How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review.

BACKGROUND: Quality improvement collaboratives are widely used to improve health care in both high-income and low and middle-income settings. Teams from multiple health facilities share learning on a given topic and apply a structured cycle of change testing. Previous systematic reviews reported positive effects on target outcomes, but the role of context and mechanism of change is underexplored. This realist-inspired systematic review aims to analyse contextual factors influencing intended outcomes and to identify how quality improvement collaboratives may result in improved adherence to evidence-based practices. METHODS: We built an initial conceptual framework to drive our enquiry, focusing on three context domains: health facility setting; project-specific factors; wider organisational and external factors; and two further domains pertaining to mechanisms: intra-organisational and inter-organisational changes. We systematically searched five databases and grey literature for publications relating to quality improvement collaboratives in a healthcare setting and containing data on context or mechanisms. We analysed and reported findings thematically and refined the programme theory. RESULTS: We screened 962 abstracts of which 88 met the inclusion criteria, and we retained 32 for analysis. Adequacy and appropriateness of external support, functionality of quality improvement teams, leadership characteristics and alignment with national systems and priorities may influence outcomes of quality improvement collaboratives, but the strength and quality of the evidence is weak. Participation in quality improvement collaborative activities may improve health professionals' knowledge, problem-solving skills and attitude; teamwork; shared leadership and habits for improvement. Interaction across quality improvement teams may generate normative pressure and opportunities for capacity building and peer recognition. CONCLUSION: Our review offers a novel programme theory to unpack the complexity of quality improvement collaboratives by exploring the relationship between context, mechanisms and outcomes. There remains a need for greater use of behaviour change and organisational psychology theory to improve design, adaptation and evaluation of the collaborative quality improvement approach and to test its effectiveness. Further research is needed to determine whether certain contextual factors related to capacity should be a precondition to the quality improvement collaborative approach and to test the emerging programme theory using rigorous research designs

Bioactive Materials: A Short Review

In every field of dentistry and medicine, bioactive materials have been widely used. These materials are used for regeneration, repair, and reconstruction in the field of conservative dentistry and endodontics. These materials are used in different forms and composition and act directly on vital tissue, helping in its healing and repair. These materials directly function because of induction of various growth factors and different cells. This article summarizes the types and uses of bioactive materials

Dental Smart Materials

Dental materials are stable and have greater durability if they do not react with the environment and remain passive. At the same time, it is hoped that the materials will be well accepted and will cause neither harm nor injury. This is an entirely negative approach to material tolerance and biocompatibility. This outlook hides the possibility through which positive gains can be achieved by using materials that behave in a more dynamic fashion in the environment in which they are placed. The current dental materials are improvised. The use of smart materials has made a great revolution in dentistry, which includes the use of restorative materials, such as smart composites, smart ceramics, compomers, resin-modified glass ionomer, amorphous calcium phosphate–releasing pit, and fissure sealants and other materials, such as orthodontic shape memory alloys, smart burs, etc.&nbsp

Esthetic Design

An attractive face is of utmost priority to people. Attractiveness is based on symmetry and various proportions of the face. This helps us to design the smile beautifully and add a lot to facial esthetics. It is a multidisciplinary approach that includes orthodontics, cosmetic dentistry, and plastic surgery. It is veryimportant to carefully analyze and plan the treatment according to the patient’s demand, which will lead us to a beautiful smile

Hand hygiene in hospitals: an observational study in hospitals from two southern states of India.

BACKGROUND: Hand hygiene is a simple and low-cost measure to reduce healthcare associated infection yet it has always been a concern in low as well as high resource settings across the globe. Poor hand hygiene during intra-partum and newborn care may result in sepsis, which is a major cause of death among newborns and puts a financial burden on already strained health systems. METHODS: We conducted non-participatory observations in newborn care units and labour rooms from secondary and tertiary level, public and private hospitals, as part of a baseline evaluation of a quality improvement collaborative across two southern states of India. We assessed hand hygiene compliance during examinations and common procedures, using tools adapted from internationally recommended checklists and World Health Organization's concept of five moments of hand hygiene. We assessed differences in compliance by type (public/private), level (secondary/tertiary) and case load (low/intermediate/high). Analysis was adjusted for clustering and weighted as appropriate. RESULTS: We included 49 newborn care units (19 private, 30 public) and 35 labour rooms (5 private, 30 public) that granted permission. We observed 3661 contacts with newborns and their environment, 242 per-vaginal examinations and 235 deliveries. For the newborns, a greater proportion of contacts in private newborn units than public complied with all steps of hand hygiene (44% vs 12%, p < 0.001), and similarly in tertiary than secondary units (33% vs 12%, p < 0.001) but there was no evidence of a difference by case load of the facility (low load-28%; intermediate load-14%; high load- 24%, p = 0.246). The component with lowest compliance was glove usage where indicated (20%). For deliveries, hand hygiene compliance before delivery was universal in private facilities but seen in only about one-quarter of observations in public facilities (100% vs 27%, p = 0.012). Average overall compliance for hand-hygiene during per-vaginal examinations was 35% and we found no evidence of differences by type of facility. CONCLUSION: Observed compliance with hand hygiene was low overall, although better in private than public facilities in both newborn units and labour rooms. Glove usage was a particular problem in newborn care units. TRIAL REGISTRATION: Retrospectively registered with Clinical Trials Registry- India ( CTRI/2018/04/013014 )

Effect of collaborative quality improvement on stillbirths, neonatal mortality and newborn care practices in hospitals of Telangana and Andhra Pradesh, India: evidence from a quasi-experimental mixed-methods study.

BACKGROUND: Improving quality of care is a key priority to reduce neonatal mortality and stillbirths. The Safe Care, Saving Lives programme aimed to improve care in newborn care units and labour wards of 60 public and private hospitals in Telangana and Andhra Pradesh, India, using a collaborative quality improvement approach. Our external evaluation of this programme aimed to evaluate programme effects on implementation of maternal and newborn care practices, and impact on stillbirths, 7- and 28-day neonatal mortality rate in labour wards and neonatal care units. We also aimed to evaluate programme implementation and mechanisms of change. METHODS: We used a quasi-experimental plausibility design with a nested process evaluation. We evaluated effects on stillbirths, mortality and secondary outcomes relating to adherence to 20 evidence-based intrapartum and newborn care practices, comparing survey data from 29 hospitals receiving the intervention to 31 hospitals expected to receive the intervention later, using a difference-in-difference analysis. We analysed programme implementation data and conducted 42 semi-structured interviews in four case studies to describe implementation and address four theory-driven questions to explain the quantitative results. RESULTS: Only 7 of the 29 intervention hospitals were engaged in the intervention for its entire duration. There was no evidence of an effect of the intervention on stillbirths [DiD - 1.3 percentage points, 95% CI - 2.6-0.1], on neonatal mortality at age 7 days [DiD - 1.6, 95% CI - 9-6.2] or 28 days [DiD - 3.0, 95% CI - 12.9-6.9] or on adherence to target evidence-based intrapartum and newborn care practices. The process evaluation identified challenges in engaging leaders; challenges in developing capacity for quality improvement; and challenges in activating mechanisms of change at the unit level, rather than for a few individuals, and in sustaining these through the creation of new social norms. CONCLUSION: Despite careful planning and substantial resources, the intervention was not feasible for implementation on a large scale. Greater focus is required on strategies to engage leadership. Quality improvement may need to be accompanied by clinical training. Further research is also needed on quality improvement using a health systems perspective

Care practices and neonatal survival in 52 neonatal intensive care units in Telangana and Andhra Pradesh, India: A cross-sectional study.

BACKGROUND: The Indian government supports both public- and private-sector provision of hospital care for neonates: neonatal intensive care is offered in public facilities alongside a rising number of private-for-profit providers. However, there are few published reports about mortality levels and care practices in these facilities. We aimed to assess care practices, causes of admission, and outcomes from neonatal intensive care units (NICUs) in public secondary and private tertiary hospitals and both public and private medical colleges enrolled in a quality improvement collaborative in Telangana and Andhra Pradesh-2 Indian states with a respective population of 35 and 50 million. METHODS AND FINDINGS: We conducted a cross-sectional study between 30 May and 26 August 2016 as part of a baseline evaluation in 52 consenting hospitals (26 public secondary hospitals, 5 public medical colleges, 15 private tertiary hospitals, and 6 private medical colleges) offering neonatal intensive care. We assessed the availability of staff and services, adherence to evidence-based practices at admission, and case fatality after admission to the NICU using a range of tools, including facility assessment, observations of admission, and abstraction of registers and telephone interviews after discharge. Our analysis is adjusted for clustering and weighted for caseload at the hospital level and presents findings stratified by type and ownership of hospitals. In total, the NICUs included just over 3,000 admissions per month. Staffing and infrastructure provision were largely according to government guidelines, except that only a mean of 1 but not the recommended 4 paediatricians were working in public secondary NICUs per 10 beds. On admission, all neonates admitted to private hospitals had auscultation (100%, 19 of 19 observations) but only 42% (95% confidence interval [CI] 25%-62%, p-value for difference is 0.361) in public secondary hospitals. The most common single cause of admission was preterm birth (25%) followed by jaundice (23%). Case-fatality rates at age 28 days after admission to a NICU were 4% (95% CI 2%-8%), 15% (9%-24%), 4% (2%-8%) and 2% (1%-5%) (Chi-squared p = 0.001) in public secondary hospitals, public medical colleges, private tertiary hospitals, and private medical colleges, respectively, according to facility registers. Case fatality according to postdischarge telephone interviews found rates of 12% (95% CI 7%-18%) for public secondary hospitals. Roughly 6% of admitted neonates were referred to another facility. Outcome data were missing for 27% and 8% of admissions to private tertiary hospitals and private medical colleges. Our study faced the limitation of missing data due to incomplete documentation. Further generalizability was limited due to the small sample size among private facilities. CONCLUSIONS: Our findings suggest differences in quality of neonatal intensive care and 28-day survival between the different types of hospitals, although comparison of outcomes is complicated by differences in the case mix and referral practices between hospitals. Uniform reporting of outcomes and risk factors across the private and public sectors is required to assess the benefits for the population of mixed-care provision

Evaluation of the Safe Care, Saving Lives (SCSL) quality improvement collaborative for neonatal health in Telangana and Andhra Pradesh, India: a study protocol.

BACKGROUND: The collaborative quality improvement approach proposed by the Institute for Healthcare Improvement has the potential to improve coverage of evidence-based maternal and newborn health practices. The Safe Care, Saving Lives initiative supported the implementation of 20 evidence-based maternal and newborn care practices, targeting labour wards and neonatal care units in 85 public and private hospitals in Telangana and Andhra Pradesh, India. OBJECTIVE: We present a protocol for the evaluation of this programme which aims to (a) estimate the effect of the initiative on evidence-based care practices and mortality; (b) evaluate the mechanisms leading to changes in adherence to evidence-based practices, and their relationship with contextual factors; (c) explore the feasibility of scaling-up the approach. METHODS: The mixed-method evaluation is based on a plausibility design nested within a phased implementation. The 29 non-randomly selected hospitals comprising wave II of the programme were compared to the 31 remaining hospitals where the quality improvement approach started later. We assessed mortality and adherence to evidence-based practices at baseline and endline using abstraction of registers, checklists, observations and interviews in intervention and comparison hospitals. We also explored the mechanisms and drivers of change in adherence to evidence-based practices. Qualitative methods investigated the mechanisms of change in purposefully selected case study hospitals. A readiness assessment complemented the analysis of what works and why. We used a difference-in-difference approach to estimate the effects of the intervention on mortality and coverage. Thematic analysis was used for the qualitative data. DISCUSSION: This is the first quality improvement collaborative targeting neonatal health in secondary and tertiary hospitals in a middle-income country linked to a government health insurance scheme. Our process evaluation is theory driven and will refine hypotheses about how this quality improvement approach contributes to institutionalization of evidence-based practices

Self assembled monolayer based liquid crystal biosensor for free cholesterol detection

A unique cholesterol oxidase (ChOx) liquid crystal (LC) biosensor, based on the disruption of orientation in LCs, is developed for cholesterol detection. A self-assembled monolayer (SAM) of Dimethyloctadecyl[3-(trimethoxysilyl)propyl]ammonium chloride (DMOAP) and (3-Aminopropyl)trimethoxy-silane (APTMS) is prepared on a glass plate by adsorption. The enzyme (ChOx) is immobilized on SAM surface for 12 h before utilizing the film for biosensing purpose. LC based biosensing study is conducted on SAM/ChOx/LC (5CB) cells for cholesterol concentrations ranging from 10 mg/dl to 250 mg/dl. The sensing mechanism has been verified through polarizing optical microscopy, scanning electron microscopy, and spectrometric techniques