NURS 8302 Discussion: Quality Improvement Initiative ANSWER

Post a brief explanation of the QI initiative you selected, and why. Be specific. Explain how adverse events are handled in your healthcare organization or nursing practice, including an explanation of how this may impact both public and internal perspectives on healthcare quality. Then, briefly describe the error rate from the article you selected, and explain how this may relate to your healthcare organization or nursing practice. Be specific and provide examples.

Sample Answer for NURS 8302 Discussion: Quality Improvement Initiative ANSWER

CMS has defined quality improvement (QI) as a systematic process used to improve and standardize care, identify and reduce variation, achieve predictable results, and to improve outcomes w

ithin the health care systems for patients and organizations (CMS, 2021). The QI project that I would like to initiate is a plan to reduce return to hospitalization (RTH).  The goal is to reduce RTH by 50% in 6 months.  The geriatric population is exceptionally vulnerable of undergoing an adverse event associated with frequent rehospitalization. Research has shown that RTH especially in the elderly community can adversely affect their overall quality of life. In an article by Admi et al. (2015) they discussed “hospitalization of the older adult is often followed by an irreversible decline in the functional status that affects their quality of life and well-being after care”(Admi et al., 2015). In the acute care setting elderly patients are more likely to be subjected to physical and chemical restraints, foley catheters insertion and restrictions in movement in the efforts to keep them safe. Some of these interventions are detrimental to the mindset of the dementia patients; and they often return confused, and withdrawn.

Currently we address adverse events based off the event that triggered the need for change. I have determined that most of the events on my facility are handled from a reactive point of view; meaning the adverse events usually take place and triggers a quality improvement initiative. As a Director of Nursing (DON) and a DNP prepared nurse my focus is to change the culture of this practice.  Being reactive and waiting for an adverse event to happen alters the perception of the physician, patient, families, and community understanding of the abilities and capabilities of staff in the long-term care setting.  Unfortunately, it leads individuals to believe that long-term care facilities are not capable of providing quality care.  As a DNP prepared nurse, I know this is where quality evidence-based practice comes into play.  By re-visiting policy and procedures, and incorporating new standards of care and algorithm; a re-education of old processes can be reintroduced.  Quality care must be addressed as an action and re-iterate into every day practice.

In an article by Hudali et al. (2017) they discussed how the utilized a transitional care model (TOC) to address and reduce the RTH rate of their project study.  It was determined that 10.6% RTH was noted within the study population, approximately 40 patients out of 378 (Hudali et al, 2017).  It was noted that this rate dropped to 3.8% with the use of TOC model.  I found this information imperative for two reasons: many times, new patients transition for acute care setting to short-term rehab/long-term and we often transition these patients back home.  The study TOC model provided insight on examples and ways to utilize this model appropriately in my current setting to reduce and prevent rehospitalization of my population setting.  Medication reconciliation is one of  the most imperative aspects of the program along with teaching effective disease management from the patient perspective.

Reference:

Admi, H., Shadmi, E., Baruch, H., & Zisberg, A. (2015). From research to reality: Minimizing the effects of hospitalization on older adults. Rambam Maimonides Medical Journal, 6(2). https://doi.org/10.5041/rmmj.10201

Hudali, T., Robinson, R., & Bhattarai, M. (2017). Reducing 30-day rehospitalization rates using a transition of care clinic model in a single medical center. Advances in Medicine, 2017, 1–6. https://doi.org/10.1155/2017/5132536

Quality Measurement and Quality Improvement. CMS. (2021, March 3). Retrieved October 8, 2021, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Measure-and-Quality-Improvement-.

Sample Answer 2 for NURS 8302 Discussion: Quality Improvement Initiative ANSWER

Quality improvement aims to understand the complex healthcare environment, apply a systematic approach, and design, test, and implement modifications using real-time measurement to improve safety, effectiveness, and care experience (Jones et al., 2019). It is an opportunity to address concerns about how care processes and systems are delivered. Quality improvement (QI) is a team activity that collaborates with other disciplines, including patients, to improve care processes (Jones et al., 2019).  Done well, QI is a valuable process, enabling clinicians to deliver actual change to benefit themselves, their organizations, and their patients (Jones et al., 2019). This week’s discussion will focus on a quality improvement initiative, how adverse events are handled at my organization and impact public and internal perspectives on healthcare quality, and review a scholarly article where a serious error occurred and how this may relate to my organization.

QI Initiative Selected 

 I have been the co-chair of the Fall Prevention Quality Improvement Team for the network for several years. My co-chair and  I have led many fall prevention initiatives, including Dr. Patricia Quigley and Dr. Amy Hester’s (Hester Davis Scale for fall risk assessment) on-site visits to educate the network on fall prevention. I am fortunate to have met both fall prevention experts.

The QI initiative selected is a Fall Prevention Agreement to reduce fall events. I chose this QI initiative because I am passionate about fall prevention. This QI initiative was initially a Nurse Residency evidence-based project in 2018 and then expanded network-wide. Most patients are unaware of their fall risk. The Fall Prevention Agreement provides a standard format for communication between nursing staff and the patient, increasing patients’ knowledge of their fall risk factors. It is a two-sided agreement with specific fall prevention interventions and things the patient can do to prevent a fall. The nurse reviews the Fall Prevention Agreement on admission, and then after review, the patient and nurse sign/date the agreement. It is scanned into the electronic health record, being a permanent part of the electronic health record.

Adverse Events in My Healthcare Organizations 

My organization supports a just culture where colleagues are encouraged to do the right thing. It is a culture that promotes reporting and open discussion when adverse events occur. The aim is to avoid similar adverse events. Frontline staff is included in root cause analysis meetings to learn and discuss adverse events, identify opportunities for improvement, and implement action items to improve safety and quality of care. Research has shown that in units where feedback about adverse events is routinely given, staff have positive views on patient safety and are more apt to report adverse events (Liukka et al., 2017).

Leadership and the organizational structure play a vital role in developing and implementing QI plans (U.S. Department of Health and Human Services Health Resources and Services Administration, 2011). In my organization, senior leadership acknowledges the importance of discussing adverse events and encouraging frontline staff involvement in decision-making and policy development, positively impacting public and internal healthcare quality perspectives. I believe it is crucial to include frontline staff to gain a firsthand perspective on potential solutions. When firsthand perspectives are not discussed in the aspects of QI planning, the QI initiative may fail.

Published Scholarly Article that Recounts a Serious Error

            Medication reconciliation is an essential component of patient safety. The scholarly article I selected refers to a 71-year old female who accidentally received Navane, an antipsychotic medication, instead of her anti-hypertensive drug Norvasc for three months (da Silva & Krishnamurthy, 2016). She sustained physical and psychological harm, including ambulatory dysfunction, tremors, mood swings, and personality changes (da Silva & Krishnamurthy, 2016). Unfortunately, multiple healthcare providers overlooked her symptoms (da Silva & Krishnamurthy, 2016). Errors occurred at numerous levels, including prescribing, pharmacy dispensation, hospitalization, and outpatient follow-up. (da Silva & Krishnamurthy, 2016). The outpatient pharmacy accidentally dispensed Navan instead of Norvasc (da Silva & Krishnamurthy, 2016). Navane/Norvasc is one of many sound-alikes, look-alike drug names (da Silva & Krishnamurthy, 2016). “It is believed that preventable medication errors impact more than seven million patients and cost almost $21 billion annually across all care settings” (da Silva & Krishnamurthy, 2016, p. 1).

Related to My Healthcare Organization

Unfortunately, this alarming medication error can occur in any healthcare organization. At my organization, medications added to the formulary are evaluated for a look-alike, sound-alike potential with other products, and then appropriate safeguard education to staff. Look-alike and sound-alike medications are stored in red bins and different locations in the pharmacy. The regularly updated list appears in the policy manual and the pharmacy website. When possible, the electronic medical record system will place a warning comment and tall man letterings such as DOPAmine and DOBUTamine. My organization has developed a series of procedures to identify look-alike and sound-alike medications to prevent medication errors from these mix-ups. Medication errors are low but still occur. By creating a culture of teamwork and communication, we learn from our mistakes and aim to decrease preventable medication errors.

 

References

da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: A patient case and review of Pennsylvania and national data. Journal of Community Hospital Internal Medicine Perspectives, 6(4), 31758. https://doi.org/10.3402/jchimp.v6.31758

Jones, B., Vaux, E., & Olsson-Brown, A. (2019). How to get started in quality improvement. BMJ, k5408. https://doi.org/10.1136/bmj.k5437

Liukka, M., Hupli, M., & Turunen, H. (2017). How transformational leadership appears in action with adverse events? A study for finnish nurse manager. Journal of Nursing Management, 26(6), 639–646. https://doi.org/10.1111/jonm.12592

U.S. Department of Health and Human Services Health Resources and Services Administration. (2011). Developing and implementing a QI plan. Retrieved October 3, 2021, from https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/developingqiplan.p

Sample Answer 3 for NURS 8302 Discussion: Quality Improvement Initiative ANSWER

Initiatives for quality improvement are methodical, data-driven strategies aimed at enhancing both the safety and quality of healthcare delivery. Initiatives to increase quality are concentrated on providing timely, safe, equitable, efficient, and patient-centered care. Analyzing medical data as well as the methods and procedures utilized in the delivery of care might serve as the basis for such initiatives. This results in the identification of areas that require improvement as well as the processes and systems that can be fixed to raise the standard of patient care.

A Brief Explanation of the QI Initiative Selected

The decrease in hospital readmission rates is the QI project that I have chosen for this discussion. Hospital readmissions occur when a patient returns to the hospital within 30 days of being released from the hospital (Gupta et al., 2019). High rates of readmission to hospitals present a serious problem for medical facilities and staff. High rates of hospital readmission also put a burden on healthcare resources and jeopardize patient outcomes. High readmission rates pose a danger to patient safety since they can result in unfavorable outcomes like increased stress levels and high death rates (Wadhera et al., 2019). Because it aims to address the several drawbacks connected to high readmission rates, a quality improvement project to lower hospital readmission rates is therefore a wonderful idea. By delivering high-quality care and improving patient outcomes, lowering hospital readmission rates guarantees lower healthcare costs (Wadhera et al., 2019).Initiatives aimed at enhancing quality are motivated by the necessity to assure the safe provision of medical care. According to Gupta et al. (2019), the six main objectives of patient care are to guarantee that medical treatment is equitable, timely, safe, effective, and patient-centered. As part of a quality improvement program, lower hospital readmission rates are linked to higher patient satisfaction and better medical results.

How Adverse Events are Handled in the Healthcare Organization or Nursing Practice

Including an Explanation of How This May Impact Both Public and Internal

Perspectives on Healthcare Quality. 

Unforeseen incidents frequently occur in the healthcare industry, and the way these incidents are managed can greatly influence the public’s and internal perceptions of the quality of service. According to Young et al. (2019), an adverse event is any unplanned or unforeseen incident that causes harm to a patient or causes them to become temporarily or permanently disabled. A healthcare provider must notify the patient and their family about an unfavorable event that has occurred. According to Hernández et al. (2023), the healthcare practitioner also needs to pay attention to the patient’s and their family’s worries and complaints regarding the adverse event. Following discussions with the patient and their family, a system of documentation has been established. The medical facility mandates that all adverse events be reported, noted, and documented. The counseling department provides emotional support to patients and their families, assuring them that all feasible measures will be made to mitigate the negative impact of the unfavorable incident. Transparency is ensured by the healthcare facility through communication with patients and their families, which increases patients’ trust in the hospital. Acknowledging and accepting culpability by acknowledging a negative incident According to Rodziewicz and Hipskind (2020), maintaining communication guarantees that patients and their values are acknowledged and honored. Healthcare practitioners are aware of the need to be open and honest. Negative occurrences should be reported, noted, and documented to identify areas that need improvement (Hernández et al., 2023). This is important because it guarantees that by fixing system flaws or other error sources that caused the unfavorable outcomes, they can be prevented in the future. Healthcare personnel understand that they won’t be criticized or shamed, according to the internal perspective on this. Nonetheless, it is expected of all healthcare workers to accept ownership and responsibility for their actions. The public gains greater faith in the healthcare organization when such incidents are disclosed and addressed because they know that ongoing quality improvement programs will be implemented to prevent such incidents in the future (Rodziewicz & Hipskind, 2020).

Error Rate From the Selected Article and How This May Relate to the Healthcare

Organization or Nursing Practice.

I chose a news statement issued on January 9, 2022, by the Michigan Department of Attorney General for this section. According to the report, a nurse was accused of seriously injuring a vulnerable adult’s physical and emotional health. The report claims that the nurse discovered two incorrect medication doses that had been given to a resident of the Grand Rapids home for veterans where she worked while carrying out her duties as a licensed practical nurse (LPN) (Michigan Department of Attorney General, 2021). However, the nurse decided not to notify her doctor or supervisor of the mistake right away, which resulted in the patient suffering severe bodily and psychological damage. The frequency of these pharmaceutical errors is not mentioned in the paper. Even though this was an isolated instance, incidents like this still happen frequently, and considerable work needs to be done to stop them from happening again. The incidence of such severe prescription errors jeopardizes the health and well-being of patients who are in danger, as the article reports (Michigan Department of Attorney General, 2021). Furthermore, according to Rodziewicz, Houseman, and Hipskind (2018), these disputes cost healthcare institutions thousands or even millions of dollars in legal fees and compensation. The inability to report a medication error upon discovering it could have been due to various reasons, such as the inability to take responsibility for the patient’s health decline, fear of hospital management’s repressive responses, fear of legal liability, fear of punishment, fear of being perceived as incompetent, or a combination of these (Rodziewicz, Houseman & Hipskind, 2018). This story highlights the need, in my healthcare setting, for an honest and open system that allows medical personnel to report prescription errors without fear of reprisal, blame, or ineptitude. The healthcare organization should implement a plan that guarantees healthcare workers’ freedom to disclose such incidents even when they accept accountability for their acts (Rodziewicz & Hipskind, 2020). It is advisable to promote the reporting of medication errors as it facilitates transparency and offers a foundation for quality improvement initiatives aimed at averting such incidents in the future. (Hernández etal., 2023). Instead than placing as much emphasis on stigmatizing and assigning blame, it would be better to fix system flaws or get rid of things that encourage prescription errors.

Conclusion

The provision of safe, effective, equitable, efficient, timely, and patient-centered care is the main goal of quality improvement activities. Reducing hospital readmission rates is one such effort, which is crucial since it improves patient outcomes, better patient satisfaction, lower medical expenses, and better care quality are a few benefits.An efficient reporting mechanism, open and honest contact with patients and their families, and the recording and documentation of such occurrences can all help manage adverse health impacts in healthcare more skillfully. Adhering to such protocols improves openness and helps healthcare organizations pinpoint areas where quality has to be improved (Gupta et al., 2019).

Sample Answer 4 for NURS 8302 Discussion: Quality Improvement Initiative ANSWER

In health care systems, the need to address safe patient care necessitates various management responses with regard to the problem in question. Quality improvement initiatives (QI) are actions undertaken by the stakeholders in a health care facility to bridge the gaps in realizing the goals of service delivery (Sadegh et al., 2013). The premise can also entail the implementation of innovative approaches to model and design various strategies aimed at addressing complex care interventions. According to Cullen (2018), assessing quality improvement initiatives is important to measure the performance of a health system to enhance the safety of patients seeking care services. In the institutions of care, quality improvement initiatives also entail an evaluation of the staff capacity and the availability of resources to handle populations seeking medical attention (Mikhail & Langabeer, 2018). Often, nursing population can be used as the yardstick to assess the quality of care since they spend the longest period with the patients (Hickey & Brosnan, 2017).    Thus, the context of safe staffing with respect to nurse-to-patient ratios needs to receive attention.

Selected Quality Measures Identification

Safe nurse-to-patient ratio is a quality initiative that most hospital leaders take into account in a bid to ensure quality care for patients. Health facility administrators often formulate strategies that address safe, effective and efficient approaches that guarantee quality care to patients. Hill and DeWitt (2018) illustrate that one of the most important approaches is to recruit adequate nursing staff and other care professionals to address patient acuity. Certainly, an interplay of many factors concerning nurse-patient ratios has often hampered the efforts to bridge the staffing gap. In many cases, care facilities lack adequate financial resources to implement nursing staff (Shekelle, 2013). Besides, access to competent and experienced nursing staff is a challenge due to the shortage of specialist nurses.

In this regard, the present article delves into the quality measures related to safe nurse-patient ratios in care setting. The premise is guided by the argument that patient-centered outcomes are compromised by inadequate nursing staff. The present nursing staff in care facilities is also overwhelmed by the high patient population. The occasion of unsafe nurse staffing is also exacerbated by the high rate of nurse turnover most of whom seek further studies or opt for institutions that offer better remuneration packages. According to Shekelle (2013), the recommended rate for nurse to patient ratio is at 1:4. However, the present health facility indicates a ratio of 1:8, which is far below the required standards. The high nurse to patient ratio is detrimental to both the institution and the clients seeking care services. It results to missed care due to untimely administration of medication and poor pain management (Sadegh et al., 2013; Lee et al., 2017). A project on nurse staffing entails addressing nursing skill mix in addition to a response on care hours as a way to look into the working patterns of nurses. Thus, the health facility can also focus on attracting high-quality nurses through redesigning the practice environment to improve patient safety.

Data Collection Plan

Data collection plan is an important aspect and a straight forward approach to indicate the patterns of nurse staffing in a care facility. The collected data will reflect aspects of patient care, particularly concerning prompt care, increase in falls, bed sores, and other infections (Hickey & Brosnan, 2017). Data on safe nurse to patient ratios can be collected through different approaches and comprises five steps.

The first step entails identifying the perceived speculated results on nurse staffing results and the ways to measure their actual number. The second step relates to developing a data gathering approach to ascertain the problem of the unsafe nurse to patient ratios in a care facility. The third step involves the analysis of the data collected in a bid to reflect on the nurse staffing deficits with respect to patient population seeking health services at the institution. Step four, on the other hand, entails relating the data collected to establish the extent of an inadequate number of nurses when compared to the patient population seeking medical attention. In the final step, the four steps are repeated to ensure the accuracy of the information collected. This also provides information that can be used to compare data from known databases to reflect the pattern of the nurse to patient ratio with recommended standards.

The manual data collection plan will be determined by observing the lifestyle, body and the environment of patient care. This provides qualitative data to gauge on adequate or poor staffing nursing patterns in a care facility (Hickey & Brosnan, 2017). It can be deduced that the behavior and the overall outlook of patients depend on the decisions they make from the information they receive as per the advice of nurses. In the event of inadequate personnel, the quality of life of patients is likely to be compromised due to insufficient education on self-care (Hill & DeWitt, 2018). The environment of care can also be altered and expose patients to hospital-acquired infections as opposed to when there is adequate nursing staff.

The data collection plan is also based on the analysis of diagnosis-related groups (DRGs). The latter denotes a case-mix of patients which categorizes clients as per their diagnoses, demographic characteristics, and treatments administered to them. In a nutshell, the DRGs provide data on the number of doctors, nurses and medical products used to offer given care to patients (Woo, Milworm & Dowding, 2017). Further, the DRGs provides feasible data on the number of care providers required to support prompt as well as quality care. The project on safe nurse-patient ratios will rely on the data from DRGs to provide a measure and indicators on the minimum number of nurse staffing ratios that can affect the quality of patient care in a given facility.

Nurse’s Role in Correct Data Collection

Nurses are integral in providing information related to patient safety in a care facility. The professionals avail data that can be used in the analysis of staffing by acuity indicators. In other words, nurses are the health professionals that have close proximity to patients, and as such, they provide actual information on the number of patients under their care. They can inform hospital administrators if the number of patients they attend to are more or less based on their ability to provide the service. Acuity in a care setting is ranked as per the severity of illness rated based on minor to major and extreme conditions. A nurse ratio of 1:4 is the recommended scale to solve thrilling severity of patient conditions. The measure indicates the level of flexibility of a hospital to provide care to patients with complicated illnesses. Studies by Hill and DeWitt (2018) and Lee et al. (2017) affirm that nurse leaders and advanced registered nurses use aggregate data to measure as well as monitor the trends in quality care to patients. The information gathered is incorporated into data collected from administrative and multiple clinical databases from the facility, which will further be used to analyze the trends or to support research in the given health facility.

Professional, Ethical, and Regulatory Standards Implementation

The project implementation requires quality improvement actions based on the ethical and regulatory standards of nurse staffing. Related standards and criteria need to conform to the federal regulations on a number of health professionals required in care facilities (Woo, Milworm & Dowding, 2017). The safe nurse-to-patient ratios program as well addressing the number of licensed registered nurses and practical nurses that conforms to the regulatory requirement of health facilities of a state become necessary. The effectiveness of a quality improvement initiative depends on the employment of nurses with competency in their area of specialty to optimize patient outcomes (Mikhail & Langabeer, 2018). However, confidentiality of the sensitive information reported by nurses on the administrative practices of a given facility must be guaranteed as a remedy to victimization.

The American Nurse Association (ANA) recommends specific rates of nurse-to-patient ratios in different departments of a health facility. In the critical unit, a ratio of 1:2 is recommended while at the emergency department the regulatory body expects 1:4. Further research by Lee et al. (2017) suggests that the standard criteria of the ANA guide on the implementation of the quality initiative. The stipulated recommended ratios will guide nurse staffing.

Communication to Stakeholders

Implementation of the quality improvement initiative can be well achieved through effective communication to stakeholders. The initial process will require the provision of accurate and adequate information for justification on the implementation of safe nurse-to-patient ratios (Wong, 2015). Stakeholders will be informed on the current state of the nurse-to-patient ratios so that they evaluate the need for quality improvement. As part of the quality improvement team, I will schedule a meeting with the stakeholders where the facts and figures related to the safe patient care will be availed. I will also collect feedback from key stakeholders regarding the program and compile a report that will steer the implementation process.

Interprofessional Collaboration

The implementation of the safe nurse-to-patient ratios will depend on the leadership skills emulated by the stakeholders in the given health facility. According to Laureani, Brady and Antony (2013), nurse leaders and the project management team must display leadership skills to inspire other nurses as they strive to improve patient care. Besides, the leaders need to create a staffing plan that aims to respond to unpredictable nursing turnover as part of the improvement initiative to address patient acuity. The stakeholders will also be expected to communicate progress to all team members and highlight areas where the program should be given priority (Laureani, Brady & Antony, 2013). However, as part of stakeholder engagement, leaders must portray interprofessional collaboration so that the program is accepted within the care facility. Cullen (2018) posits that successful implementation of the program depends on how the leaders define the financial requirement, emulate time management skills and address potential challenges that might impede achievement of safe patient care.

Conclusion

In conclusion, the need to improve quality in healthcare necessitates the introduction of systematic approaches to prioritize on actions required for care delivery. Safe nurse staffing in health facilities is essential in improving the well-being of patients. However, in addressing the nurse staff deficit, the stakeholders will need to employ skilled and competent professionals. Further, it will be vital to assess the acuity in the selected hospital and allocate nurses based on the severity of patients’ illnesses. All these approaches are aimed at minimizing medication errors as well as to improve the quality of health outcomes.

References

Cullen, L. (2018). Translating EBP into the Reality of Daily Practice: Leadership Solutions for Creating a Path Forward. Journal of PeriAnesthesia Nursing, 33(5), 752-756.

Hickey, J. V., & Brosnan, C. A. (2017). Evaluation of health care quality in for DNPs (2nd ed.). New York, NY: Springer Publishing Company.

Hill, M., & DeWitt, J. (2018). Staffing Is More Than a Number: Using Workflow to Determine an Appropriate Nurse Staffing Ratio in a Tertiary Care Neurocritical Care Unit. Journal of Neuroscience Nursing, 50(5), 268-272.

Laureani, A., Brady, M., & Antony, J. (2013). Applications of lean six sigma in an Irish hospital. Leadership in health services, 26(4), 322-337.

Lee, A., Cheung, Y. S. L., Joynt, G. M., Leung, C. C. H., Wong, W. T., & Gomersall, C. D. (2017). Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study. Annals of intensive care, 7(1), 46.

Mikhail, O., & Langabeer, J. (2018). Strategy and Performance Management. In Performance Improvement in Hospitals and Health Systems (pp. 39-60). New York, NY: Productivity Press.

Sadeghi, S., Barzi, A., Mikhail, O., & Shabot, M. M. (2013). Integrating quality and strategy in health care organizations. Burlington, MA: Jones & Bartlett Publishers.

Shekelle, P. G. (2013). Nurse-patient ratios as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5_Part_2), 404-409.

Wong, P. S. P. (2015). To learn or not to learn from project monitoring feedback: In search of explanations for the contractor’s dichromatic responses. In The Soft Power of Construction Contracting Organisations (pp. 141-164).

Woo, K., Milworm, G., & Dowding, D. (2017). Characteristics of Quality Improvement Champions in Nursing Homes: A Systematic Review With Implications for Evidence‐Based Practice. Worldviews on Evidence‐Based Nursing, 14(6), 440-446.