Implementing and Sustaining Quality Improvement Behaviors in a Resource-Limited ICU System: A 12-Month Prospective Study

Technical Summary: Implementing and Sustaining Quality Improvement Behaviors in a Resource-Limited ICU System

Problem Statement
Intensive care units (ICUs) in resource-limited settings, specifically within the Jordanian public healthcare network, face significant barriers to effective Quality Improvement (QI) and patient safety. These barriers include staffing shortages, limited infrastructure, and deep-seated cultural challenges regarding adverse event reporting, such as fear of blame and hierarchical communication patterns. While the Ministry of Health (MoH) launched the Jordan Health Accreditation Project (JHAP) in 2007 to enhance quality, progress has been hindered by resource constraints, variability in staff training, and an over-reliance on accreditation without standardized quality indicators. Consequently, a sustainable culture of continuous improvement and transparency has been difficult to establish. The study addresses the need to characterize these implementation barriers and evaluate whether a context-sensitive educational intervention can improve QI knowledge, engagement, and sustained practice among ICU providers.

Methodology
The study employed a prospective, mixed-methods educational intervention design conducted between January and March 2024 within the Jordanian Ministry of Health ICU network (330 beds, ~13,621 annual admissions).

• Intervention: A two-day, comprehensive QI workshop was developed by a multinational faculty team using a systematic, evidence-based approach (informed by AMEE Guide No. 87). The curriculum was tailored to local needs identified through preliminary assessments and stakeholder consultations. Key domains included QI foundations, adverse event reporting systems, quality metrics, practical applications, Morbidity and Mortality (M&M) conference structures, data analysis, and action planning.
• Participants: A purposive, stratified sample of 50 healthcare professionals was recruited, including physicians, nurses, pharmacists, quality officers, and administrators.
• Data Collection: Anonymous electronic surveys (Qualtrics) were administered at three time points: pre-intervention, immediately post-intervention, and at a 12-month follow-up. Survey items were adapted from validated instruments (SAQ, TeamsSTEPPS) and refined for the local context.
• Analysis: Due to the anonymous nature of the surveys, responses were unlinked across time points. Consequently, the study utilized descriptive statistics (frequencies and percentages) to evaluate aggregate shifts in confidence, engagement, and tool usage rather than paired longitudinal comparisons. Likert-scale responses were collapsed into three categories (Agree, Neutral, Disagree) for analysis.

Key Results

• Confidence in QI and Patient Safety: Participants reported a substantial increase in confidence immediately following the workshop. Agreement with the ability to apply QI principles rose from 73.5% (pre) to 93.2% (post) and remained elevated at 73.7% at 12 months. Similarly, confidence in patient safety principles increased from 75.8% to 93.2% post-intervention and was sustained at 68.4% at 12 months.
• Behavioral Engagement: At the 12-month follow-up, 82% of participants reported ongoing use of adverse event reporting tools, and 86.7% expressed willingness to engage in future QI initiatives. Furthermore, 83.3% of respondents indicated they were actively applying best practices introduced during the workshop.
• Specific Competencies: Confidence in using process/outcome measures and participating in M&M conferences remained high at 12 months (77.8% and 72.2% agreement, respectively), though a modest increase in disagreement was observed compared to immediate post-workshop levels.
• Persistent Barriers: Qualitative data identified enduring structural obstacles, including staffing shortages, high clinical workload/burnout, equipment limitations, and usability challenges with reporting systems.

Significance and Claims
The paper claims that a structured, context-sensitive educational intervention is feasible and effective in improving ICU providers' confidence and engagement in QI practices within a resource-constrained environment. The study demonstrates that such training can produce immediate gains in knowledge and confidence, with effects sustained above baseline levels at 12 months.

The authors argue that while educational interventions alone are insufficient to drive sustained change without parallel investments in infrastructure and leadership support, they serve as a critical bridge. The intervention successfully aligned with local needs, addressing gaps in reporting familiarity and M&M structures, thereby promoting lasting engagement with safety systems. The sustained willingness to participate in QI projects and the continued use of reporting tools suggest that targeted training can strengthen frontline capability and shared understanding, potentially fostering early signals of cultural change regarding psychological safety and non-punitive error discussion.

Limitations
The authors explicitly note limitations, including the inability to draw causal inferences due to unlinked, self-reported data; the reduced sample size at the 12-month follow-up (n=19); and the lack of access to objective clinical outcome data (e.g., infection rates, mortality) to verify if attitude changes translated into improved patient care. Additionally, the study was conducted in a single country, limiting generalizability without adaptation.