Organizational system thinking as a cognitive framework to meet climate targets.

System thinking is a crucial cognitive framework to enable individual pro-environmental behavioral changes. Indeed, a large body of literature has shown a significant and positive association between individuals' system thinking capacities and perceptions of the threat posed by climate change. However, individual behavioral changes play a limited role in addressing climate change compared to large organizations involved in a significantly larger share of economic activities. Do organizations exhibit system thinking capacities? Here, we conjecture that system thinking is a cognitive framework observable at an aggregated group level and, therefore, organizations, not just individuals, can exhibit characteristic levels of system thinking. We conceptualize a definition of organizational system thinking and develop an empirical method to estimate it using a large body of textual data from business organizations. Then, we show that system thinking organizations are more likely to lower emissions and align them with the pathways required to meet the climate targets set by the Paris Agreement. Finally, we discussed the theoretical and policy implication of our study. Overall, our results suggest that system thinking is a relevant organization-level cognitive framework that can help organizations align their emissions with global climate targets.

Prosocial motives underlie scientific censorship by scientists: A perspective and research agenda.

Science is among humanity's greatest achievements, yet scientific censorship is rarely studied empirically. We explore the social, psychological, and institutional causes and consequences of scientific censorship (defined as actions aimed at obstructing particular scientific ideas from reaching an audience for reasons other than low scientific quality). Popular narratives suggest that scientific censorship is driven by authoritarian officials with dark motives, such as dogmatism and intolerance. Our analysis suggests that scientific censorship is often driven by scientists, who are primarily motivated by self-protection, benevolence toward peer scholars, and prosocial concerns for the well-being of human social groups. This perspective helps explain both recent findings on scientific censorship and recent changes to scientific institutions, such as the use of harm-based criteria to evaluate research. We discuss unknowns surrounding the consequences of censorship and provide recommendations for improving transparency and accountability in scientific decision-making to enable the exploration of these unknowns. The benefits of censorship may sometimes outweigh costs. However, until costs and benefits are examined empirically, scholars on opposing sides of ongoing debates are left to quarrel based on competing values, assumptions, and intuitions.

Why postmortems fail.

Most high-profile disasters are followed by demands for an investigation into what went wrong. Even before they start, calls for finding the missed warning signs and an explanation for why people did not "connect the dots" will be common. Unfortunately, however, the same combination of political pressures and the failure to adopt good social science methods that contributed to the initial failure usually lead to postmortems that are badly flawed. The high stakes mean that powerful actors will have strong incentives to see that certain conclusions are-and are not-drawn. Most postmortems also are marred by strong psychological biases, especially the assumption that incorrect inferences must have been the product of wrong ways of thinking, premature cognitive closure, the naive use of hindsight, and the neglect of the comparative method. Given this experience, I predict that the forthcoming inquiries into the January 6, 2021, storming of the US Capitol and the abrupt end to the Afghan government will stumble in many ways.

Unlocking the Benefits of Gender Diversity: How an Ecological-Belonging Intervention Enhances Performance in Science Classrooms.

Gender diversity signals inclusivity, but meta-analyses suggest that it does not boost individual or group performance. This research examined whether a social-psychological intervention can unlock the benefits of gender diversity on college physics students' social and academic outcomes. Analyses of 124 introductory physics classrooms at a large research institution in the eastern United States (N = 3,605) indicated that in classrooms doing "business as usual," cross-gender collaboration was infrequent, there was a substantial gender gap in physics classroom belonging, and classroom gender diversity had no effect on performance. The ecological-belonging intervention aimed to establish classroom norms that adversity in the course is normal and surmountable. In classrooms receiving the intervention, cross-gender interaction increased 51%, the gender gap in belonging was reduced by 47%, and higher classroom diversity was associated with higher course grades and 1-year grade point average for both men and women. Addressing contextual belongingness norms may help to unlock the benefits of diversity.

Four System Enablers of Large-System Transformation in Health Care: A Mixed Methods Realist Evaluation.

Policy Points The implementation of large-scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge. Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture. Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty. CONTEXT: Large-scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large-scale transformation in health care systems. METHODS: A realist study of the implementation of a value-based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context-mechanism-outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers. FINDINGS: Forty-two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large-system transformation that illustrates when, for whom, and in what circumstances large-system transformation worked well or worked poorly. CONCLUSIONS: System enablers offer nuanced guidance for the implementation of large-scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large-system value-based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care.

Walking the Talk: "Reflexivity" to Advance Integration of Patient Reported Outcomes for Cancer Care Screening.

In this commentary, we propose the use of video-reflexive ethnography (VRE) as a means to support integration of patient-reported outcomes (PROs) in cancer care screening. As for any policy or intervention, the optimization of PROs depends on moving beyond their mere formal introduction, and depends on the integration of PROs in the everyday practice contexts of health care professionals (HPEs). The use of VRE allows for video-playback sessions among oncology professionals to support team-based learning and practice-change grounded in "reflexivity." Through a review of previous methods used to support organizational change in healthcare settings (e.g., policies, quality improvement initiatives, simulation sessions), we present some unsung advantages of VRE that can be applied to a complex integrated setting, such as cancer care. As opposed to other methods to create change, VRE does not dictate new measures, but rather supports "bottom-up" provider-initiated changes to health care practices and contexts, grounded in collaborative day-to-day practice. We argue that VRE optimizes PROs in cancer care by facilitating their effective and sustainable integration, to promote improved patient care.

Associations between 24/7 workforce coverage, organizational challenges, and well-being of emergency radiologists: a national survey.

BACKGROUND: The last decade has seen a surge in the demand for imaging exams in emergency radiology (ER), necessitating an evolution in organizational systems for departments offering round-the-clock care, while safeguarding patient care quality and physician well-being to prevent burnout. PURPOSE: To develop a nationwide overview of ER organizations in France and identify structures that promote job satisfaction. MATERIAL AND METHODS: Two surveys were sent to 709 radiological centers across France from March to June 2022, inquiring about organizational aspects and quality of life (QOL), incorporating four validated QOL questionnaires. The organization of each center was mapped, and correlations between respondent characteristics and mental health were analyzed using Pearson's and Wilcoxon tests. RESULTS: A total of 284 centers answered the organizational survey, with a response rate of about 41.6%. Among them, there were 32 university hospitals, 208 general hospitals, 2 teaching army hospitals, and 42 private facilities. Of these, night-time operations showed 14% on-site coverage, 12% on-call from home, 69% utilized external teleradiology, and 4% used in-house teleradiology. These trends persisted over weekends and holidays. Regarding the quality of working life, academic, general, and private radiologists are more satisfied with their practice compared to trainees. Depersonalization, part of the three dimensions of burnout, was high in every class, at 60% (n = 210/350). CONCLUSION: Outside of university hospitals, most radiology centers in France no longer have on-site radiologists during off hours. Residents are prone to lower job satisfaction and quality of life than more experienced radiologists. CLINICAL RELEVANCE STATEMENT: The survey illustrates how French ER is structured, pointing out the escalating significance of teleradiology and noting that radiologists generally experience high job satisfaction while also confronting typical organizational challenges. KEY POINTS: The need for continuous radiology coverage comes with unique logistical challenges, especially in ER. Night shifts show a significant reliance on teleradiology services, especially by external companies. Pay, shift patterns, and seniority affect the well-being of emergency radiologists, particularly the residents.

A tale of 2 digital hospitals: A qualitative study of antimicrobial stewardship teams.

AIMS: We aim to examine and understand the work processes of antimicrobial stewardship (AMS) teams across 2 hospitals that use the same digital intervention, and to identify the barriers and enablers to effective AMS in each setting. METHODS: Employing a contextual inquiry approach informed by the Systems Engineering Initiative for Patient Safety (SEIPS) model, observations and semistructured interviews were conducted with AMS team members (n = 15) in 2 Australian hospitals. Qualitative data analysis was conducted, mapping themes to the SEIPS framework. RESULTS: Both hospitals utilized similar systems, however, they displayed variations in AMS processes, particularly in postprescription review, interdepartmental AMS meetings and the utilization of digital tools. An antimicrobial dashboard was available at both hospitals but was utilized more at the hospital where the AMS team members were involved in the dashboard's development, and there were user champions. At the hospital where the dashboard was utilized less, participants were unaware of key features, and interoperability issues were observed. Establishing strong relationships between the AMS team and prescribers emerged as key to effective AMS at both hospitals. However, organizational and cultural differences were found, with 1 hospital reporting insufficient support from executive leadership, increased prescriber autonomy and resource constraints. CONCLUSION: Organizational and cultural elements, such as executive support, resource allocation and interdepartmental relationships, played a crucial role in achieving AMS goals. System interoperability and user champions further promoted the adoption of digital tools, potentially improving AMS outcomes through increased user engagement and acceptance.

Family Medicine Presence on Labor and Delivery: Effect on Safety Culture and Cesarean Delivery.

PURPOSE: Currently, 40% of counties in the United States do not have an obstetrician or midwife, and in rural areas the likelihood of childbirth being attended to by a family medicine (FM) physician is increasing. We sought to characterize the effect of the FM presence on unit culture and a key perinatal quality metric in Iowa hospital intrapartum units. METHODS: Using a cross-sectional design, we surveyed Iowa physicians, nurses, and midwives delivering intrapartum care at hospitals participating in a quality improvement initiative to decrease the incidence of cesarean delivery. We linked respondents with their hospital characteristics and outcomes data. The primary outcome was the association between FM physician, obstetrician (OB), or both disciplines' presence on labor and delivery and hospital low-risk, primary cesarean delivery rate. Unit culture was compared by hospital type (FM-only, OB-only, or Both). RESULTS: A total of 849 clinicians from 39 hospitals completed the survey; 13 FM-only, 11 OB-only, and 15 hospitals with both. FM-only hospitals were all rural, with <1,000 annual births. Among hospitals with <1,000 annual births, births at FM-only hospitals had an adjusted 34.3% lower risk of cesarean delivery (adjusted incident rate ratio = 0.66; 95% CI, 0.52-.0.98) compared with hospitals with both. Nurses endorsed unit norms more supportive of vaginal birth and stronger safety culture at FM-only hospitals (P <.05). CONCLUSIONS: Birthing hospitals staffed exclusively by FM physicians were more likely to have lower cesarean rates and stronger nursing-rated safety culture. Both access and quality of care provide strong arguments for reinforcing the pipeline of FM physicians training in intrapartum care.

Optimization of Electronic Health Record Usability Through a Department-Led Quality Improvement Process.

BACKGROUND: Electronic health records (EHR) have become commonplace in medicine. A disconnect between developers and users while creating the interface often fails to create a product that captures clinical workflow, and issues become apparent with implementation. Optimization allows collaboration of clinicians and informaticists after implementation, but documentation of success has only been at the institutional level. METHODS: A 4-month, department-wide EHR optimization was conducted with information technology (IT). Optimizations were developed from an intensive quality improvement process involving all levels of clinicians and clinical staff. The optimizations were then categorized as accommodations (department adjusted workflow to EHR), creations (IT developed new workflows within EHR), discoveries (department found workflows within EHR), and modifications (IT changed workflows within EHR). Departmental productivity, defined as number of visits, charges, and payments, was standardized to ratios prior to the COVID-19 pandemic and evaluated by Taylor's change point analysis. Significant improvements were defined as shifts (change points), trends (5 or more consecutive values above/below the mean), and values outside 95% CIs. RESULTS: The 124 optimizations were categorized as 43 accommodations, 13 creations, 54 discoveries, and 14 modifications. Productivity ratios of monthly charges (0.74 to 1.28) and payments (0.83 to 1.58) significantly improved with the optimization efforts. Monthly visit ratios increased (0.65 to 0.98) but did not change significantly. CONCLUSION: Departmental collaboration with organizational IT for EHR optimization focused on detailed analysis of how workflows can impact productivity. Discovery optimization predominance indicates many solutions to EHR usability problems were already in the system. A large proportion of accommodation optimizations reinforced the need for better developer-user collaboration before implementation.Annals Early Access.

Primary Care Practice Characteristics Associated With Medical Assistant Staffing Ratios.

This study characterized adult primary care medical assistant (MA) staffing. National Survey of Healthcare Organizations and Systems (n = 1,252) data were analyzed to examine primary care practice characteristics associated with MA per primary care clinician (PCC) staffing ratios. In 2021, few practices (11.4%) had ratios of 2 or more MAs per PCCs. Compared with system-owned practices, independent (odds ratio [OR] = 1.76, P <0.05) and medical group-owned (OR = 2.09, P <0.05) practices were more likely to have ratios of 2 or more MAs per PCCs, as were practices with organizational cultures oriented to innovation (P <0.05). Most primary care practices do not have adequate MA staffing.

Power Dynamics Perpetuate DEI Inaction: A Qualitative Study of Community Health Clinic Teams.

PURPOSE: Despite increased clinician awareness of systemic racism, lack of substantial action toward antiracism exists within health care. Clinical staff perspectives, particularly those of racial-ethnic minorities/persons of color (POC) who disproportionately occupy support staff roles with less power on the team, can yield insights into barriers to progress and can inform future efforts to advance diversity, equity, and inclusion (DEI, also referred to as EDI) within health care settings. This qualitative study explored the perspectives of staff members on race and role power dynamics within community health clinic teams. METHODS: We conducted semistructured 45-minute interviews with staff members working in community health clinics in a large urban health care system from May to July 2021. We implemented purposeful recruitment to oversample POC and support staff and to achieve equal representation from the 13 community health clinics in the system. Interviews were audio recorded, transcribed, and analyzed over 6 months using a critical-ideological paradigm. Themes reflecting experiences related to race and role power dynamics were identified. RESULTS: Our cohort had 60 participants: 42 (70%) were support staff (medical assistants, front desk clerks, care navigators, nurses) and 18 (30%) were clinicians and clinic leaders. The large majority of participants were aged 26 to 40 years (60%), were female (83%), and were POC (68%). Five themes emerged: (1) POC face hidden challenges, (2) racial discrimination persists, (3) power dynamics perpetuate inaction, (4) interpersonal actions foster safety and equity, and (5) system-level change is needed for cultural shift. CONCLUSIONS: Understanding the race and role power dynamics within care teams, including experiences of staff members with less power, is critical to advancing DEI in health care.

Ongoing Decline in Continuity With GPs in English General Practices: A Longitudinal Study Across the COVID-19 Pandemic.

PURPOSE: Relationship continuity of care has declined across English primary health care, with cross-sectional and longitudinal variations between general practices predicted by population and service factors. We aimed to describe cross-sectional and longitudinal variations across the COVID-19 pandemic and determine whether practice factors predicted the variations. METHODS: We conducted a longitudinal, ecological study of English general practices during 2018-2022 with continuity data, excluding practices with fewer than 750 patients or National Health Service (NHS) payments exceeding £500 per patient. Variables were derived from published data. The continuity measure was the product of weighted responses to 2 General Practice Patient Survey questions. In a multilevel mixed-effects model, the fixed effects were 11 variables' interactions with time: baseline continuity, NHS region, deprivation, location, percentage White ethnicity, list size, general practitioner and nurse numbers, contract type, NHS payments per patient, and percentage of patients seen on the same day as booking. The random effects were practices. RESULTS: Main analyses were based on 6,010 practices (out of 7,190 active practices). During 2018-2022, mean continuity in these practices declined (from 29.3% to 19.0%) and the coefficient of variation across practices increased (from 48.1% to 63.6%). Both slopes were steepest between 2021 and 2022. Practices having more general practitioners and higher percentages of patients seen the same day had slower declines. Practices having higher baseline continuity, located in certain non-London regions, and having higher percentages of White patients had faster declines. The remaining variables were not predictors. CONCLUSIONS: Variables potentially associated with greater appointment availability predicted slower declines in continuity, with worsening declines and relative variability immediately after the COVID-19 lockdown, possibly reflecting surges in demand. To achieve better levels of continuity for those seeking it, practices can increase appointment availability within appointment systems that prioritize continuity.Annals Early Access article.

When Pandemics Collide: Actionable Lessons in HIV Prevention, Treatment and Care During the Era of COVID-19.

The articles in this special issue of AIDS and Behavior focus on the collision between HIV/AIDS and COVID-19 as intersecting pandemics that profoundly impacted communities globally. This editorial highlights the complex interplay between these two public health crises. The pandemic disrupted access to HIV prevention, testing, and treatment services, potentially jeopardizing decades of progress. Mental health challenges and social vulnerability among people living with HIV (PWH) were exacerbated, with preexisting health disparities amplified, disproportionately affecting marginalized populations. However, despite these challenges, the pandemic also spurred innovation and adaptation in HIV prevention and care, with increased use of telehealth and other modalities. The enduring and actionable lessons learned from the collision of HIV and COVID-19 pandemics can prepare us for the next public health challenge with two calls for action. First, we call for integrated and equitable responses that address the multifaceted challenges faced by individuals and communities affected by HIV in the post-COVID-19 era. Second, we call for a strengthened commitment to building resilient health systems and community-engaged interventions that can withstand future challenges.

The dynamic feasibility of resisting (R), accepting (A), or directing (D) ecological change.

Ecological transformations are occurring as a result of climate change, challenging traditional approaches to land management decision-making. The resist-accept-direct (RAD) framework helps managers consider how to respond to this challenge. We examined how the feasibility of the choices to resist, accept, and direct shifts in complex and dynamic ways through time. We considered 4 distinct types of social feasibility: regulatory, financial, public, and organizational. Our commentary is grounded in literature review and the examples that exist but necessarily has speculative elements because empirical evidence on this newly emerging management strategy is scarce. We expect that resist strategies will become less feasible over time as managers encounter situations where resisting is ecologically, by regulation, financially, or publicly not feasible. Similarly, we expect that as regulatory frameworks increasingly permit their use, if costs decrease, and if the public accepts them, managers will increasingly view accept and direct strategies as more viable options than they do at present. Exploring multiple types of feasibility over time allows consideration of both social and ecological trajectories of change in tandem. Our theorizing suggested that deepening the time horizon of decision-making allows one to think carefully about when one should adopt different approaches and how to combine them over time.

La viabilidad dinámica de resistir (R), aceptar (A) o dirigir (D) el cambio ecológico Resumen Las transformaciones ecológicas ocurren por el cambio climático, lo que representa un reto para los enfoques tradicionales para decidir en torno a la gestión de tierras. El marco resistir­aceptar­dirigir (RAD) ayuda a los gestores a considerar cómo responder a este reto. Analizamos cómo la viabilidad de las opciones para resistir, aceptar y dirigir cambia de manera compleja y dinámica con el tiempo. Consideramos cuatro tipos distintos de viabilidad: regulatoria, económica, pública y de organización. Nuestro comentario está basado en la revisión bibliográfica y los ejemplos que existen, pero por necesidad tiene elementos especulativos ya que la evidencia empírica sobre esta estrategia emergente de gestión es escasa. Esperamos que las estrategias de resistir se vuelvan menos viables con el tiempo conforme los gestores encuentren situaciones en las que resistir no es viable de forma ecológica, económica, pública o por regulación. Al igual esperamos que cada vez más los marcos regulatorios permitan su uso, si el costo disminuye, y si el público los acepta, los gestores verán cada vez más viables las estrategias de aceptar y dirigir que las que utilizan actualmente. La exploración de varios tipos de viabilidad a lo largo del tiempo permite considerar las trayectorias sociales y ecológicas del cambio en conjunto. Nuestra teoría sugiere que profundizar en el horizonte temporal de las decisiones permite que se analice con cuidado sobre cuando se deben adoptar enfoques diferentes y cómo combinarlos con el tiempo.

Physical Exercise in Kidney Renal Recipients: Where Have We Come?

BACKGROUND: Kidney transplantation constitutes the most effective therapeutic option for patients suffering from end-stage renal disease but remains burdened by a high incidence of cardiovascular disease. To date, exercise is an important preventive strategy that has been underestimated; in kidney transplant patients, exercise programs lead to an improvement in cardiorespiratory performance, muscle strength, arterial stiffness, and patients' quality of life perception. SUMMARY: The nephrology and transplant community have moved from generic suggestions to specific indications regarding frequency, intensity, time, type, volume, and progression of physical exercise both in the pre- and posttransplant phase. The latest guidelines from the World Health Organization for patients with chronic conditions propose a combination of aerobic, muscle-strengthening, and multicomponent exercises (e.g., balance) to improve health. Based on recent evidence, a combined exercise program (aerobic and strength exercise) is largely proposed to kidney transplant recipients. Aerobic exercise should be performed at an intensity >60% of theoretical maximum heart rate or maximum oxygen uptake possibly every day, and strength training should be performed at a >60% the estimate single maximum repetition, at least 2 times per week. KEY MESSAGES: Physical exercise should be personalized in relation to the patient's baseline performance; increases must be progressive and gradual. Regular physical activity should also be recommended to patients awaiting for a transplant. Eventually, organizational models based on a network of nephrology units, transplant centers, sports medicine centers, and fitness center or outdoor gym are essential elements for overcoming the logistical barriers for prescribing and carrying out regular physical activity.

Oncology Intensive Care Units: Distinguishing Features and Clinical Considerations.

The rapidly advancing field of cancer therapeutics has led to increased longevity among cancer patients as well as increasing complexity of cancer-related illness and associated comorbid conditions. As a result, institutions and organizations that specialize in the in-patient care of cancer patients have similarly evolved to meet the constantly changing needs of this unique patient population. Within these institutions, the intensive care units that specialize in the care of critically ill cancer patients represent an especially unique clinical resource. This article explores some of the defining and distinguishing characteristics associated with oncology ICUs.

Designing viable, durable physical activity programs for cancer survivors: reflections from program participants and organizational leaders.

PURPOSE: Despite recommendations for cancer survivors to participate in routine physical activity (PA), offering programs that fit both survivors' needs and sponsoring organizations' resources remains a challenge. The purpose of this study is to explore the perspectives of cancer survivors and organizational stakeholders with the intent of developing PA peer-led programs that organizations can implement into their programming. METHODS: This study explored cancer survivors' (n = 11) and cancer care organizational stakeholders' (n = 27) perspectives on the design and feasibility of PA programs targeted for cancer survivors. Semi-structured interview guides were developed for survivors and stakeholders; interviews lasted approximately 30 min. Two analysts used a thematic analysis approach and independently conducted a line-by-line coding of each transcript. With guidance from a senior analyst, the codes were collapsed into themes and subthemes. RESULTS: The qualitative analysis of the interview data resulted in seven major themes relating to PA program development and success. Survivor-related themes included the following: (1) developing PA programs based on cancer survivors' characteristics and experiences; (2) perceived value and importance of accessible, face-to-face instruction; (3) ensuring success based on physical abilities and limitations of the survivor; and (4) the value of physician recommendation for PA participation. Organization-related themes included the following: (1) incorporating participant and community input into program offerings; (2) program feasibility and sustainability; (3) incorporating organizational experience when adopting new program initiatives. CONCLUSION: These findings highlight the challenges of developing viable PA programs for cancer survivors and may guide organizations in future program development and implementation.

A strategy to implement the American College of Sports Medicine's Exercise is Medicine® (EIM) initiative in a community oncology clinic.

PURPOSE: Despite proven benefits, few cancer patients exercise during chemotherapy. The American College of Sports Medicine's Exercise is Medicine® (EIM) initiative describes a model to integrate exercise into oncology care, based upon assessing patients' ability to exercise safely, advising on exercise benefits, and referring patients to exercise. We developed and tested a strategy to implement EIM in a community-based oncology clinic, to assess-advise-refer 20 patients undergoing chemotherapy to a 3-month online exercise class, and measured implementation outcomes. METHODS: Using a community-based provider participation in research (CBPPR) model, researchers and staff co-designed and tested a 4-level implementation strategy, with a goal of assessing-advising-referring 20 cancer patients to exercise. Surveys and interviews were conducted with 12 (100%) staff at baseline and post-implementation on acceptability/appropriateness/feasibility, perceptions of individual implementation roles, and organizational strengths/conditions. Data were analyzed using correlations, t-tests, and content analysis. RESULTS: The proposed strategy was revised in collaboration with staff who requested assistance for recruitment and data collection. EIM was successfully implemented with 41 (92%) patients assessed, 37 (90%) advised, and 22 (60%) referred to exercise classes. Barriers to implementation were staff shortages and time constraints; facilitators included research team supports. Staff's perceived organizational strengths were positively correlated with exercise promotion acceptability, appropriateness, and feasibility. There were no statistically significant changes in implementation outcomes (acceptability/appropriateness/feasibility) post-implementation. CONCLUSIONS: Using a collaborative model, EIM was successfully implemented in a community oncology clinic; however, the clinic required significant support from the research team. Adaptations to the EIM process may be required to improve implementation outcomes.

Increasing access to pediatric surgical care: Assessing district hospital readiness in rural Rwanda.

Introduction/Background: Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda. Methods: We administered the Children's Surgical Assessment Tool (CSAT), adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains. Results: None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure, and information management for pediatric outpatients and referrals. In SSORT interviews (n=47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score=2.6 out of 5), psychological safety (median score=3.0 out of 5), and resistance to change (mean score=1.5 out of 5 with 5=no resistance). Conclusions: This study highlights challenges in providing safe and high-quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity.