistent. To achieve and sustain health equity, it is critical that learning health systems (LHS) adapt and function in ways that directly prioritize equity. METHODS: We present guidance, including seven core practices, borne from theory, evidence, and experience, for actors within LHS pursuing equity. RESULTS: We provide a foundational definition of equity. We then offer seven core practices for how LHS may effectively pursue equity in health: establish principle, measure for equity, lead from lived experience, co-produce, redistribute power, practice a growth mindset, and engage beyond the healthcare system. We include three use cases that illustrate ways in which we have begun to center equity in the work of our own LHS. CONCLUSION: The achievement of equity requires real transformation at individual, institutional, and structural levels and requires sustained and persistent effort.

Applying Implementation Science in Surgical Infection Quality Improvement.

Background: Medical knowledge is constantly growing at an exponential rate. Despite this growth, it is estimated to take 17 years for medical innovation to reach the bedside and improve clinical care. Implementation science is the scientific study of methods to facilitate the update of evidence-based practice and research into regular use and policy. Discussion: Implementation science offers theories, models, and frameworks aimed at decreasing the time it takes to get medical innovation to the patient and to sustain the care improvements. Implementation science principles center around five main fundamental concepts that include information diffusion, dissemination, implementation, adoption, and sustainability. Understanding these fundamental concepts allow clinicians to prepare for an implementation by asking the correct questions such as: Are we ready for change?; What is our current process that we want to change?; Who needs to be involved in the implementation?; and How do we measure success? This article describes a successful catheter-associated urinary tract infection quality improvement program implemented using implementation science principles. Conclusion: Implementation science offers many proven tools and strategies to implement new evidence-based medicine and medical innovations into common practice. Clinicians are often the leaders of change and should develop an understanding of implementation science fundamentals to allow successful implementation of quality improvement and research initiatives.

Providing quality improvement training in an advanced pharmacy practice experience elective.

BACKGROUND AND PURPOSE: Quality Improvement (QI) science is a burgeoning component of healthcare systems and the practice of pharmacy. There is limited published literature on the implementation of QI training in undergraduate pharmacy education. We describe the development and implementation of QI training in an experiential course. EDUCATIONAL ACTIVITY AND SETTING: A QI curriculum was developed for an existing eight-week pharmacy practice elective experience for year four pharmacy students. The curriculum was divided into two, four-week blocks, combining didactic instruction and applied learning activities. A partnership between university departments and a local health organization provided a QI preceptor along with an interdisciplinary clinical team in an acute care setting to improve clinical services. FINDINGS: Six students have completed the elective along with completing three QI projects. The Kirkpatrick 4 level model guided course evaluation. A curriculum strength was no additional cost or educational burden on the faculty of pharmacy and pharmaceutical sciences. Students recognized benefit from (1) course flexibility and independence to learn, (2) clear expectations and weekly guidance from the preceptor, (3) alignment of weekly readings and real-time application of QI concepts, and (4) the Institute for Healthcare Improvement education modules. Reducing the number of assigned tasks per week and improving availability of the clinical QI team to support student learning were identified as areas for improvement. SUMMARY: This elective course demonstrated a starting point from which QI education can be formally included in pharmacy undergraduate education.

Transforming the Future Healthcare Workforce across Europe through Improvement Science Training: A Qualitative Approach.

Healthcare improvement science (HIS) is the generation of knowledge to cultivate change towards improving health systems performance. Our purpose was to evaluate the experience of European nursing students after an intensive one-week summer program conducted in 2019 at the University of Alicante in Spain. The educational intervention combined theoretical and practical HIS contents, with students from different countries, educational programs, and health systems. The intervention was evaluated under a qualitative approach through the open discussion group technique based on the method of participatory action research (PAR), with a total of 25 students who reflected about their experiences and perceptions during the intervention. The responses were used to improve the program's contents, its didactics, and organization. Nursing empowerment, professional recognition, and healthcare research were some of the seven main categories identified through the systematic content analysis method triangulated by three experienced researchers. According to the students' replies, values like compassion, respect, or empathy were identified as key elements of care. Promoting international students' networking emerged as the key to creating a positive provision for change and the generation of improvement initiatives. Building a HIS culture may potentially provide future healthcare professionals with critical thinking skills and the resources needed to improve their future work settings.