Changing Parental Perceptions Adding Value to School Improvement Processes in Gilgit-Baltistan, Pakistan

Parental perceptions and perspectives play a critical role in their motivation, interest, participation, and valuation of children’s education which ultimately influences the quality of education in schools. This article reports the change of perception and perspectives of the parents under the influence of a comprehensive school improvement intervention. A quantitative survey approach was employed in this study including 680 parents from 6 districts. The data was collected in two rounds following the pre- and post- intervention approach. The first round of data was collected at the beginning of the project and the second round was collected at its end. The paired sample t-test showed significant difference between pre- and postintervention responses of parents about improved relationships between the school and the parents (p < 0.000), increased cocurricular activities in the school (p < 0.000), fulfillment of students’ educational curriculum requirements (p < 0.000), the provision of equal attention to both boys and girls (p < 0.002), the obligation of the parents to ensure the physical and moral development of their children (p < 0.000), the provision of a safe, healthy, and educational environment at home by the parents (p < 0.000), and the development and maintenance of positivity expressed by parents for the success of their children (p < 0.000). Hence, the study found that a planned intervention has the potential to positively change the perceptions, perspectives, and valuation of children’s academic development.

Mixed effect of increasing outflow of medical patients from an emergency department

Background and aim Since 2014, the annual number of patients entering our emergency department (ED) has increased significantly. These were primarily Internal Medicine (IM) patients, and of these, 25–30% were admitted. The present governmental policy presents a deterrent to adding IM beds for these patients, and Emergency and IM departments cope with ever-increasing number of IM patients. We describe a quality improvement intervention to increase outflow of IM patients from the ED to the IM departments. Methods We conducted a quality improvement intervention at the Shaare Zedek Medical Center from 2014 to 2018. The first stage consisted of an effort to increase morning discharges from the IM departments. The second stage consisted of establishing a process to increase the number of admissions to the IM departments from the ED. Results Implementation of the first stage led to an increased morning discharge rate from a baseline of 2–4 to 18%. The second stage led to an immediate mean (± SD) morning transfer of 35 ± 7 patients to the medical departments (8–12 per department), providing significant relief for the ED. However, the additional workload for the IM departments’ medical and nursing staff led to a rapid decrease in morning discharges, returning to pre-intervention rates. Throughout the period of the new throughput intervention, morning admissions increased from 30 to > 70%, and were sustained. The number of patients in each department increased from 36 to 38 to a new steady state of 42–44, included constant hallway housing, and often midday peaks of 48–50 patients. Mean length of stay did not change. IM physician and nurse dissatisfaction led to increased number of patients being admitted during the evening and night hours and fewer during the morning. Conclusion We describe a quality improvement intervention to improve outflow of medical patients from the ED in the morning hours. The new ED practices had mixed effects. They led to less ED crowding in the morning hours but increased dissatisfaction among the IM department medical and nursing staff due to an increased number of admissions in a limited number of hours. The present governmental reimbursement policy needs to address hospital overcrowding as it relates to limited community healthcare beds and an aging population.

Labour after caesarean counselling documentation: a quality improvement intervention on labour and delivery

BackgroundMost women who have had previous caesareans are eligible to have labour after caesarean (LAC), but only 11.9% do so. Studies show the majority of women have already decided about future mode of birth (FMOB) before a subsequent pregnancy. Hence, providing women with LAC counselling soon after birth may help women plan for future pregnancies. Prior to our intervention, our hospital had no method of ensuring that women received LAC counselling after caesarean section. The purpose of this QI initiative was to assess whether formal LAC documentation on labour and delivery (L&D) improves rates of LAC counselling post partum.MethodsOur three-part intervention included: (1) surgeon’s assessment of LAC feasibility in the operative note, (2) written LAC education for women in discharge paperwork and (3) documentation of LAC counselling in the discharge summary. We implemented these changes on L&D in January 2019. We conducted phone surveys of 40 women after caesarean preintervention and postintervention. Surveys included questions regarding three primary outcomes: whether or not they had received LAC counselling either in the hospital or at a postpartum visit, and whether or not they would pursue LAC as FMOB. Surveys also assessed two secondary outcomes: (1) women’s understanding of the indications for surgery and (2) their involvement in the decision process. We used a χ2 analysis to assess primary outcomes and a Fisher’s exact test to assess secondary outcomes. We also surveyed providers about the culture of LAC counselling at our hospital.ResultsAfter our intervention, there was a significant difference between the number of women reporting LAC postpartum counselling (30.77% vs 53.8%, p=0.04). There was also a significant difference in the number of women feeling involved in the decision-making process (68% vs 95%, p=0.03). Providers reported improved knowledge/confidence around LAC counselling (58%–100%). Providers universally stated that LAC counselling has become more ingrained in the culture on L&D.ConclusionsDocumentation of LAC counselling improved the consistency with which providers incorporated LAC counselling into postpartum care. Addressing FMOB at the time of pLTCS and documenting that counselling may be an effective first step in empowering women to pursue LAC in future pregnancies.

Creating Conditions for Effective Knowledge Brokering: A Qualitative Case Study

Background: Process improvement in healthcare is informed by knowledge from the private sector. Following which, individuals broker such knowledge to the frontline of care delivery. Their effect is likely limited where the context proves unreceptive to brokering knowledge. We need greater insight into what organizational and system level conditions are necessary to support individuals to broker process improvement knowledge to the frontline of care delivery, and how policy makers and organizations might generate such conditions. Methods: Our research took place in a healthcare system within an Australian State. Following COREQ guidelines for qualitative research, we undertook qualitative research over the four year period of the process improvement intervention encompassing 57 semi-structured interviews, 12 focus groups, and 137 hours observation of process improvement workshops, which involved improvement advisors (the knowledge brokers), policy makers, and executive sponsors. Results: We identified four phases of the process improvement intervention that moved towards a mature collaboration within which knowledge brokering by improvement advisors emerged as effective. In the first phase knowledge brokering was not established. In a second phase, whilst initiated, it lacked legitimacy amongst frontline practitioners, following which they resisted the brokering of process improvement knowledge by improvement advisors. Only following reflection by policy makers, and actions to engender a receptive context were improvement advisors able to effectively broker knowledge to frontline professionals for process improvement. Conclusion: We highlight four interlinked prescriptions for the conditions policy makers need to engender to support individuals to broker process improvement knowledge to the frontline of care delivery, and how they go about this. Policy makers should: respect local context through building cultural linkages between people and organizations; build individuals’ knowledge integration skills; awaken and enable active and latent “seekers” of knowledge to pull knowledge upward; strengthen collaboration, not competition so as to be friend, not foe, to healthcare organizations on their knowledge integration journey.