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Record W4416268164 · doi:10.1136/bmjoq-2025-003531

Improving departmental Quality Improvement Plans through standardisation, structured peer-to-peer feedback and building improvement capacity and culture

2025· article· en· W4416268164 on OpenAlexafffund
Hailey Hobbs, Samantha Calder‐Sprackman, Amelia Wilkinson, Geneviève C. Digby

Bibliographic record

VenueBMJ Open Quality · 2025
Typearticle
Languageen
FieldHealth Professions
TopicHealth Policy Implementation Science
Canadian institutionsQueen's UniversityMcMaster University
FundersSoutheastern Ontario Academic Medical Organization
KeywordsQuality managementCLARITYPsychological interventionQuality (philosophy)Performance improvementFocus (optics)Total quality management

Abstract

fetched live from OpenAlex

INTRODUCTION: Quality Improvement Plans (QIPs) can improve healthcare quality by raising awareness and providing a focus for improvement efforts. The physician-led quality committee at our institution set out to improve the previously heterogenous quality and content of clinical department QIPs and increase alignment between clinical department and hospital quality improvement (QI) priorities. We describe these initiatives and assess their impact on the quality of departmental QIPs. METHODS: The Physician Quality Committee at our academic tertiary care hospital implemented a series of interventions, including a peer-to-peer feedback mechanism, longitudinal education and coaching, standardised QI project templates and efforts to facilitate culture change. The QIPs from 13 clinical departments were reviewed for the years before (2018-2019) and after the interventions (2022-2023) and scored according to a structured rubric, created by consensus among physician quality leads. Data are reported as means and medians (IQR). A Wilcoxon signed-rank test was used to evaluate for statistical significance. A Likert-scale survey was used to assess physician QI leads' perception of the impact of the initiatives. RESULTS: The mean score on the structured rubric was 4.4/12 for the QIPs from 2018 to 2019 and 8.0/12 for the QIPs from 2022 to 2023 (Z=3.06, p=0.0005). The median score (25th, 75th percentile) in 2018-2019 was 4.5 (3.5, 5.13), which increased to 8.5 (7.0, 9.0) in 2022-2023. The survey response for physician QI leads was 10/13 (76.9%). The most positive response was the QI lead's knowledge and understanding of how to structure a QI project (mean score of 4.4/5); the least positive response was related to departmental focus and clarity regarding QI priorities (mean score of 3.9/5). CONCLUSIONS: Multifaceted physician-led interventions resulted in improvements in the quality and content of clinical department QIPs, improved physician knowledge of QI methodology, enhanced focus and clarity around departmental QI priorities, and improved awareness of hospital-wide improvement efforts.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.

How this classification was reachedexpand

Direct model labels (unvalidated)

Per-model category and study-design labels from the labeling rounds. They are machine output, unvalidated, and the disagreement between models ships as data. No study design here is MEDLINE-validated yet.

Model armCategoriesStudy designConfidence
gemmano category
Domain: not available · Genre: Empirical
About the Canadian research system: no · About a Canadian topic: no
Not applicablelow
gptno category
Domain: not available · Genre: Empirical
About the Canadian research system: no · About a Canadian topic: no
Other designlow
models splitAgreement compares identical category sets and study designs across arms.

Full frame distilled prediction

Teacher imitation

Not calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.

metaresearch head score (Codex)0.015
metaresearch head score (Gemma)0.005
Version: codex-gemma-dda1882f352aValidation status: machine_predicted_unvalidated
Candidate categoriesMeta-epidemiology (narrow), Science and technology studies
Consensus categoriesnone
DomainCandidate signal: none · Consensus signal: none
Study designCandidate signal: Observational · Consensus signal: Observational
GenreCandidate signal: Empirical · Consensus signal: Empirical
Teacher disagreement score0.326
Threshold uncertainty score1.000

Codex and Gemma teacher scores by category

CategoryCodexGemma
Metaresearch0.0150.005
Meta-epidemiology (narrow)0.0000.000
Meta-epidemiology (broad)0.0010.000
Bibliometrics0.0000.000
Science and technology studies0.0020.000
Scholarly communication0.0000.001
Open science0.0010.002
Research integrity0.0000.001
Insufficient payload (model declined to judge)0.0000.000

Machine scores (provisional)

The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.

Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.

Opus teacher head0.416
GPT teacher head0.658
Teacher spread0.242 · how far apart the two teachers sit on this one work
Validation statusscore_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from it

Classification

machine, unvalidated

Labeled directly by 2 models reading the full record.

The models applied no category: nothing in the taxonomy fit this work.

The models disagree on parts of this classification; every voice is preserved in the section at the end of the page.

Study designNot applicable · Other design
Domainnot available
GenreEmpirical

How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".

Quick stats

Citations1
Published2025
Admission routes2
Has abstractyes

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