Service improvement in health care: a literature review

Affiliation.

  • 1 Subject Lead Adult Nursing, Senior Lecturer, Northumbria University, Newcastle upon Tyne.
  • PMID: 30089059
  • DOI: 10.12968/bjon.2018.27.15.893

Service improvements in health care can improve provision, make cost savings, streamline services and reduce clinical errors. However, on its own it may not be adequate for improving patient outcomes and quality of care. The complexity of healthcare provision makes service improvement a challenge, and there is little evidence on whether improvement initiatives change healthcare practices and improve care. To understand the concept of service development within health care, it is necessary to explore the national context and how the NHS has adopted improvement initiatives. To equip the nursing workforce with the skills necessary to make positive change, higher education institutions have developed courses that include the topic within their pre-registration programmes. However, service improvement is a learned skill that nurses need to practise in order to become competent.

Keywords: Nursing, practice development; Quality improvement; Service improvement.

Publication types

  • Delivery of Health Care / standards*
  • Health Services / standards*
  • Quality Improvement*

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Developing and sustaining nurses' service improvement capability: a phenomenological study

Subject Lead, Adult Nursing, and Senior Lecturer, Northumbria University, Newcastle upon Tyne

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Alison Machin

Professor of Nursing and Interprofessional Education, Northumbria University/Executive Member (workforce), Council of Deans of Health

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Background:

Service improvement to enhance care quality is a key nursing responsibility and developing sustainable skills and knowledge to become confident, capable service improvement practitioners is important for nurses in order to continually improve practice. How this happens is an under-researched area.

A hermeneutic, longitudinal study in Northern England aimed to better understand the service improvement lived experiences of participants as they progressed from undergraduate adult nursing students to registrants.

Twenty year 3 student adult nurses were purposively selected to participate in individual semi-structured interviews just prior to graduation and up to 12 months post-registration. Hermeneutic circle data analysis were used.

Themes identified were service improvement learning in nursing; socialisation in nursing practice; power and powerlessness in the clinical setting; and overcoming service improvement challenges. At the end of the study, participants developed seven positive adaptive behaviours to support their service improvement practice and the ‘model of self-efficacy in service improvement enablement’ was developed.

Conclusion:

This study provides a model to enable student and registered nurses to develop and sustain service improvement capability.

Embedding a nursing service improvement culture has been a focus of successive UK policy initiatives ( Craig, 2018 ), such as the NHS Safety Thermometers scheme ( NHS Improvement, 2017 ), the 2012 nurse-led quality framework Energise for Excellence, High Impact Actions for Nursing and Midwifery ( NHS website, 2010 ) and the NHS Productive Series ( NHS website, 2020 ). However, information about how nurses develop and sustain service improvement skills beyond their initial education is lacking.

Service improvement can be defined as ‘the combined efforts of everyone to make changes, leading to better patient outcomes (health), better system performance (care) and better professional development (learning) regardless of the theoretical concept or tool utilised’ ( Batalden and Davidoff, 2007:2 ).

In 2007, a national initiative to embed this learning in undergraduate programmes created many opportunities for pre-registration nursing students to develop these skills ( Johnson et al, 2010 ). Students involved in the initiative evaluated it very positively and subsequent studies suggest it enhanced their understanding of the practicalities of implementing service improvement activity ( Machin and Jones 2014 ). Johnson et al's (2010) study suggested that resistance from staff, lack of time and student status were barriers to the success of students' service improvement efforts. Despite challenges, service improvement learning and the opportunity to improve the patient care experience is valued by pre-registration students ( Smith and Lister, 2011 ), with classroom-based sessions seen as beneficial for learning ( Baillie et al, 2014 ; Smith et al, 2014 ). Educational programmes encompassing service improvement have helped prepare student nurses to make changes in practice when qualified ( Machin and Jones, 2014 ; James et al, 2016 ). However, little is known about the sustainability of this learning.

This study aimed to understand service improvement experiences of undergraduate adult nursing students in their final year of university and up to 12 months into their graduate practice. The following research questions were posed:

  • What are student adult nurses' experiences of service improvement in education and its application in the practice learning setting?
  • What are registered adult nurses' experiences of service improvement in their first year of clinical practice?

A longitudinal hermeneutic phenomenological design was used to explore participants' perceptions of their pre- and post-qualification experiences of service improvement in nursing. Phenomenology was appropriate as a research methodology because it seeks to understand particular phenomenon as it is lived by participants.

Sampling from five to 25 participants is often suggested for qualitative research methodologies, which include phenomenology. A longitudinal hermeneutic study carried out by Standing (2009) explored the experiences of transition from student to registered nurse. Following the post-qualifying period, there was 50% attrition. This helped inform the decision to include 20 participants in the present study, a sufficient number to enable rich data collection and allow for potential attrition during phase 2 (there were 15 participants for phase 2, an attrition of 5).

Participants had completed a service improvement module as part of their second-year education programme, where they engaged with service improvement, explored theoretical improvement methodologies and appraised via a written assessment of their experiences.

All participants' placements were in the NHS trust that was likely to be the location of their first staff nurse job. This was important to enable post-graduate follow-up. The 20 students gave consent to be individually interviewed twice, once as a student and again in their first year of being qualified.

An interview schedule was developed to facilitate semi-structured interviews in both phases of the study. Robson (2011) suggested that interview schedules should incorporate an introduction, a focused lead question and several key questions or prompts:

  • What does service improvement mean to you?
  • What do you understand about service improvement?
  • What experience have you had of service improvement learning?
  • What experience have you had of service improvement in practice?
  • Has there been anything in your service improvement experience that has changed the way you feel about it or the way you facilitate it?
  • Is there anything else you want to tell me about your role in service improvement?

Each participant was asked the same opening question and the same final question.

Forty interviews lasting 30-45 minutes were undertaken by the lead researcher (LC) at the university, digitally recorded and transcribed verbatim. Digital and written data were stored in line with data protection policy. Data were analysed using a phenomenological, hermeneutic circle approach ( van Manen, 1990 ), comprising three stages ( Lindseth and Norberg, 2004 ), and the process was informed by re-reading the relevant literature:

  • Transcripts were read and recordings listened to in order to understand the context of each participant
  • Key themes across the transcripts were identified and clustered into overarching themes
  • These themes were then interpreted to develop in-depth understanding of participant experiences of service improvement learning and practice.

Researcher understanding of participants' experiences was checked with them throughout data collection. Member checking occurred with participants concurrently as part of each interview during both phases.

A transparent audit trail of researcher decision-making ensured that the study and its results were trustworthy ( Guba and Lincoln, 1994 ).

Ethical permission

Ethical permission was given by the university's ethical approval committee and the research development department at the participating NHS trust.

van Manen's (1990) six-step approach was used because it was congruent with the research methodology and is conducive to analysing hermeneutic phenomenological data. Although there are six steps, the process undertaken was not linear and the lead researcher (LC) frequently returned to the hermeneutic circle for naive reading, re-reading and interpretation of the transcripts throughout each stage of analysis ( Table 1 ). Gadamer (1979) supports this approach, suggesting that movement between the six activities, forward and backward, allows researchers the time to consider, reconsider and reflect on the parts and the whole. It is through these activities that the researcher can fully engage in the hermeneutic circle and enabled them to identify convergent and divergent viewpoints.

Four overarching themes emerged from the hermeneutic data analysis of the participants' ( Figure 1 ):

service improvement assignment in nursing

Service improvement learning in nursing

Socialisation in nursing practice, power and powerlessness in the clinical setting.

  • Challenges in changing practice.

Service improvement in nursing was an overarching theme incorporating subthemes, such as a personal understanding of service improvement, seeing a need for service improvement, micro and macro perspectives of service improvement and linking theory to practice. It was evident in the findings that all participants had socially constructed an understanding of service improvement and were able to give a definition of what this meant to them. The findings illustrated that participants had experienced service improvement both in university and in their clinical practice.

As students, they conveyed their understanding of service improvement, citing their rationale, and applied theoretical models and different approaches for the process:

‘[Service improvement] means trying to improve and change the service so patients have a better experience, an overall experience’

Another participant also identified a patient-focused rationale for service improvement:

‘[Service improvement is] changing any service or [a] service that you give to patients, so it could be an intervention or some other way care is given or organised’

This understanding stayed with the newly qualified participants; however, they talked about their nursing role in service improvement in a more personalised way, recognising the scope of the contribution they could make as individual newly qualified practitioners:

‘Looking back, you gain knowledge and skills as your career progresses. You don't want to go in with a huge service improvement, just start little and build up. I have used some of the theory about change and PDSA [plan, do, study, act]. I am always reflecting and learning’

Another talked about the importance of having service improvement confidence, despite being newly qualified and still on a learning journey:

‘I am still learning, but if you have a good idea about something, having the confidence to go with it, giving reasons and rationale as to how and why you want to do it, to improve the patients service’

Several participants described service improvement opportunities within the preceptorship period as consolidating their learning:

‘As part of preceptorship I did service improvement. We have the knowledge and skills framework, which we have to work towards. Without learning, you would never be getting to best practice. I think, if you don't look for how you can improve your service, you don't improve things for your patients’

Several of the new registrants recognised that, as lifelong learners, there may be a time when they would need to refresh their understanding of service improvement learning theory, for example:

‘If I was doing some service improvement, I would look back at the theories behind it. I would have a good read and re-educate myself’

It was apparent that socialisation and learning in nursing practice was an important feature for participants, both when they were students and as registered nurses. Socialisation is a process that starts during nurse education and continues throughout a nurse's career ( Dinmohammadi et al, 2013 ; Strouse and Nickerson, 2016 ). Socialisation in nursing occurs through social interactions with colleagues in clinical practice and can have both positive and negative consequences concerning the development of nurses ( Gray and Smith, 1999 ; Mackintosh, 2006 ).

Service improvement confidence was not always experienced by student participants who, arguably, had not yet been fully socialised into the nursing community of practice. One student participant felt they did not really belong to the clinical area team within which they were trying to make improvements:

‘As a student, I think it is difficult to fit in, you haven't been properly socialised into the team’

Another expressed the same feelings, describing having to ‘fit in’ as a prerequisite to making changes of any kind:

‘You don't feel you belong. It doesn't matter what you do. You have to just learn to fit in. You're not part of the social scene. I felt not supported [in service improvement activity]’

Several suggested that they tried to join conversations to develop relationships with work colleagues, but were ignored:

‘They did not like the idea of me coming in as an outsider and changing [service improvements]. You don't fit in. You would go to lunch and try and join the conversation, and they would blank you. It wasn't sociable’

At a time when retention of nursing students on their course is a national priority, this perceived lack of support on placement is of concern. However, this perception changed after the nurses became qualified and were employed in their first job. Fitting in and having supportive relationships was perceived as important:

‘As a student you weren't embedded in a culture or in a team quite yet. You were an outsider with outside views which is sometimes good, but when you are working here all the time it is easier to pick up the things that need a little bit of help’

This sense of becoming an ‘insider’ is an indication of the participants' socialisation into the nursing profession post-qualification. Another newly qualified participant also reflected on how different she had felt as a student:

‘When I look back to being a student, I don't think I was ever really part of the team. Compared to now’

As students, and later as registered nurses, the participants discussed an awareness of power in the context of making changes through service improvements. They were aware of power as a dynamic in the clinical environment and that this influenced how they approached and undertook service improvements in practice. Power and powerlessness emerged as an important feature in how they experienced service improvements in nursing.

Nursing occurs in a social environment, where power impacts nurses in context of their working situation ( Gray and Thomas, 2005 ). Power pervades social norms and sustains power-imbalanced relationships ( Potter, 1996 ; Gray and Thomas, 2005 ). In this context, this theme had three related subthemes: personal influence, fear of failure and professional responsibility. Student participants were aware of the power imbalance in the clinical environment and this influenced how they approached their service improvements projects. Some felt powerless because of their student nurse status:

‘There was nothing, nothing [service improvement] I could do as a lowly student nurse’

Another, who had also felt powerless, suggested that common assumptions were that service improvements were implemented ‘top-down’, driven by people more ‘senior’ with more organisational power:

‘I am still in my little white student nurse uniform, not higher up. I have no power. I think a lot of people expect service improvement to come from higher up’

This perception reflects a lack of confidence as a student for engaging in ‘bottom-up’ improvements and change. As registered nurses participants noted a tangible change in their power, status, responsibility and authority in making improvements once they had qualified:

‘It's completely different, looking back. [As a staff nurse] I am aware of it [service improvement] in everything I do. I am aware of small things every day that you can do to improve the service. You can see where the flaws are. We have the power now to say, “maybe we can change this’ ”

Another participant felt empowered in her newly qualified status, and able to suggest changes proactively:

‘Now, when qualified, you do have a say [in service improvement] and it's important that I do speak up … you do have the power to say how things are done’

Another recently qualified participant described the transition phase between student and becoming a registered nurse as being an optimum time to engage in service improvement:

‘Looking back, you are in the best place. You just come in from university with new eyes and want to improve’

This suggests that harnessing service improvement enthusiasm in the important preceptorship period and empowering graduates might be a way of maintaining the sustainability of service improvement learning and practice.

Challenges in changing practice

There were several subthemes associated with challenges to change: mentors and staff as practice-based support, ward manager as change agent, resistance to change and ritual and routine. Positive relationships in clinical practice were key enablers for overcoming challenges in implementing service improvement. For students, perhaps understandably, it was the positive, effective mentors they had encountered who helped them to feel good about their service improvement efforts:

‘It depends who you work with. You can have some mentors who are quite good at facilitating change and asking for ideas, and they have some respect for the student. You are not just another body’

‘My mentor was brilliant, she respected student nurses … She was a role model for me [in service improvement]’

Some of the newly qualified nurse participants reflected on their student experiences. They were able to make comparisons between their experiences then and now, in trying to overcome service improvement challenges. They also identified relationships within teams as factor influencing nurses' ability and opportunity to challenge and improve practice:

‘As a student, you don't have the confidence to implement anything. I guess it's how well you get on in the team, but moving from placement to placement all the time makes it really difficult. As a qualified member of the team you get on well with everyone. You fit in and you wouldn't be afraid to say to someone, “maybe we can do it this way” ’

Having colleagues on the ward with a research role seemed to be something that could enhance the receptivity of staff to new ideas and try them out:

‘I would go and see the other nurses and see what they thought, if there was enough “oomph” behind it. We have a lot of research nurses … They are a great support’

People-focused ward managers were key enablers in empowering qualified participants to make improvements:

‘Definitely our ward manager supports change and values your ideas, and always listens to what you have to say’

‘She [the sister] was really receptive. She was a great help to me’

Strong leadership skills were identified by another as pivotal to embedding a service improvement culture where challenges could be overcome:

‘They [the ward manager] is confident, they are a strong leader. They are supportive, open to staff opinions; not only listening to senior staff member, but to everybody’

Self-determination was identified as a way of overcoming the challenges of implementing service improvement. One student participant said:

‘I just got on with it [service improvement]. I got a bit more confident. Sometimes you can't please everyone, you just have to get on with things’

Several participants, once qualified, discussed how, despite challenges, they would persevere, believing that they had an important role to play in improving care for patients:

‘If you don't look at how you can improve your services, you don't improve things for your patients. There are not going to be any advances, you are not going to use any evidenced-based practice’

One participant suggested that continuous improvement and change were essential to ensure that patients received the best, contemporary, evidence-based nursing care:

‘If you are stuck in your ways and set in a certain pattern, you are not always going to meet everybody's needs, and it could be detrimental to patients’

Summary of findings and further theoretical development

In keeping with hermeneutic phenomenology, the four key themes and related subthemes have been presented supported by literature to inform the analysis of the findings ( Draucker, 1999 ). Through further theoretical analysis of each key theme, there was evidence that a range of contextual, professional and behavioural factors were influencing the lived experience of the participants engaging in service improvement ( Figure 2 ). These factors and the four themes identified were synthesised into three overarching processes experienced by participants: professional transformation, developing resilience and becoming empowered in making service improvements. This helped to develop further understanding of the participants' lived experiences.

service improvement assignment in nursing

This study aimed to better understand the service improvement experiences of participants as student nurses and throughout their first year of post-registration practice. Across the themes identified common behaviours helped participants engage in service improvement, sustaining their knowledge and enthusiasm post-qualification. Participants were revealing behaviours they had developed in response to their learning and experiences of service improvement in nursing. These ‘positive adaptive behaviours’ are consistent with Bandura (2002) , who found that effective problem solvers are motivated to improve their own practice. The adaptive behaviours identified included ( Figure 3 ):

service improvement assignment in nursing

Valuing positive role models

Developing reflective practice, becoming a lifelong learner, growing in self-confidence, playing the game to fit in, adapting to role transition.

  • Seeking ward manager feedback and support.

Several participants (P9, P14, P17, P19, P20) talked about role model mentors and colleagues. They described how their sense of self-efficacy had grown from watching and learning from them as students to seeking to emulate them as qualified nurses. Positive role modelling in nursing usually occurs through a process of mentorship, and helping students to fit in and develop the skills necessary for professional practice (Gignac-Caille and Oermann, 2010; Huybrecht et al, 2011 ; Houghton, 2014 ; Ó Lúanaigh, 2015 ). This study identified that service improvement role models are also important for students and new registrants.

Many participants (P2, P8, P7, P13, P20) reflected on their service improvement experiences. In keeping with other research ( Hatlevik, 2012 ), they perceived that reflection helped bridge the service improvement theory–implementation gap, facilitating development of their identity and knowledge as service improvers. Through reflection, participants developed resilience, as has been reported in other studies ( Jackson et al, 2007 ; Thomas and Revell, 2016 ). Reflection also helped them to identify strategies to overcome service improvement challenges, believing passionately in the positive impact service improvement has on patient care. Bandura (1977) found that learners model their behaviours through being self-reflective and self-reactive.

Two participants (P2, P15) discussed preceptorship and lifelong learning as being integral to the nursing role ( Benner, 1984 ; Nursing and MIdwifery Council, 2018 ). Other studies have shown that professional development that starts in the pre-qualifying period continues throughout a nursing career through lifelong learning ( Davis et al, 2014 ; Coventry et al, 2015 ). In this study, the preceptorship period was crucial for sustaining and further developing service improvement learning. A service improvement mindset was synonymous with a lifelong learning philosophy mindset. Where confidence dipped, participants would return to study the theory underpinning their practice.

Effective ward managers were viewed as those willing to listen and learn from students, as well as qualified staff, where new learning could improve patient care. Effective integration of lifelong service improvement learning into a clinical practice setting culture will also have positive benefits for future students.

Participants (P2, P4, P5, P6, P14, P19) who felt supported in practice developed more self-confidence as service improvers. Conversely, a lack of support from mentors and colleagues impacted negatively on participants' confidence as change agents. Other research has also indicated that student nurses develop self-confidence in practice through positive mentoring experiences, peer support and being successful in practice ( Bahn, 2001 ; Chesser-Smyth and Long, 2013 ). Self-confidence is linked to self-efficacy and reflects an individual's perception of their own ability to perform a goal or task ( Bandura, 1997 ; Potter and Perry, 2001 . Once qualified, participants described growing service improvement self-confidence and self-efficacy through reflective practice and colleague support.

Several participants (P20, P7, P13, P8) described developing what might be called ‘belongingness’ in social psychological terms; through social contact, working on incremental acceptance and becoming an integral component of the group in the clinical practice area ( Baumeister and Leary, 1995 ; Maslow, 2014). Studies suggest that nursing socialisation starts during training, through social interactions in practice placements, and continues throughout a nursing career ( Gray and Smith, 1999 ; Mackintosh, 2006 ; Dinmohammadi et al, 2013 ; Strouse and Nickerson, 2016 ).

As students, participants perceived that their lack of confidence in making service improvements was linked to feelings of not fitting in or lack of belonging, and this was exacerbated by the short length of time spent in any one area. They described the adaptive behaviours they adopted to fit in, such as using previous work and personal stories to start conversations. Some participants perceived that these casual, non-threatening conversations could help them get their service improvement ideas accepted.

Role transition was an important point in participants' service improvement experiences. As students, some of them felt powerless to make service improvements. Research suggests that social norms in nursing sustain power-imbalanced relationships: where this is negative, it can affect practice efficacy ( Potter, 1996 ; Gray and Thomas, 2005 ). Some participants described a feeling akin to ‘transition shock’ ( Duchscher, 2009 ) in the newly qualified period, finding it hard to cope with the competing demands of clinical practice and ongoing learning, including service improvement learning.

This is in keeping with other research suggesting that role transition is complex and challenging ( Maben et al, 2006 ; Feng and Tsai, 2012 ; Hatlevik, 2012 ). In this context, some participants also found it hard to make service improvements during role transition unless it was part of their preceptorship programme expectations ( Chang and Hancock, 2003 ; Schoessler and Waldo, 2006 ; Duchscher, 2008 ; Duchscher, 2009 ; Feng and Tsai, 2012 ; Hatlevik, 2012 ). Nevertheless, through professional transformation, some participants (P1, P2, P4, P16) recognised an increased accountability and responsibility for making service improvements now that they were qualified.

Seeking ward manager feedback and support

Most participants (P2, P4, P5, P12, P9, P16) described ward managers as important in fostering a culture of service improvement and change. The significance of the ward manager in creating ward learning cultures is well documented ( Orton, 1981 ; Fretwell, 1982 ; Ogier, 1986 ; Welsh and Swann, 2002 ; McGowan, 2006 ; Carlin and Duffy, 2013 ). Whether student participants felt empowered to make service improvements depended mainly on ward manager leadership. This leadership was also identified as important by the new registrants. Active engagement from those in senior positions is critical to successful service improvement ( Gollop et al, 2004 ). Nurses can experience high levels of empowerment when ward managers nurture perceptions of autonomy and confidence ( Madden, 2007 ). This study confirms that ward manager leadership is integral to nurse-led service improvement models ( Shafer and Aziz, 2013 ).

A proposed model of self-efficacy in service improvement enablement

The seven positive adaptive behaviours identified ( Figure 3 ) underpinned a process of participant professional transformation towards self-efficacy ( Bandura, 1997 ). With increasing resilience, they felt more empowered to make service improvements as they transitioned from student to registered nurse. The ‘model of self-efficacy in service improvement enablement’ brings together these positive adaptive behaviours as a way of understanding how participants' education and practice were interrelated to influence their service improvement learning and practice.

Although the model is presented as a linear process, the rate of service improvement engagement and development differed between participants, and was influenced by the context of their learning and practice. However, by the time they had made the transition from student to registered nurse they had all achieved a degree of empowerment, resilience and transformation, enabling them to move forward with service improvements in their own work context. This model offers an explanation for other research, which found that nurse-led service improvement requires knowledge and skills that must be continually practised and refined in order to be successful ( Wilcock and Carr, 2001 ; Christiansen et al, 2010 ).

Nursing undergraduate and preceptorship programmes should focus on developing these positive adaptive behaviours towards sustainable service improvement knowledge and skills. Policymakers at local level need to ensure that students and new registrants are supported by ward managers in their implementation of service improvement projects in order to develop their service improvement self-efficacy. Further research with other professional groups and in different healthcare contexts is needed to refine and test the model.

Limitations

This study took place in one university and NHS foundation trust; it is therefore context specific. Participants were in adult nursing only, which reduces transferability of the findings.

This study explored service improvement experiences of adult nurses as students and as qualified practitioners. It showed that they used positive adaptive behaviours to navigate their service improvement learning and practice contexts. The process of becoming service improvement practitioners has been explained through the ‘model of self-efficacy in service improvement enablement’. This provides a framework for understanding how nurses undergo concurrent processes of professional transformation, empowerment and resilience building, through service improvement experiences.

Ward management leadership approaches, supportive colleagues and an opportunity to practise service improvement skills pre-qualifying and in the preceptorship period were identified as essential to develop and sustain service improvement capability. This was important for participants as students but also as qualified nurses, at which time they believed that service improvement practice could be sustained through reflection and lifelong learning.

For all participants the central motivation to push past challenges encountered was a commitment to improving care for the patients they were caring for. This study's findings can inform the practice of nurse educators, practitioners, policy makers and healthcare delivery organisations, thereby potentially making a contribution to global efforts to embed a service improvement culture for the ongoing benefit of all.

  • Looking for ways to continually improve the experience of those they care for is a professional responsibility of all nurses in all settings
  • Service improvement learning in pre-registration programmes enables the development of nurses' ability to facilitate positive changes in practice
  • The positive adaptive behaviours developed through service improvement learning can be sustained through lifelong learning, reflective practice and a supportive work environment, where a commitment to high-quality patient care delivery is prioritised

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Quality improvement into practice

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  • Peer review
  • Adam Backhouse , quality improvement programme lead 1 ,
  • Fatai Ogunlayi , public health specialty registrar 2
  • 1 North London Partners in Health and Care, Islington CCG, London N1 1TH, UK
  • 2 Institute of Applied Health Research, Public Health, University of Birmingham, B15 2TT, UK
  • Correspondence to: A Backhouse adam.backhouse{at}nhs.net

What you need to know

Thinking of quality improvement (QI) as a principle-based approach to change provides greater clarity about ( a ) the contribution QI offers to staff and patients, ( b ) how to differentiate it from other approaches, ( c ) the benefits of using QI together with other change approaches

QI is not a silver bullet for all changes required in healthcare: it has great potential to be used together with other change approaches, either concurrently (using audit to inform iterative tests of change) or consecutively (using QI to adapt published research to local context)

As QI becomes established, opportunities for these collaborations will grow, to the benefit of patients.

The benefits to front line clinicians of participating in quality improvement (QI) activity are promoted in many health systems. QI can represent a valuable opportunity for individuals to be involved in leading and delivering change, from improving individual patient care to transforming services across complex health and care systems. 1

However, it is not clear that this promotion of QI has created greater understanding of QI or widespread adoption. QI largely remains an activity undertaken by experts and early adopters, often in isolation from their peers. 2 There is a danger of a widening gap between this group and the majority of healthcare professionals.

This article will make it easier for those new to QI to understand what it is, where it fits with other approaches to improving care (such as audit or research), when best to use a QI approach, making it easier to understand the relevance and usefulness of QI in delivering better outcomes for patients.

How this article was made

AB and FO are both specialist quality improvement practitioners and have developed their expertise working in QI roles for a variety of UK healthcare organisations. The analysis presented here arose from AB and FO’s observations of the challenges faced when introducing QI, with healthcare providers often unable to distinguish between QI and other change approaches, making it difficult to understand what QI can do for them.

How is quality improvement defined?

There are many definitions of QI ( box 1 ). The BMJ ’s Quality Improvement series uses the Academy of Medical Royal Colleges definition. 6 Rather than viewing QI as a single method or set of tools, it can be more helpful to think of QI as based on a set of principles common to many of these definitions: a systematic continuous approach that aims to solve problems in healthcare, improve service provision, and ultimately provide better outcomes for patients.

Definitions of quality improvement

Improvement in patient outcomes, system performance, and professional development that results from a combined, multidisciplinary approach in how change is delivered. 3

The delivery of healthcare with improved outcomes and lower cost through continuous redesigning of work processes and systems. 4

Using a systematic change method and strategies to improve patient experience and outcome. 5

To make a difference to patients by improving safety, effectiveness, and experience of care by using understanding of our complex healthcare environment, applying a systematic approach, and designing, testing, and implementing changes using real time measurement for improvement. 6

In this article we discuss QI as an approach to improving healthcare that follows the principles outlined in box 2 ; this may be a useful reference to consider how particular methods or tools could be used as part of a QI approach.

Principles of QI

Primary intent— To bring about measurable improvement to a specific aspect of healthcare delivery, often with evidence or theory of what might work but requiring local iterative testing to find the best solution. 7

Employing an iterative process of testing change ideas— Adopting a theory of change which emphasises a continuous process of planning and testing changes, studying and learning from comparing the results to a predicted outcome, and adapting hypotheses in response to results of previous tests. 8 9

Consistent use of an agreed methodology— Many different QI methodologies are available; commonly cited methodologies include the Model for Improvement, Lean, Six Sigma, and Experience-based Co-design. 4 Systematic review shows that the choice of tools or methodologies has little impact on the success of QI provided that the chosen methodology is followed consistently. 10 Though there is no formal agreement on what constitutes a QI tool, it would include activities such as process mapping that can be used within a range of QI methodological approaches. NHS Scotland’s Quality Improvement Hub has a glossary of commonly used tools in QI. 11

Empowerment of front line staff and service users— QI work should engage staff and patients by providing them with the opportunity and skills to contribute to improvement work. Recognition of this need often manifests in drives from senior leadership or management to build QI capability in healthcare organisations, but it also requires that frontline staff and service users feel able to make use of these skills and take ownership of improvement work. 12

Using data to drive improvement— To drive decision making by measuring the impact of tests of change over time and understanding variation in processes and outcomes. Measurement for improvement typically prioritises this narrative approach over concerns around exactness and completeness of data. 13 14

Scale-up and spread, with adaptation to context— As interventions tested using a QI approach are scaled up and the degree of belief in their efficacy increases, it is desirable that they spread outward and be adopted by others. Key to successful diffusion of improvement is the adaption of interventions to new environments, patient and staff groups, available resources, and even personal preferences of healthcare providers in surrounding areas, again using an iterative testing approach. 15 16

What other approaches to improving healthcare are there?

Taking considered action to change healthcare for the better is not new, but QI as a distinct approach to improving healthcare is a relatively recent development. There are many well established approaches to evaluating and making changes to healthcare services in use, and QI will only be adopted more widely if it offers a new perspective or an advantage over other approaches in certain situations.

A non-systematic literature scan identified the following other approaches for making change in healthcare: research, clinical audit, service evaluation, and clinical transformation. We also identified innovation as an important catalyst for change, but we did not consider it an approach to evaluating and changing healthcare services so much as a catch-all term for describing the development and introduction of new ideas into the system. A summary of the different approaches and their definition is shown in box 3 . Many have elements in common with QI, but there are important difference in both intent and application. To be useful to clinicians and managers, QI must find a role within healthcare that complements research, audit, service evaluation, and clinical transformation while retaining the core principles that differentiate it from these approaches.

Alternatives to QI

Research— The attempt to derive generalisable new knowledge by addressing clearly defined questions with systematic and rigorous methods. 17

Clinical audit— A way to find out if healthcare is being provided in line with standards and to let care providers and patients know where their service is doing well, and where there could be improvements. 18

Service evaluation— A process of investigating the effectiveness or efficiency of a service with the purpose of generating information for local decision making about the service. 19

Clinical transformation— An umbrella term for more radical approaches to change; a deliberate, planned process to make dramatic and irreversible changes to how care is delivered. 20

Innovation— To develop and deliver new or improved health policies, systems, products and technologies, and services and delivery methods that improve people’s health. Health innovation responds to unmet needs by employing new ways of thinking and working. 21

Why do we need to make this distinction for QI to succeed?

Improvement in healthcare is 20% technical and 80% human. 22 Essential to that 80% is clear communication, clarity of approach, and a common language. Without this shared understanding of QI as a distinct approach to change, QI work risks straying from the core principles outlined above, making it less likely to succeed. If practitioners cannot communicate clearly with their colleagues about the key principles and differences of a QI approach, there will be mismatched expectations about what QI is and how it is used, lowering the chance that QI work will be effective in improving outcomes for patients. 23

There is also a risk that the language of QI is adopted to describe change efforts regardless of their fidelity to a QI approach, either due to a lack of understanding of QI or a lack of intention to carry it out consistently. 9 Poor fidelity to the core principles of QI reduces its effectiveness and makes its desired outcome less likely, leading to wasted effort by participants and decreasing its credibility. 2 8 24 This in turn further widens the gap between advocates of QI and those inclined to scepticism, and may lead to missed opportunities to use QI more widely, consequently leading to variation in the quality of patient care.

Without articulating the differences between QI and other approaches, there is a risk of not being able to identify where a QI approach can best add value. Conversely, we might be tempted to see QI as a “silver bullet” for every healthcare challenge when a different approach may be more effective. In reality it is not clear that QI will be fit for purpose in tackling all of the wicked problems of healthcare delivery and we must be able to identify the right tool for the job in each situation. 25 Finally, while different approaches will be better suited to different types of challenge, not having a clear understanding of how approaches differ and complement each other may mean missed opportunities for multi-pronged approaches to improving care.

What is the relationship between QI and other approaches such as audit?

Academic journals, healthcare providers, and “arms-length bodies” have made various attempts to distinguish between the different approaches to improving healthcare. 19 26 27 28 However, most comparisons do not include QI or compare QI to only one or two of the other approaches. 7 29 30 31 To make it easier for people to use QI approaches effectively and appropriately, we summarise the similarities, differences, and crossover between QI and other approaches to tackling healthcare challenges ( fig 1 ).

Fig 1

How quality improvement interacts with other approaches to improving healthcare

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QI and research

Research aims to generate new generalisable knowledge, while QI typically involves a combination of generating new knowledge or implementing existing knowledge within a specific setting. 32 Unlike research, including pragmatic research designed to test effectiveness of interventions in real life, QI does not aim to provide generalisable knowledge. In common with QI, research requires a consistent methodology. This method is typically used, however, to prove or disprove a fixed hypothesis rather than the adaptive hypotheses developed through the iterative testing of ideas typical of QI. Both research and QI are interested in the environment where work is conducted, though with different intentions: research aims to eliminate or at least reduce the impact of many variables to create generalisable knowledge, whereas QI seeks to understand what works best in a given context. The rigour of data collection and analysis required for research is much higher; in QI a criterion of “good enough” is often applied.

Relationship with QI

Though the goal of clinical research is to develop new knowledge that will lead to changes in practice, much has been written on the lag time between publication of research evidence and system-wide adoption, leading to delays in patients benefitting from new treatments or interventions. 33 QI offers a way to iteratively test the conditions required to adapt published research findings to the local context of individual healthcare providers, generating new knowledge in the process. Areas with little existing knowledge requiring further research may be identified during improvement activities, which in turn can form research questions for further study. QI and research also intersect in the field of improvement science, the academic study of QI methods which seeks to ensure QI is carried out as effectively as possible. 34

Scenario: QI for translational research

Newly published research shows that a particular physiotherapy intervention is more clinically effective when delivered in short, twice-daily bursts rather than longer, less frequent sessions. A team of hospital physiotherapists wish to implement the change but are unclear how they will manage the shift in workload and how they should introduce this potentially disruptive change to staff and to patients.

Before continuing reading think about your own practice— How would you approach this situation, and how would you use the QI principles described in this article?

Adopting a QI approach, the team realise that, although the change they want to make is already determined, the way in which it is introduced and adapted to their wards is for them to decide. They take time to explain the benefits of the change to colleagues and their current patients, and ask patients how they would best like to receive their extra physiotherapy sessions.

The change is planned and tested for two weeks with one physiotherapist working with a small number of patients. Data are collected each day, including reasons why sessions were missed or refused. The team review the data each day and make iterative changes to the physiotherapist’s schedule, and to the times of day the sessions are offered to patients. Once an improvement is seen, this new way of working is scaled up to all of the patients on the ward.

The findings of the work are fed into a service evaluation of physiotherapy provision across the hospital, which uses the findings of the QI work to make recommendations about how physiotherapy provision should be structured in the future. People feel more positive about the change because they know colleagues who have already made it work in practice.

QI and clinical audit

Clinical audit is closely related to QI: it is often used with the intention of iteratively improving the standard of healthcare, albeit in relation to a pre-determined standard of best practice. 35 When used iteratively, interspersed with improvement action, the clinical audit cycle adheres to many of the principles of QI. However, in practice clinical audit is often used by healthcare organisations as an assurance function, making it less likely to be carried out with a focus on empowering staff and service users to make changes to practice. 36 Furthermore, academic reviews of audit programmes have shown audit to be an ineffective approach to improving quality due to a focus on data collection and analysis without a well developed approach to the action section of the audit cycle. 37 Clinical audits, such as the National Clinical Audit Programme in the UK (NCAPOP), often focus on the management of specific clinical conditions. QI can focus on any part of service delivery and can take a more cross-cutting view which may identify issues and solutions that benefit multiple patient groups and pathways. 30

Audit is often the first step in a QI process and is used to identify improvement opportunities, particularly where compliance with known standards for high quality patient care needs to be improved. Audit can be used to establish a baseline and to analyse the impact of tests of change against the baseline. Also, once an improvement project is under way, audit may form part of rapid cycle evaluation, during the iterative testing phase, to understand the impact of the idea being tested. Regular clinical audit may be a useful assurance tool to help track whether improvements have been sustained over time.

Scenario: Audit and QI

A foundation year 2 (FY2) doctor is asked to complete an audit of a pre-surgical pathway by looking retrospectively through patient documentation. She concludes that adherence to best practice is mixed and recommends: “Remind the team of the importance of being thorough in this respect and re-audit in 6 months.” The results are presented at an audit meeting, but a re-audit a year later by a new FY2 doctor shows similar results.

Before continuing reading think about your own practice— How would you approach this situation, and how would you use the QI principles described in this paper?

Contrast the above with a team-led, rapid cycle audit in which everyone contributes to collecting and reviewing data from the previous week, discussed at a regular team meeting. Though surgical patients are often transient, their experience of care and ideas for improvement are captured during discharge conversations. The team identify and test several iterative changes to care processes. They document and test these changes between audits, leading to sustainable change. Some of the surgeons involved work across multiple hospitals, and spread some of the improvements, with the audit tool, as they go.

QI and service evaluation

In practice, service evaluation is not subject to the same rigorous definition or governance as research or clinical audit, meaning that there are inconsistencies in the methodology for carrying it out. While the primary intent for QI is to make change that will drive improvement, the primary intent for evaluation is to assess the performance of current patient care. 38 Service evaluation may be carried out proactively to assess a service against its stated aims or to review the quality of patient care, or may be commissioned in response to serious patient harm or red flags about service performance. The purpose of service evaluation is to help local decision makers determine whether a service is fit for purpose and, if necessary, identify areas for improvement.

Service evaluation may be used to initiate QI activity by identifying opportunities for change that would benefit from a QI approach. It may also evaluate the impact of changes made using QI, either during the work or after completion to assess sustainability of improvements made. Though likely planned as separate activities, service evaluation and QI may overlap and inform each other as they both develop. Service evaluation may also make a judgment about a service’s readiness for change and identify any barriers to, or prerequisites for, carrying out QI.

QI and clinical transformation

Clinical transformation involves radical, dramatic, and irreversible change—the sort of change that cannot be achieved through continuous improvement alone. As with service evaluation, there is no consensus on what clinical transformation entails, and it may be best thought of as an umbrella term for the large scale reform or redesign of clinical services and the non-clinical services that support them. 20 39 While it is possible to carry out transformation activity that uses elements of QI approach, such as effective engagement of the staff and patients involved, QI which rests on iterative test of change cannot have a transformational approach—that is, one-off, irreversible change.

There is opportunity to use QI to identify and test ideas before full scale clinical transformation is implemented. This has the benefit of engaging staff and patients in the clinical transformation process and increasing the degree of belief that clinical transformation will be effective or beneficial. Transformation activity, once completed, could be followed up with QI activity to drive continuous improvement of the new process or allow adaption of new ways of working. As interventions made using QI are scaled up and spread, the line between QI and transformation may seem to blur. The shift from QI to transformation occurs when the intention of the work shifts away from continuous testing and adaptation into the wholesale implementation of an agreed solution.

Scenario: QI and clinical transformation

An NHS trust’s human resources (HR) team is struggling to manage its junior doctor placements, rotas, and on-call duties, which is causing tension and has led to concern about medical cover and patient safety out of hours. A neighbouring trust has launched a smartphone app that supports clinicians and HR colleagues to manage these processes with the great success.

This problem feels ripe for a transformation approach—to launch the app across the trust, confident that it will solve the trust’s problems.

Before continuing reading think about your own organisation— What do you think will happen, and how would you use the QI principles described in this article for this situation?

Outcome without QI

Unfortunately, the HR team haven’t taken the time to understand the underlying problems with their current system, which revolve around poor communication and clarity from the HR team, based on not knowing who to contact and being unable to answer questions. HR assume that because the app has been a success elsewhere, it will work here as well.

People get excited about the new app and the benefits it will bring, but no consideration is given to the processes and relationships that need to be in place to make it work. The app is launched with a high profile campaign and adoption is high, but the same issues continue. The HR team are confused as to why things didn’t work.

Outcome with QI

Although the app has worked elsewhere, rolling it out without adapting it to local context is a risk – one which application of QI principles can mitigate.

HR pilot the app in a volunteer specialty after spending time speaking to clinicians to better understand their needs. They carry out several tests of change, ironing out issues with the process as they go, using issues logged and clinician feedback as a source of data. When they are confident the app works for them, they expand out to a directorate, a division, and finally the transformational step of an organisation-wide rollout can be taken.

Education into practice

Next time when faced with what looks like a quality improvement (QI) opportunity, consider asking:

How do you know that QI is the best approach to this situation? What else might be appropriate?

Have you considered how to ensure you implement QI according to the principles described above?

Is there opportunity to use other approaches in tandem with QI for a more effective result?

How patients were involved in the creation of this article

This article was conceived and developed in response to conversations with clinicians and patients working together on co-produced quality improvement and research projects in a large UK hospital. The first iteration of the article was reviewed by an expert patient, and, in response to their feedback, we have sought to make clearer the link between understanding the issues raised and better patient care.

Contributors: This work was initially conceived by AB. AB and FO were responsible for the research and drafting of the article. AB is the guarantor of the article.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: This article is part of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ , including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ ’s quality improvement editor post are funded by the Health Foundation.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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Using service improvement methodology to change practice, william gage lead nurse for practice development and innovation, imperial college healthcare nhs trust, london..

This article discusses the role of service improvement methodology in changing the quality of care delivered. It outlines the six-stage framework for quality improvement recommended by the NHS Institute for Innovation and Improvement. The reader is encouraged to complete a series of activities to plan and deliver a service improvement project. Potential challenges to the successful delivery of a service improvement project are also considered. The article concludes with an example of the use of the six-stage framework to improve the quality of urinary catheter care in one acute NHS trust.

Nursing Standard . 27, 23, 51-57. doi: 10.7748/ns2013.02.27.23.51.e7241R1

This article has been subject to double blind peer review

Received: 03 October 2012

Accepted: 16 November 2012

management - leadership - quality - change management - quality improvement - service improvement

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service improvement assignment in nursing

06 February 2013 / Vol 27 issue 23

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In this section

Service improvement: an introduction, service improvement: discover and understand, service improvement: generate and develop ideas, service improvement: implementation.

Service improvement and transformation is best approached in a structured way.

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This includes understanding the challenge, analysis, creativity and prototyping (testing to learn) techniques that that allow teams to develop innovative solutions. It’s an approach that uses your understanding of the needs of your patients, the wider population and your organisational and service requirements, to deliver the best care.

Firstly, you must understand what improvement is and what transformation is. Improvement is about making things (eg processes, systems, ways of working, behaviour, location) better. Transformation is about changing their form, appearance, or structure.

Three phases of service improvement

The patient experience is always central to this approach. There are three phases in the approach and three themes/activities that you need to consider.

The three phases are:

  • Discover and understand
  • Generate and develop ideas
  • Implementation

Within each phase there are three things to consider:

  • Stakeholder management : if you know who your stakeholders are then you will be able to identify and raise potential issues and challenges more easily. Remember that patients, carers and staff are key stakeholders in any change and improvement work.
  • Measurement and evaluation : monitoring your project ensures you know the difference you have made or are making.
  • Sustainability : will you be able to maintain the improvements you are making?

You can apply this approach across a range of projects. These might be small improvements or larger organisational or system transformations. The framework will help you to develop innovative solutions to the challenges faced in delivering health and care.

There are a range of different tools and models to use for improving and transforming services. It’s always a good idea to check if your organisation has a particular model or approach. The local approach should include all the elements described within this framework.

  • Push yourself out of your comfort zone: think differently and be creative
  • Test out new ideas early: fail often and learn to develop innovative solutions
  • If you are unsure about what to do, remember that someone will have been there before, so talk to them
  • Take responsibility for what you achieve
  • Have fun: being creative and innovative should be enjoyable!

Further information

  • NHS Institute for Innovation and Improvement Service Improvement handbook : 75 tools and technique for service improvement which have been used in health and care.
  • NHS Institute for Innovation and Improvement Improvement Leaders Guides : 15 guides covering the themes of General Improvement Skills, Process and Systems Thinking and Personal and Organisational Development. They provide practical advice on service improvement in health and care.
  • The Health Foundation Quality improvement made simple : an overview of approaches to health care quality improvement.
  • NHS England Leading Large Scale Change : a guide to help all those seeking and leading transformational change in complex health and social care environments.

Find Out More

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Service improvement and transformation

Service improvement and transformation include empowering staff to take on a wider range of clinical tasks. Here the matron should:

  • gain support from the senior management team for staff to take on a wider range of clinical tasks
  • allocate protected management time to Band 7 leaders and hold regular one-to-one meetings with them
  • carry out talent mapping and training needs analysis (TNA) relevant to the personalised and department development plan, checking that all staff are ready and committed to life-long learning
  • provide development opportunities to all, ensuring all staff are given equitable access to development that meets their specific needs and requirements
  • ensure the TNA and education programme cover the development of nurse consultants, advanced nurse practitioners, emergency nurse practitioners, midwives, all levels of clinical nurse specialists, Band 7 leaders who empower the Band 5 and 6 staff to support and develop the Band 2 to 4 staff
  • encourage continuous quality improvement and be a change agent
  • share learning and knowledge with other organisations
  • motivate others to give the highest quality care
  • engage with primary care partners and community services.

Quality improvement

Quality improvement (QI) is ‘a systematic approach to improving service quality, efficiency and morale – not just a mechanism to solve problems in failing parts of the organisation. It is a way of expanding improvement beyond organisational or functional boundaries, so that impact is possible across the wider health and social care system’.45 Various QI programmes and accreditation schemes are available; trusts should choose the most appropriate for their circumstances. QI programmes are a means of achieving clinical effectiveness and encouraging collaboration in clinical areas.

What are the benefits of QI?

The literature about nurse involvement in QI highlights benefits to patients and to staff. Patient harm is reduced, operational performance improves, and financial savings can be made. Staff satisfaction increases, and staff sickness absence reduces. Trusts taking part in NHS Improvement collaboratives have benefited in many ways: the table below contains links to examples.

Matrons have a pivotal role in QI as they are the link between the executive nurse and frontline staff. They can help in measuring current practice against best practice and monitoring improvement. They can encourage staff to suggest ideas for improving services, allocate resources to improvement projects and support staff to test change on a small scale before rolling it out. This may include administrative support and providing an objective view of everyday practice.

Matron’s Handbook – next sections

  • Appendix: The matron’s developmental framework and competencies
  • Acknowledgements

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    "It was an amazing day of sharing ideas and discussion," said Coral Drane, Lecturer in Adult Nursing at UEA. "We are so proud of our final year student nurses, both in terms of the quality of their service improvement posters and their professionalism." The event was attended by NNUH staff, who were also impressed by what they saw.

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  11. Using service improvement methodology to change practice

    This article discusses the role of service improvement methodology in changing the quality of care delivered. It outlines the six-stage framework for quality improvement recommended by the NHS Institute for Innovation and Improvement. The reader is encouraged to complete a series of activities to plan and deliver a service improvement project.

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  13. Service improvement: an introduction

    Service improvement and transformation is best approached in a structured way. This includes understanding the challenge, analysis, creativity and prototyping (testing to learn) techniques that that allow teams to develop innovative solutions. It's an approach that uses your understanding of the needs of your patients, the wider population ...

  14. Influencing Practice For Service Improvement In Primary Care Nursing Essay

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