An updated species list for "Smoky Bears": Tardigrades of the Great Smoky Mountains National Park, USA.

One of the largest inventories of tardigrades ever conducted occurred from 20002010 in the Great Smoky Mountains National Park, USA. Over 16,000 specimens were catalogued, 85 species were identified, 11 species new to science were described, and 16 other possible new species await further study. More than 20 papers have resulted from the GSMNP tardigrade inventory, making the Smokies the most thoroughly studied area in North America for tardigrades. Several species lists have been published over this 20-year period, but many taxonomic revisions and new identifications have led to significant changes to the list. Biogeographical studies citing species records from earlier studies could yield serious errors. Here we update the species list from the Smokies to accommodate the many recent changes in tardigrade taxonomy, we re-analyze some species in light of delineations of cryptic species groups that have occurred recently via integrative taxonomy, and we provide a table of all synonyms that have been used in previous publications. We also make available, for the first time, the Smokies tardigrade database, complete with all locations, elevations, and substrates.

Integrative taxonomy resolves species identities within the Macrobiotus pallarii complex (Eutardigrada: Macrobiotidae).

The taxonomy of many groups of meiofauna is challenging due to their low number of diagnostic morphological characters and their small body size. Therefore, with the advent of molecular techniques that provide a new source of traits, many cryptic species have started to be discovered. Tardigrades are not an exception, and many once thought to be cosmopolitan taxa are being found to be complexes of phenotypically similar species. Macrobiotus pallarii Maucci, 1954 was originally described in South Italy and has been subsequently recorded in Europe, America, and Asia. This allegedly wide geographic range suggests that multiple species may be hidden under this name. Moreover, recently, genetic evidence to support this was put forward, and the Macrobiotus pallarii complex has been proposed to accommodate putative species related to M. pallarii. Here, we describe three new pseudocryptic species based on populations that would have been all classified as Macrobiotus pallarii if molecular methods were not employed. Using an integrative taxonomy approach, we analyzed animals and eggs from the topotypic population of Macrobiotus pallarii, together with four other populations of the complex. We recovered four distinct phylogenetic lineages that, despite the overlap of morphometric traits, can be separated phenotypically by subtle but discrete morphological characters. One lineage corresponds to Macrobiotus pallarii, whereas the other three are newly described as Macrobiotus margoae Stec, Vecchi & Bartels, sp. nov. from the USA, Macrobiotus ripperi Stec, Vecchi & Michalczyk, sp. nov. from Poland and Finland, and Macrobiotus pseudopallarii Stec, Vecchi & Michalczyk, sp. nov. from Montenegro. To facilitate species identification, we provide a dichotomous key for species of the M. pallarii complex. Delimitation of these pseudocryptic taxa highlights the need for an integrative approach to uncover the phylum's diversity in full.

Protein Micropatterning in 2.5D: An Approach to Investigate Cellular Responses in Multi-Cue Environments.

The extracellular microenvironment is an important regulator of cell functions. Numerous structural cues present in the cellular microenvironment, such as ligand distribution and substrate topography, have been shown to influence cell behavior. However, the roles of these cues are often studied individually using simplified, single-cue platforms that lack the complexity of the three-dimensional, multi-cue environment cells encounter in vivo. Developing ways to bridge this gap, while still allowing mechanistic investigation into the cellular response, represents a critical step to advance the field. Here, we present a new approach to address this need by combining optics-based protein patterning and lithography-based substrate microfabrication, which enables high-throughput investigation of complex cellular environments. Using a contactless and maskless UV-projection system, we created patterns of extracellular proteins (resembling contact-guidance cues) on a two-and-a-half-dimensional (2.5D) cell culture chip containing a library of well-defined microstructures (resembling topographical cues). As a first step, we optimized experimental parameters of the patterning protocol for the patterning of protein matrixes on planar and non-planar (2.5D cell culture chip) substrates and tested the technique with adherent cells (human bone marrow stromal cells). Next, we fine-tuned protein incubation conditions for two different vascular-derived human cell types (myofibroblasts and umbilical vein endothelial cells) and quantified the orientation response of these cells on the 2.5D, physiologically relevant multi-cue environments. On concave, patterned structures (curvatures between κ = 1/2500 and κ = 1/125 µm-1), both cell types predominantly oriented in the direction of the contact-guidance pattern. In contrast, for human myofibroblasts on micropatterned convex substrates with higher curvatures (κ ≥ 1/1000 µm-1), the majority of cells aligned along the longitudinal direction of the 2.5D features, indicating that these cells followed the structural cues from the substrate curvature instead. These findings exemplify the potential of this approach for systematic investigation of cellular responses to multiple microenvironmental cues.

From accreditation to quality improvement-The Danish National Quality Programme.

The Danish government launched a new National Quality Programme (NQP) in healthcare in 2015. It has changed the focus from old public management in terms of accreditation, regulation, rules and standards to new public governance focusing on delivering high quality healthcare and outcomes of value for the patients, health professionals and the Danish healthcare system. The NQP aims to strengthen the focus on continuous quality improvement and the launch of the programme was accompanied by a decision to phase out accreditation of public hospitals. The NQP includes 1) eight specific national quality goals, 2) a national educational programme for quality management, and 3) establishment of quality improvement collaboratives. Since the establishment of the NQP the indicator results have improved in several important clinical areas. However, causal conclusions related to the effect of the NQP cannot yet be made. This perspective on quality paper aims to give a short introduction to the NQP and documented outcomes.

Supramolecular Additive-Initiated Controlled Atom Transfer Radical Polymerization of Zwitterionic Polymers on Ureido-pyrimidinone-Based Biomaterial Surfaces.

Surface-initiated controlled radical polymerization is a popular technique for the modification of biomaterials with, for example, antifouling polymers. Here, we report on the functionalization of a supramolecular biomaterial with zwitterionic poly(sulfobetaine methacrylate) via atom transfer radical polymerization from a macroinitiator additive, which is embedded in the hard phase of the ureido-pyrimidinone-based material. Poly(sulfobetaine methacrylate) was successfully polymerized from these surfaces, and the polymerized sulfobetaine content, with corresponding antifouling properties, depended on both the macroinitiator additive concentration and polymerization time. Furthermore, the polymerization from the macroinitiator additive was successfully translated to functional electrospun scaffolds, showing the potential for this functionalization strategy in supramolecular material systems.

Batillipes pennaki Marcus, 1946 (Arthrotardigrada: Batillipedidae): deciphering a species complex.

Batillipes pennaki has been considered a common and a cosmopolitan marine tardigrade species. However, the original diagnosis of this species is very incomplete, and consequently there is a high probability of incorrect records. Therefore, a comparative analysis of quantitative and qualitative morphological characters among eight different populations from the Atlantic basin was done in this study to investigate if B. pennaki is a complex of similar species, each with a restricted distribution range. The result of discriminant analyses showed clear morphometric differences between populations that were arranged into three main groups, distinguishing Western Atlantic populations, Eastern Atlantic populations and a Mediterranean population. Furthermore, the result of analyses of morphological structures revealed peculiarities of some traits with taxonomic relevance, such as leg IV sensory organs and primary clavae, consistent with the clusters revealed by quantitative data, allowing us to distinguish three different pseudocryptic species and supporting the hypothesis that B. pennaki is a species complex.

Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects.

BACKGROUND: The Plan-Do-Study-Act (PDSA) method is widely used in quality improvement (QI) strategies. However, previous studies have indicated that methodological problems are frequent in PDSA-based QI projects. Furthermore, it has been difficult to establish an association between the use of PDSA and improvements in clinical practices and patient outcomes. The aim of this systematic review was to examine whether recently published PDSA-based QI projects show self-reported effects and are conducted according to key features of the method. METHODS: A systematic literature search was performed in the PubMed, Embase and CINAHL databases. QI projects using PDSA published in peer-reviewed journals in 2015 and 2016 were included. Projects were assessed to determine the reported effects and the use of the following key methodological features; iterative cyclic method, continuous data collection, small-scale testing and use of a theoretical rationale. RESULTS: Of the 120 QI projects included, almost all reported improvement (98%). However, only 32 (27%) described a specific, quantitative aim and reached it. A total of 72 projects (60%) documented PDSA cycles sufficiently for inclusion in a full analysis of key features. Of these only three (4%) adhered to all four key methodological features. CONCLUSION: Even though a majority of the QI projects reported improvements, the widespread challenges with low adherence to key methodological features in the individual projects pose a challenge for the legitimacy of PDSA-based QI. This review indicates that there is a continued need for improvement in quality improvement methodology.

Marine tardigrades of the Bahamas with the description of two new species and updated keys to the species of Anisonyches and Archechiniscus.

This is the first survey of subtidal marine tardigrades from the Bahamas, and we compare our results with earlier studies of Bahamian intertidal habitats. In 2011 and 2014 we collected 60 subtidal sand samples from Bimini, the Berry Islands, New Providence, Eleuthera, and the Exumas. We found 11 species only one of which, Dipodarctus subterraneus (Renaud-Debyser, 1959), had been found in the previous intertidal Bahamian collections. Thus, 10 species are new records for the Bahamas, and four of these are new to science. We describe two of the new species (Archechiniscus bahamensis sp. nov. and Anisonyches eleutherensis sp. nov.). Additional material is needed for a conclusive identification of the undescribed species of Batillipes and Florarctus. Based on examination of the holotype of Anisonyches diakidius Pollock, 1975, we redescribe this species and give an emended diagnosis of the genus and the species. We also provide new keys to the species in the genera Archechiniscus and Anisonyches. A Chao2 species richness estimate indicated that our sampling effort was extensive and probably recovered most common species. Correlations of abundance and diversity indices with regard to depth, distance to nearest shore, and sediment grain size were not significant.

Regional variation in surgery for pancreatic cancer in Denmark 2011-2015.

INTRODUCTION: Surgical treatment for pancreatic cancer carries a high risk of both morbidity and mortality. Even so, it remains the best curative treatment option. In Denmark, pancreatic surgery has been extensively centralised since the millennium, but the effect of this centralisation on patient outcome has not been evaluated. This study describes regional variation within pancreatic surgery on a malignant indication, focusing on production volume, length of stay, readmission rates and mortality. METHODS: This is a retrospective cohort study of all patients with pancreatic cancer who underwent surgical treatment in Denmark from 2011 to 2015. We obtained data from the Danish National Patient Registry and the National Pathology Data Bank on length of stay, transfers, mortality (both short and long term), age, co-morbidity, and disease stage. RESULTS: Four hospital units performed a total of 691 surgical procedures (476 pancreaticoduodenectomies) in the study period. Production volume varied considerably across units with two units accounting for nearly 80% of surgery performed. Data revealed variation on rates of transfers and readmissions as well as disease stage and mortality (both short and long term). CONCLUSIONS: Data suggest that mortality is linked to production volume as well as disease stage, but the small data quantity impedes rigorous statistical analysis. Further studies on the observed associations are required. FUNDING: none. TRIAL REGISTRATION: not relevant.

Implementation of a politically initiated national clinical guideline for cardiac rehabilitation in hospitals and municipalities in Denmark.

A politically initiated national clinical guideline was launched in Denmark in 2013 to improve quality and equality of cardiac rehabilitation (CR) services. The guideline is to be implemented in both hospital and community (municipality) settings due to shared responsibility for provision of CR services. Little is known about implementation outcomes of a guideline in these two settings. We aimed to study this by determining the extent to which Danish CR services in hospitals and municipalities adhered to national recommendations following the launch of the guideline. The study employed an observational, longitudinal design. Data were gathered by a questionnaire survey to compare CR services at baseline, measured in 2013 immediately before the guideline was launched, with CR services at a two-year follow up in 2015. All Danish hospital departments offering CR services (N = 36) and all municipalities (N = 98) were included. Data were analysed using inferential statistics. Hospitals reported improvement of both content and quality of CR services. Municipalities reported no change in content of services, and lower level of fulfilment of one quality aspect. The results suggest that the guideline had different impact in hospitals and municipalities and that the differences in content and quality of services between the two settings increased in the study period, thus contradicting the guideline´s aim of uniform, evidence-based content of CR services across settings.

Bottlenose dolphin (Tursiops truncatus) sperm revisited: Motility, morphology and ultrastructure of fresh sperm of consecutive ejaculates.

Computer aided sperm analysis systems allow detailed examination of sperm motility and morphology variables, which are important for the understanding of the spermatology of a species and the development of assisted reproductive techniques. Cetacean biology is too complex to study in the wild and data from captive individuals provide an important alternative for the conservation of these charismatic animals. The present study evaluates ejaculate and sperm characteristics, including sperm motility, kinematic variables and quantitative sperm morphology and ultrastructure, of consecutive ejaculates from Atlantic bottlenose dolphins (Tursiops truncatus). Sperm concentrations and total and progressive motilities were greater in the second than the first ejaculate, with all ejaculates being of very high quality (6.9-1127 × 106/ml sperm concentration, 75% to 91% total motility and 89% to 96% normal sperm). Most sperm in an ejaculate (≥84%) were highly (VCL>150 µm/s) and progressively motile with very few abnormal sperm. The sperm have small heads, a short but very bulky midpiece and a long tail. Detailed sperm morphometrics using CASA indicated there were similarities from one ejaculate to the next. The large mitochondria with extensive cristae mitochondriales are tightly packed in the midpiece resulting in a large midpiece volume. All the semen and sperm characteristics indicate high quality sperm and support the assumption that a multimale mating system is present in T. truncatus.

A Hypothesis for the Composition of the Tardigrade Brain and its Implications for Panarthropod Brain Evolution.

Incredibly disparate brain types are found in Metazoa, which raises the question of how this disparity evolved. Ecdysozoa includes representatives that exhibit ring-like brains-the Cycloneuralia-and representatives that exhibit ganglionic brains-the Panarthropoda (Euarthropoda, Onychophora, and Tardigrada). The evolutionary steps leading to these distinct brain types are unclear. Phylogenomic analyses suggest that the enigmatic Tardigrada is a closely related outgroup of a Euarthropoda + Onychophora clade; as such, the brains of tardigrades may provide insight into the evolution of ecdysozoan brains. Recently, evolutionarily salient questions have arisen regarding the composition of the tardigrade brain. To address these questions, we investigated brain anatomy in four tardigrade species-Hypsibius dujardini, Milnesium n. sp., Echiniscus n. sp., and Batillipes n. sp.-that together span Tardigrada. Our results suggest that general brain morphology is conserved across Tardigrada. Based on our results we present a hypothesis that proposes direct parallels between the tardigrade brain and the segmental trunk ganglia of the tardigrade ventral nervous system. In this hypothesis, brain neuropil nearly circumscribes the tardigrade foregut. We suggest that the tardigrade brain retains aspects of an ancestral cycloneuralian brain, while exhibiting ganglionic structure characteristic of euarthropods and onychophorans.

Trophy Hunting and Sustainability: Temporal Dynamics in Trophy Quality and Harvesting Patterns of Wild Herbivores in a Tropical Semi-Arid Savanna Ecosystem.

The selective nature of trophy hunting may cause changes in desirable phenotypic traits in harvested species. A decline in trophy size of preferred species may reduce hunting destination competitiveness thus compromising the sustainability of trophy hunting as a conservation tool. We explored the trophy quality and trends in harvesting patterns (i.e., 2004-2015) of Cape buffalo (Syncerus caffer), African elephant (Loxodonta africana), greater kudu (Tragelaphus strepsiceros) and sable (Hippotragus niger) in Matetsi Safari Area, northwest Zimbabwe. We used long-term data on horn and tusk size, age, quota size allocation and offtake levels of selected species. To analyse the effect of year, area and age on the trophy size, quota size and offtake levels, we used linear mixed models. One sample t-test was used to compare observed trophy size with Safari Club International (SCI) minimum score. Trophy sizes for Cape buffalo and African elephant were below the SCI minimum score. Greater kudu trophy sizes were within the minimum score threshold whereas sable trophy sizes were above the SCI minimum score between 2004 and 2015. Age at harvest for Cape buffalo, kudu and sable increased whilst that of elephant remained constant between 2004 and 2015. Quota size allocated for buffalo and the corresponding offtake levels declined over time. Offtake levels of African elephant and Greater kudu declined whilst the quota size did not change between 2004 and 2015. The quota size for sable increased whilst the offtake levels fluctuated without changing for the period 2004-2015. The trophy size and harvesting patterns in these species pose a conservation and management dilemma on the sustainability of trophy hunting in this area. We recommend: (1) temporal and spatial rotational resting of hunting areas to create refuge to improve trophy quality and maintenance of genetic diversity, and (2) introduction of variable trophy fee pricing system based on trophy size.

Mandatory national quality improvement systems using indicators: An initial assessment in Europe and Israel.

INTRODUCTION: Quality improvement systems (QIS) that are based on empirical performance assessment have increasingly been implemented as a mandatory part of health systems across countries. This study aims to describe national mandatory QIS in Europe in 2014. MATERIALS AND METHODS: Relevant national agencies for national mandatory QIS in Europe were identified through online searches and key informants. A questionnaire was compiled during a workshop with these agencies and filled out by representatives from these particular agencies. RESULTS: Agencies in charge of national mandatory QIS in seven countries (Denmark, France, Germany, Israel, Scotland, Sweden and Switzerland) were included in the study. An analysis of QIS revealed similarities, such as the use of routine data for performance assessment and the aim to hold healthcare providers accountable. Differences relate to the different forms of feedback systems and improvement mechanisms used. Trends include the development towards greater implementation of QIS within health systems, the inclusion of the patient's perspective in performance assessment, and experiments with pay for performance-related measures. CONCLUSION: On a country level, for health systems striving for newly implementing QIS it is recommended to start where routine data is available, add qualitative methodologies once the QIS is getting more complex, report performance data back to service providers and be patient centred. On the inter-country level exchange of information between agencies commissioned with implementing national QIS is very much needed for.

Habitat Heterogeneity Variably Influences Habitat Selection by Wild Herbivores in a Semi-Arid Tropical Savanna Ecosystem.

An understanding of the habitat selection patterns by wild herbivores is critical for adaptive management, particularly towards ecosystem management and wildlife conservation in semi arid savanna ecosystems. We tested the following predictions: (i) surface water availability, habitat quality and human presence have a strong influence on the spatial distribution of wild herbivores in the dry season, (ii) habitat suitability for large herbivores would be higher compared to medium-sized herbivores in the dry season, and (iii) spatial extent of suitable habitats for wild herbivores will be different between years, i.e., 2006 and 2010, in Matetsi Safari Area, Zimbabwe. MaxEnt modeling was done to determine the habitat suitability of large herbivores and medium-sized herbivores. MaxEnt modeling of habitat suitability for large herbivores using the environmental variables was successful for the selected species in 2006 and 2010, except for elephant (Loxodonta africana) for the year 2010. Overall, large herbivores probability of occurrence was mostly influenced by distance from rivers. Distance from roads influenced much of the variability in the probability of occurrence of medium-sized herbivores. The overall predicted area for large and medium-sized herbivores was not different. Large herbivores may not necessarily utilize larger habitat patches over medium-sized herbivores due to the habitat homogenizing effect of water provisioning. Effect of surface water availability, proximity to riverine ecosystems and roads on habitat suitability of large and medium-sized herbivores in the dry season was highly variable thus could change from one year to another. We recommend adaptive management initiatives aimed at ensuring dynamic water supply in protected areas through temporal closure and or opening of water points to promote heterogeneity of wildlife habitats.

The virgin land of quality management: a first measure of patient safety climate at the National Hospital of the Faroe Islands.

PURPOSE: The Faroe Islands are formally part of the Kingdom of Denmark, but the islands enjoy extensive autonomy as home ruled. In Denmark, extensive quality management initiatives have been implemented throughout hospitals, this was not the case in the Faroese Islands in 2013. The purpose of this study is to investigate the patient safety culture in the National Hospital of the Faroe Islands prior to implementation of quality management initiatives. METHODS: The Danish version of the Safety Attitudes Questionnaire (SAQ-DK) was distributed electronically to 557 staff members from five medical centers of the hospital, and one administrative unit. SAQ-DK has six cultural dimensions. The proportion of respondents with positive attitudes and mean scale scores were described, and comparison between medical specialties, and between clinical leaders and frontline staff was made using analysis of variance and chi-square test, respectively. RESULTS: The response rate was 65.8% (N=367). Job satisfaction was rated most favorable, and the perceived culture of the top management least favorable. Safety climate was the dimension with the greatest variability across the 28 units. The diagnostic center had the most favorable culture of all centers. More leaders than frontline staff had positive attitudes toward teamwork and safety climate, and working conditions, respectively. Also, the leaders perceived these dimensions more positive than the frontline staff, P<0.05. Among three management levels, the unit management was perceived most favorable and the top management least favorable. CONCLUSION: The management group is recommended to raise awareness of their role in supporting a safe and caring environment for patients and staff, moreover the leaders should ensure that every day work achieves its objectives; keeping the patients safe. Furthermore, following the development in patient safety culture over time is recommended.

Strengthening leadership as a catalyst for enhanced patient safety culture: a repeated cross-sectional experimental study.

OBJECTIVES: Current literature emphasises that clinical leaders are in a position to enable a culture of safety, and that the safety culture is a performance mediator with the potential to influence patient outcomes. This paper aims to investigate staff's perceptions of patient safety culture in a Danish psychiatric department before and after a leadership intervention. METHODS: A repeated cross-sectional experimental study by design was applied. In 2 surveys, healthcare staff were asked about their perceptions of the patient safety culture using the 7 patient safety culture dimensions in the Safety Attitudes Questionnaire. To broaden knowledge and strengthen leadership skills, a multicomponent programme consisting of academic input, exercises, reflections and discussions, networking, and action learning was implemented among the clinical area level leaders. RESULTS: In total, 358 and 325 staff members participated before and after the intervention, respectively. 19 of the staff members were clinical area level leaders. In both surveys, the response rate was >75%. The proportion of frontline staff with positive attitudes improved by ≥5% for 5 of the 7 patient safety culture dimensions over time. 6 patient safety culture dimensions became more positive (increase in mean) (p<0.05). Frontline staff became more positive on all dimensions except stress recognition (p<0.05). For the leaders, the opposite was the case (p<0.05). Staff leaving the department after the first measurement had rated job satisfaction lower than the staff staying on (p<0.05). CONCLUSIONS: The improvements documented in the patient safety culture are remarkable, and imply that strengthening the leadership can act as a significant catalyst for patient safety culture improvement. Further studies using a longitudinal study design are recommended to investigate the mechanism behind leadership's influence on patient safety culture, sustainability of improvements over time, and the association of change in the patient safety culture measures with change in psychiatric patient safety outcomes.

The Zoogeography of Marine Tardigrada.

This monograph describes the global records of marine water bears (Phylum Tardigrada). We provide a comprehensive list of marine tardigrades recorded from around the world, providing an up-to-date taxonomy and a complete bibliography accompanied by geographic co-ordinates, habitat, substrate and biogeographic comments. A link is provided to an on-line interactive map where all occurrences for each species are shown. In total we list 197 taxa and their 2240 records from 39 oceans and seas and 18 Major Fishing Areas (FAO). It is hoped this work will serve as a reference point and background for further zoogeographic and taxonomic studies on marine tardigrades.

Implementation of Departmental Quality Strategies Is Positively Associated with Clinical Practice: Results of a Multicenter Study in 73 Hospitals in 7 European Countries.

BACKGROUND: Given the amount of time and resources invested in implementing quality programs in hospitals, few studies have investigated their clinical impact and what strategies could be recommended to enhance its effectiveness. OBJECTIVE: To assess variations in clinical practice and explore associations with hospital- and department-level quality management systems. DESIGN: Multicenter, multilevel cross-sectional study. SETTING AND PARTICIPANTS: Seventy-three acute care hospitals with 276 departments managing acute myocardial infarction, deliveries, hip fracture, and stroke in seven countries. INTERVENTION: None. MEASURES: Predictor variables included 3 hospital- and 4 department-level quality measures. Six measures were collected through direct observation by an external surveyor and one was assessed through a questionnaire completed by hospital quality managers. Dependent variables included 24 clinical practice indicators based on case note reviews covering the 4 conditions (acute myocardial infarction, deliveries, hip fracture and stroke). A directed acyclic graph was used to encode relationships between predictors, outcomes, and covariates and to guide the choice of covariates to control for confounding. RESULTS AND LIMITATIONS: Data were provided on 9021 clinical records by 276 departments in 73 hospitals. There were substantial variations in compliance with the 24 clinical practice indicators. Weak associations were observed between hospital quality systems and 4 of the 24 indicators, but on analyzing department-level quality systems, strong associations were observed for 8 of the 11 indicators for acute myocardial infarction and stroke. Clinical indicators supported by higher levels of evidence were more frequently associated with quality systems and activities. CONCLUSIONS: There are significant gaps between recommended standards of care and clinical practice in a large sample of hospitals. Implementation of department-level quality strategies was significantly associated with good clinical practice. Further research should aim to develop clinically relevant quality standards for hospital departments, which appear to be more effective than generic hospital-wide quality systems.