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.

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.

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.

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.

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.

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 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.

Improvement Science and Implementation Science in Cancer Care: Identifying Areas of Synergy and Opportunities for Further Integration.

Efforts to improve cancer care primarily come from two fields: improvement science and implementation science. The two fields have developed independently, yet they have potential for synergy. Leveraging that synergy to enhance alignment could both reduce duplication and, more importantly, enhance the potential of both fields to improve care. To better understand potential for alignment, we examined 20 highly cited cancer-related improvement science and implementation science studies published in the past 5 years, characterizing and comparing their objectives, methods, and approaches to practice change. We categorized studies as improvement science or implementation science based on authors' descriptions when possible; otherwise, we categorized studies as improvement science if they evaluated efforts to improve the quality, value, or safety of care, or implementation science if they evaluated efforts to promote the implementation of evidence-based interventions into practice. All implementation studies (10/10) and most improvement science studies (6/10) sought to improve uptake of evidence-based interventions. Improvement science and implementation science studies employed similar approaches to change practice. For example, training was employed in 8/10 implementation science studies and 4/10 improvement science studies. However, improvement science and implementation science studies used different terminology to describe similar concepts and emphasized different methodological aspects in reporting. Only 4/20 studies (2 from each category) described using a formal theory or conceptual framework to guide program development. Most studies were multi-site (10/10 implementation science and 6/10 improvement science) and a minority (2 from each category) used a randomized design. Based on our review, cancer-related improvement science and implementation science studies use different terminology and emphasize different methodological aspects in reporting but share similarities in purpose, scope, and methods, and are at similar levels of scientific development. The fields are well-positioned for alignment. We propose that next steps include harmonizing language and cross-fertilizing methods of program development and evaluation.

Quality and safety in the time of Coronavirus: design better, learn faster.

The COVID-19 pandemic has required health systems to change much faster than normal. Many staff have experienced training in quality improvement and patient safety methods which can be used to support the design of new systems and to accelerate learning about new and adapted practices. This article sets out the principles of quality improvement and patient safety science, applying them in a selection of approaches, methods and tools, which may be useful in crisis situations such as the current pandemic. The article also makes reference to several resources which may be of use to those keen to advance their knowledge.

Sustaining and spreading penicillin allergy delabelling: A narrative review of the challenges for service delivery and patient safety.

Many patients report allergies to penicillin, although in over 90% of these the label of penicillin allergy is shown to be incorrect following comprehensive testing. Inappropriate and inaccurate penicillin allergy labelling is a barrier to antimicrobial stewardship and can lead to patient harm. This review assesses an emergent evidence base and trend favouring delabelling using direct oral penicillin challenges following a stratified risk assessment of the likelihood and existence of true penicillin allergy, to identify and make recommendations for key components for implementation in standard practice. Research to date has focussed on the feasibility and clinical and financial outcomes of these direct delabelling strategies. There is a paucity of studies exploring the views and engagement of patients and healthcare professionals, and a gap in the evidence for prerequisites to safely deliver, sustain and spread the implementation of such services across health systems.

Age and Ageing to introduce a new category of paper: healthcare improvement science.

Age and Ageing is now inviting papers on healthcare improvement for older people. In this article we outline the nature and scope of healthcare improvement and reference improvement models and the tools and methods of improvement science. We emphasise the issues of sustainability, including scale and spread; evaluation - including associated ethical consideration and the involvement of patients and the public in healthcare improvement and associated research. Throughout we refer to resources the authors have found useful in their own work, and provide a bibliography of sources and web-links which will provide essential guidance and support for potential contributors to this new category of submission to Age and Ageing.

"Change is what can actually make the tough times better": A patient-centred patient safety intervention delivered in collaboration with hospital volunteers.

BACKGROUND: The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect patient feedback to support service improvement. To provide a sustainable mechanism for the PRASE intervention, a 2-year improvement project explored the potential for hospital volunteers to facilitate the collection of PRASE feedback. OBJECTIVE: To explore the implementation of the PRASE intervention delivered in collaboration with hospital volunteers from the perspectives of key stakeholders. DESIGN: A qualitative case study design was utilized across three acute NHS trusts in the United Kingdom between March 2016 and October 2016. Ward level data (staff interviews; action planning meeting recordings; implementation fidelity information) were analysed taking a pen portrait approach. We also carried out focus groups with hospital volunteers and interviews with voluntary services/patient experience staff, which were analysed thematically. RESULTS: Whilst most ward staff reported feeling engaged with the intervention, there were discordant views on its use and usefulness. The hospital volunteers were positive about their involvement, and on some wards, worked with staff to produce actions to improve services. The voluntary services/patient experience staff participants emphasised the need for PRASE to sit within an organisations' wider governance structure. CONCLUSION: From the perspective of key stakeholders, hospital volunteers facilitating the collection of PRASE feedback is a feasible means of implementing the PRASE intervention. However, the variability around ward staff being able to use the feedback to make changes to services demonstrates that it is this latter part of the PRASE intervention cycle that is more problematic.

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.

Health outcomes measurement and organizational readiness support quality improvement: a systematic review.

BACKGROUND: Using outcome measures to advance healthcare continues to be of widespread interest. The goal is to summarize the results of studies which use outcome measures from clinical registries to implement and monitor QI initiatives. The second objective is to identify a) facilitators and/or barriers that contribute to the realization of QI efforts, and b) how outcomes are being used as a catalyst to change outcomes over time. METHODS: We searched the PubMed, EMBASE and Cochrane databases for relevant articles published between January 1995 and March 2017. We used a standardized data abstraction form. Studies were included when the following three criteria were fulfilled: 1) they relied on structural data collection, 2) when a structural and comprehensive QI intervention had been implemented and evaluated, and 3) impact on improving clinical and/or patient-reported outcomes was described. Data on QI strategies, QI initiatives and the impact on outcomes was extracted using standardized assessment tools. RESULTS: We included 21 articles, of which eight showed statistically significant improvements on outcomes using data from clinical registries. Out of these eight studies, the Chronic Care Model, IT application as feedback, benchmarking and the Collaborative Care Model were used as QI methods. Encouraging trends in realizing improved outcomes through QI initiatives were observed, ranging from improving teamwork, implementation of clinical guidelines, implementation of physician alerts and development of a decision support system. Facilitators for implementing QI initiatives included a high quality database, audits, frequent reporting and feedback, patient involvement, communication, standardization, engagement, and leadership. CONCLUSION: This review suggests that outcomes collected in clinical registries are supportive to realize QI initiatives. Organizational readiness and an active approach are key in achieving improved outcomes.

Improvement Science Meets Improvement Scholarship: Reframing Research for Better Healthcare.

In this editorial essay I explore the possibilities of 'improvement scholarship' in order to set the scene for the theme of, and the other papers in, this issue. I contrast a narrow conception of quality improvement (QI) research with a much broader and more inclusive conception, arguing that we should greatly extend the existing dialogue between 'problem-solving' and 'critical' currents in improvement research. I have in mind the potential for building a much larger conversation between those people in 'improvement science' who are expressly concerned with tackling the problems facing healthcare and the wider group of colleagues who are engaged in health-related scholarship but who do not see themselves as particularly interested in quality improvement, indeed who may be critical of the language or concerns of QI. As one contribution to that conversation I suggest that that the increasing emphasis on theory and rigour in improvement research should include more focus on normative theory and rigour. The remaining papers in the issue are introduced including the various ways in which they handle the 'implicit normativity' of QI research and practice, and the linked theme of combining relatively 'tidy' and potentially 'unruly' forms of knowledge.

"Don't Mind the Gap!" Reflections on Improvement Science as a Paradigm.

Responding to this issue's invitation to bring new disciplinary insights to the field of improvement science, this article takes as its starting point one of the field's guiding metaphors: the imperative to "mind the gap". Drawing on insights from anthropology, history, and philosophy, the article reflects on the origins and implications of this metaphoric imperative, and suggests some ways in which it might be in tension with the means and ends of improvement. If the industrial origins of improvement science in the twentieth century inform a metaphor of gaps, chasms, and spaces of misalignment as invariably imperfect and potentially dangerous, and therefore requiring bridging or closure, other currents that feed the discipline of improvement science suggest the potential value and uses of spaces of openness and ambiguity. These currents include the science of complex adaptive systems, and certain precepts of philosophical pragmatism acknowledged to inform improvement science. Going a step further, I reflect on whether or not these two contrasting approaches within improvement science should be treated as incommensurable paradigms, and what each approach tells us about the very possibility of accommodating seemingly irreconcilable or incommensurable approaches within improvement science.

Valuing Healthcare Improvement: Implicit Norms, Explicit Normativity, and Human Agency.

I argue that greater attention to human agency and normativity in both researching and practicing service improvement may be one strategy for enhancing improvement science, illustrating with examples from cancer screening. Improvement science tends to deliberately avoid explicit normativity, for paradigmatically coherent reasons. But there are good reasons to consider including explicit normativity in thinking about improvement. Values and moral judgements are central to social life, so an adequate account of social life must include these elements. And improvement itself is unavoidably normative: it assumes that things could and should be better than they are. I seek to show that normativity will always be implicated in the creation of evidence, the design of programs, the practice of healthcare, and in citizens' judgements about that care, and to make a case that engaging with this normativity is worthwhile.

A qualitative formative evaluation of a patient-centred patient safety intervention delivered in collaboration with hospital volunteers.

BACKGROUND: Evidence suggests that patients can meaningfully feed back to healthcare providers about the safety of their care. The PRASE (Patient Reporting and Action for a Safe Environment) intervention provides a way to systematically collect feedback from patients to support service improvement. The intervention is being implemented in acute care settings with patient feedback collected by hospital volunteers for the first time. OBJECTIVE: To undertake a formative evaluation which explores the feasibility and acceptability of the PRASE intervention delivered in collaboration with hospital volunteers from the perspectives of key stakeholders. DESIGN: A qualitative evaluation design was adopted across two acute NHS trusts in the UK between July 2014 and November 2015. We conducted five focus groups with hospital volunteers (n=15), voluntary services and patient experience staff (n=3) and semi-structured interviews with ward staff (n=5). Data were interpreted using framework analysis. RESULTS: All stakeholders were positive about the PRASE intervention as a way to support service improvement, and the benefits of involving volunteers. Volunteers felt adequate training and support would be essential for retention. Staff concentrated on the infrastructure needed for implementation and raised concerns around sustainability. Findings were fed back to the implementation team to support revisions to the intervention moving into the subsequent summative evaluation phase. CONCLUSION: Although there are concerns regarding sustainability in practice, the PRASE intervention delivered in collaboration with hospital volunteers is a promising approach to collect patient feedback for service improvement.

Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy?

There is extensive health and public health literature on the 'evidence-policy gap', exploring the frustrating experiences of scientists trying to secure a response to the problems and solutions they raise and identifying the need for better evidence to reduce policymaker uncertainty. We offer a new perspective by using policy theory to propose research with greater impact, identifying the need to use persuasion to reduce ambiguity, and to adapt to multi-level policymaking systems.We identify insights from secondary data, namely systematic reviews, critical analysis and policy theories relevant to evidence-based policymaking. The studies are drawn primarily from countries such as the United States, United Kingdom, Canada, Australia and New Zealand. We combine empirical and normative elements to identify the ways in which scientists can, do and could influence policy.We identify two important dilemmas, for scientists and researchers, that arise from our initial advice. First, effective actors combine evidence with manipulative emotional appeals to influence the policy agenda - should scientists do the same, or would the reputational costs outweigh the policy benefits? Second, when adapting to multi-level policymaking, should scientists prioritise 'evidence-based' policymaking above other factors? The latter includes governance principles such the 'co-production' of policy between local public bodies, interest groups and service users. This process may be based primarily on values and involve actors with no commitment to a hierarchy of evidence.We conclude that successful engagement in 'evidence-based policymaking' requires pragmatism, combining scientific evidence with governance principles, and persuasion to translate complex evidence into simple stories. To maximise the use of scientific evidence in health and public health policy, researchers should recognise the tendency of policymakers to base judgements on their beliefs, and shortcuts based on their emotions and familiarity with information; learn 'where the action is', and be prepared to engage in long-term strategies to be able to influence policy; and, in both cases, decide how far you are willing to go to persuade policymakers to act and secure a hierarchy of evidence underpinning policy. These are value-driven and political, not just 'evidence-based', choices.

The potential for nurses to contribute to and lead improvement science in health care.

AIM: A discussion of how nurses can contribute to and lead improvement science activities in health care. BACKGROUND: Quality failures in health care have led to the urgent need for healthcare quality improvement. However, commonly quality improvement interventions proceed to practice implementation without rigorous methods or sufficient empirical evidence. This lack of evidence for quality improvement has led to the development of improvement science, which embodies quality improvement research and quality improvement practice. This paper discusses how the discipline of nursing and the nursing profession possesses many strengths that enable nurses to lead and to play an integral role in improvement science activities. However, we also discuss that there are insufficiencies in nursing education that require attention for nurses to truly contribute to and lead improvement science in health care. DESIGN: Discussion paper. DATA SOURCES: This paper builds on a collection of our previous work, a 12-month scoping review (March 2013-March 2014), baseline study on a quality improvement management system (Lean), interviews with nurses on quality improvement implementation and supporting literature. IMPLICATIONS FOR NURSING: This paper highlights how nurses have the philosophical, theoretical, political and ethical positioning to contribute to and lead improvement science activities. However up to now, the potential for nurses to lead improvement science activities has not been fully used. CONCLUSION: We suggest that one starting point is to include improvement science in nursing education curricula. Specifically, there needs to be increased focus on the nursing roles and skills needed to contribute to and lead healthcare improvement science activities.