Quality Improvement in Stroke Rehabilitation: A Scoping Review

Figures & data

Figure 1 PRISMA diagram.

Notes: PRISMA figure adapted from Liberati A, Altman D, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health careinterventions: explanation and elaboration. Journal of clinical epidemiology. 2009;62(10). Creative Commons.¹³

Table 1 Study Characteristics (Design, Type, Population and Primary Outcomes)

Author	Year	Location	Setting	Study Design	Study Type	Population	Outcomes Measures	Results
Falconer, J.A, el al.	1993	USA	Rehabilitation Institute of Chicago (RIC)	Randomized Control Trial (RCT)	Implementation of Critical Path Method (CPM) using multidisciplinary teams. CPM is a project network technique used for visually charting the project steps to develop a project network diagram illustrating activities, relationships, timeframes, costs, schedules.	128 adults admitted with a recent (within 120 days) diagnosis of stroke.	Length of Stay (LOS) Hospital charges Functional status using Functional Independence Measure (FIM), motor function, cognitive function	CPM did not contain costs or improve outcomes of inpatient stroke rehabilitation. Groups demonstrated no statistically significant differences for LOS or functional status. Interaction effects propose that CPM could have selectively advantaged males and patients with lower cognitive functions.
Hancock, N.J, et al	2019	England	Cambridge and Peterborough NHS Foundation Trust (CPFT)	Qualitative	Qualitative PDSA (plan-do-study-act) intervention for technology adoption	A service improvement team of four expert neurological PTs and a group of 13 clinical partners of community-based neurological Physiotherapists (PTs) and Occupational Therapists (OTs).	Integration of the use of “Via Therapy” tool predominantly in mobile app form (a technology utilizing an underpinning algorithm providing evidence-based intervention recommendations) Accessibility of the tool in practice Impact on clinician confidence and treatment planning and provision.	22% increase in confidence and use of evidence-based practice from the baseline and the technology was reported to be simple, easy to use, accessible, concise and straightforward. Changes to the delivery of interventions (dosage and treatment planning) was also reported due to the rapid access of recommended doses through the tool.
Holstege, M.S, et al	2017	Netherlands	16 skilled nursing facilities geriatric rehabilitation	Quasi-experimental/before and after	Dutch National Program as a prospective longitudinal study to improve quality of care through implementation of integrated case	16 skilled nursing facilities, 743 patients and their healthcare professionals.	Successful rehabilitation as the primary outcome measure was defined as independence in activities of daily living (Barthel Index more than or equal to 15), discharge to home, and a short LOS (in lowest 25% of diagnostic group).	More independence in activities of daily living at discharge, but the combined outcome of successful GR with only patients with traumatic injuries demonstrating significant improvement.
Janzen, S, et al	2016	Canada	Single stroke rehabilitation unit in Southwestern Ontario	Quasi-experimental/before and after	Knowledge to Action (KTA) Project with audit-feedback process using Rehabilitation Knowledge to action Project (REPAK) and Knowledge Creation (EBRSR) to improve clinical practice guideline (CPG) adherence.	121 patients in a single 26 bed stroke rehabilitation unit and multidisciplinary working group for each knowledge-practice gap identified.	Primary outcome for REPAK was improved adherence to best practice recommendations for stroke rehabilitation. The audit looked at several elements in stroke rehabilitation including the “assessment and management of depression, cognitive screening and assessment, bladder management, intensity of therapy, benzodiazepine use, and the management of hypertension”.	Significant and positive influence on clinical practice and patient outcomes including increased depression screening, decreased benzodiazpin use and improved hypertension management. Results of REPAK demonstrated improved adherence to best practice recommendations.
Joliffe, L, et al	2019	Australia	Metropolitan inpatient injury rehabilitation unit.	Quasi-experimental/before and after	Before-and-after study using audit-feedback process and knowledge translation activities	All clinicians (medical staff, nursing staff and allied health staff) working in the unit were involved. During the study period, 58 clinical staff were employees. Fortnightly audit-feedback cycles selected two random patients for audit during the 12 month intervention period.	16 guideline indicators (and 114 observable criteria) were used including “behavioural support plan, care plan, continuity of care, discharge planning, equipment use, patient/family education, goal setting, medical management, medical records, minimally conscious care, safety, patient care regime, post-traumatic amnesia management, roles and responsibilities, therapy and ward rounds”.	There was a significant increase in clinician’s adherence to guideline recommendation at the end of the intervention. This was at a median 38.8% at baseline and changed to 83.6% at the end of the intervention. After termination of the audit and feedback program, there was a decline of 7% in clinician adherence levels from the completion of the intervention to the follow up stage but continued to be higher than 75% adherence goal.
Oyeyemi, A, and B.Sedenu	2010	USA	Inpatient facility in New York	Quasi-experimental/before and after	Care Planning Process (patient profiling, treatment tracking and outcome staircasing)	110 stroke patients from the subacute rehabilitation unit that were admitted in the years 2004–2007 (pre-program years were 2004–2005, program years were 2006–2007).	Functional Independence Measure (FIM) scores in daily living: Included admission and discharge total FIM and change in FIM (FIM gain). Length of Stay (LOS): Included the “Total number of days a stroke survivor received at least one of physical occupation and language speech therapy”. FIM change at discharge LOS efficiency: Ratio of FIM change to LOS.	Discharge FIM for 2006 group was significantly higher than pre-program. The program years demonstrated significantly better LOS. LOS efficiency improvements demonstrated throughout the program years, with only 2006 improvement significantly greater than the pre-program years.
Perry S.B, H. Zeleznik, and T. Breisinger	2014	USA	Urban, tertiary care trauma center (University of Pittsburgh Medical Center Mercy Hospital)	Quasi-experimental/before and after	Multidimentional Knowledge Translation Activities Program	2 Physical Therapy team leaders, 10 staff Physical Therapists, 1 Physical Therapy assistant, and 4 to 5 rehabilitation aides. Six therapists were Certified Brain Injury Specialists in a tertiary care trauma centre. The expected caseload was 4–5 patients and 8 visits each day.	Implementation and progression of non-supported gait training (NSGT) NSGT attempts Walking-related outcomes	Results demonstrated increased familiarity and usage of NSGT increased by 69% and 33% respectively.
Power, M, et al	2014	England	Twenty-four NHS hospitals in the Northwest of England	Randomized Control Trial (RCT)	Stroke 90:10 Quality Improvement Collaborative (QIC)	3533 patients across 12 intervention hospitals, 3059 patients across 12 control hospitals	Compliance with two bundles of processes for bundle 1 early hours (brain imaging, antiplatelet administration, swallow screen, weight assessment) and bundle 2 rehabilitation (Ward of 50%+ of stay, physiotherapist assessment within 72 hours of admission, assessment by the occupational therapist within 4 days of admission, mood assessment and rehabilitation goals set).	Demonstrated a modest improvement from baseline in the odds of compliance, in Bundle 1, there was a relative improvement by the end of the study of 10.9% increase in the intervention (with largest differences in administration of aspirin, 95% CI 1.3%, 20.6%). In Bundle 2, there was a relative improvement by the end of the study of 11.2% increase in the intervention (with increases in moods assessment and rehabilitation goals, 95% CI 1.4%, 21.5%) Analysis suggesting some processes being more sensitive to the intervention effect.
Tistad, M, et al	2016	Sweden	Five outpatient stroke rehabilitation centers	Qualitative	Leadership Intervention program to support managers in implementation of national guideline recommendations in outpatient rehabilitation.	Eleven senior and frontline managers and twelve staff members from five outpatient stroke rehabilitation centres.	Categories for participants responses included: Developing a leadership plan with clear goals Intervention content and structure Pertinence beyond stroke rehab Involving Staff Leadership for change	Managers found the intervention beneficial, structure appropriate and content useful and stimulating. All managers developed the leadership plan, with only two of the units identifying goals particular to implementation of the stroke rehabilitation recommendations. Of these two units, only one unit went on to identify leadership behaviours that support implementation. There was limited sense of staff involvement. Majority of managers considered the intervention applicable beyond rehab.
Torres, A, et al	2014	USA	Free-standing inpatient rehabilitation facility	Quasi-experimental/before and after	Shared Governance Program	All members of the rehabilitation team (physical therapist, occupational therapist, speech therapist, registered nurse and nurse aide).	The team trailed shared governance for 6 months and met weekly for 30 minutes including a facilitator and explored: Improve overall patient outcomes Improve patient centered care	Results demonstrated improvements in staff communication, problem solving, patient outcomes, and staff satisfaction.
Vratsistas A, et al	2017	Australia	One stroke service	Quasi-experimental/before and after	Before-and-after study using audit-feedback and education.	31 stroke unit staff across eight disciplines that included medical, nursing, speech pathology, occupational therapy, orthoptics, physiotherapy, social work, dieticians.	Percentage of eligible patients that receive best practice against targets, through audit data on communication, swallowing, mobility, sensation impairment, neglect, patient education, carer education, anxiety, and depression, return to driving and return to work.	Results demonstrated an increase percentage in stroke patients receiving best practice rehabilitation in the majority (74%) but not all of the targeted areas. The largest changes were in rehabilitation (+100%), assessment (+100%), sensation screening (+92%), and neglect screening (+75%)
Voogdt-Pruis, H.R, et al	2019	Netherlands	Five stroke services	Quasi-experimental/before and after	Before-and-after study for shared decision-making (SDM). They initially administered a baseline self-administered email questionnaire for validation and quantification of the interview statements. This was followed by an implementation program including decision-making (DM) training, action planning, feedback, regular guidance consultation and coaching and regular team meetings, followed by in-depth interviews and a second email questionnaire was done for validation and quantification after six months.	25 Healthcare Professionals (HCPs) across five stroke services, representing all participating regions and professional disciplines (rehabilitation nurses, occupational therapists, physiotherapists, speech therapists, psychologist, rehab specialist and care manager).	Adoption of shared decision-making.	Results demonstrated strong agreement (>4.0/5) on essential actions for SDM adoption including training, embedding SDM in multidisciplinary meetings, taking patient preferences, wishes and worries in consideration for treatment follow-up, provision of time for practice and apply SDM, using understandable language using teach-back methods, clear intrinsic patient motivation and the major role of stroke patient relatives in adoption of SDM.

Table 2 Summary of Abstracts on Quality Interventions in Stroke Rehabilitation

Author	Year	Location	Study Design	Background and Intervention	Methods	Results	Conclusion
Allen, L, et al	2013	Canada	Quasi-experimental / before-and after	Intervention aimed to improve monitoring of blood pressure managing hypertension in a stroke rehabilitation unit.	Evidence-practice gap identified with a new hypertension strategy developed and implemented. Strategy uptake was assessed six months after implementation.	A significant decrease in mean days without blood pressure measured/recorded between initial and second audit. No significant difference in mean untreated days amid baseline and post implementation.	Intervention resulted in improved adherence to best practice guidelines for blood pressure monitoring.
Britt, E.J, et al	2010	Canada	Quasi-experimental / before-and after	Intervention aimed to establish reasonable severity-specific LOS targets to aid in reducing LOS without altering patient outcomes.	Functional Independence Measure (FIM) gain and efficiency using three years of patient data (April 2005-March 2008) were summarized and targets for median length of stay were established.	Early results demonstrate 1. LOS reduction 2. Maintenance of patient/staff satisfaction 3. Goal attainment.	Intervention demonstrated success and continued evaluation is necessary.
Bassei, M, et al	2015	Canada	Plan-Do-Study-Act methodology	Intervention aimed for improvements in knowledge and confidence involving patient assessment, management and documentation.	Intervention included a pre and post-test survey, education intervention, and electronic documentation using PDSA.	Improvements were noted in self-rated knowledge and confidence, tactile learning enhanced the didactic teaching methods.	The Plan-Do-Study-Act methodology demonstrated effectiveness in advancing the project in the defined time.
Bayley, MT, et al	2011	Canada	Quasi-experimental / before-and after	Intervention aimed to compare patient outcomes post rehabilitation using an outcome orientated or a process orientated knowledge transfer intervention strategy.	Intervention included training, educational resources, ongoing education session with instruction. Practice audits and focus groups were conducted.	Practice in the process orientated sites demonstrated more changes than the outcome orientated sites. Patients in the process orientated sites were more likely to be discharged home versus outcome orientated sites.	A process oriented knowledge transfer strategy lead to improved adherence to evidence-based practice and resulted in modest recovery benefits.
Bishev, M.	2018	Canada	Quasi-experimental / before-and after	Intervention aimed to provide individual patient care plans and improve rehabilitation intensity.	After conducting gap analysis, multiple quality improvement initiatives and ongoing evaluation changes implemented included interdisciplinary collaborative team rounds models, improved communication and discharge planning and modified workload measurement.	Rehabilitation Intensity (RI)	Improved RI to 123 minutes per active rehab day (a 78% increase from 2010)
Craven, F, et al	2018	Ireland	Lean	Review of existing positive aspects in the Stroke Rehabilitation Unit, identification and implementation of improvement initiatives for service optimization utilizing a person-centered care approach.	Lean methodologies were used, which included process mapping, A3 thinking, gaps analysis. Engagement of relevant stakeholders (patient, staff and executive management). Communication between staff and patients, service structure changes included patient cohorting, referral pathway definition for transferred patients were identified.	Changes included referrals made at point of transfer, each patient being assigned a family liaison key worker and arranged standardized care planning meetings. Access of patients and families to hospital canteen. 90 days review for key areas signifies positive sustainability.	Intervention resulted in positive outcomes for patients and staff and recommended the necessity of on-going QI initiatives and sufficient staffing levels.
Garratt, E, and S, Bolton	2018	England	Quasi-experimental / before-and after	Intervention aimed to consolidate two stroke units into one specialist stroke rehabilitation ward.	A stroke quality improvement plan was developed based on current guidelines and evidence base. Movement of 10 beds from Town A to Town B occurred. Success was measured through defined Key Performance Indicators.	Single-site ward relocation, reaching an average 45 minutes for the therapy session, receiving occupational therapy as well as physiotherapy on admission, and improving Barthel index from admission to discharge.	Quality improvement was evident as a result of this project.
Hahn, N.	2019	Canada	PDSA	Intervention aimed to increase therapy delivery to stroke survivors on a general rehabilitation ward.	Changes included decreased meetings attendance for therapists, optimizations in interdisciplinary rounds aiming to maximize the communication efficiency for clinical staff and operations and patient scheduling changes.	Increase in stroke patients minutes of therapy per day, and total minutes per day therapists spent providing therapy to patients was seen.	Through physician leadership and QI interventions, improvement in care can be achieved without higher costs.
Halabi, M.L, et al	2018	Canada	Quasi-experimental / before-and after	Intervention aimed to evaluate internal processes to increase efficiency using existing resources and to determine the feasibility of expansion.	Six quality dimensions (acceptability, accessibility, appropriateness, effectiveness, efficiency, safety) used for outcome measures. Team meetings held to formulate action plans and score carding methodology used to establish baseline and monitor implementation.	Almost quintupled percent of clients achieving target intensity. Access within 48 hours of discharge for acute care clients increased. Statistically significant change in client performance and satisfaction from 28% to 88 and 84% respectively.	Research recommended the need to select and monitor appropriate outcome to demonstrate efficiency and make informed program planning decisions regarding program expansion.
Liang, J, et al	2019	Canada	Quasi-experimental / before-and after	The intervention aimed to increase the completion rate of stroke investigation workup (SIW) from 43% to 90% by 3 May 2019 in eligible patients admitted for inpatient stroke rehabilitation.	Changes included development of a checklist, a new Holter referral form (HRF) and Holter’s procedure. Outcome measures encompassed SIW completion rates and arrhythmia identification rates. Process measures encompassed quantity of successful Holter’s placement and HRF completion rates. Balancing measures encompassed staff work time.	Results demonstrated successful placement and reading of 12 Holter monitors, gap identification of gaps in the Holter’s ordering procedure and necessary revisions implemented in HRF	Process to increase completion rate of SIW was successful. Satisfaction of both staff and patients with ordering procedure and Holter’s placement.
Lo, A. and J. Fortin	2014	Canada	Qualitative analysis	Intervention included Rehabilitation Quality and Patient Safety Rounds (QPSRs)	Through qualitative analysis, identification of patient care trends and system process concerns occurred, followed by developing an educational model and reporting structure. Surveys were used to assess safety culture.	Results included practice changes; using visible “W” for wanderer in chart spine for flight risk; prohibiting complex patients discharge on Monday, team huddles, and designations for alternate level of care. Other solutions required longer-term follow-up. Elimination of solutions that were complex, expensive or not in line with patient-centered care models.	Intervention demonstrated improvements to quality and safety. Recommended the requirement of an educational process and reporting structure for sustainability of changes.
Lo, A, and C. Fancott	2015	Canada	Qualitative	Intervention aimed to introduce monthly Quality and Patient Safety Rounds (QPSRs) and assess impact on patient care, team communication and patient safety awareness.	Qualitative evaluation was performed through exit surveys after each QPSR. Structured interviews of eight Stroke team members occurred.	QPSR resulted in changes to clinical practice, are highly valued by the team and increased staff awareness of patient safety, systems-based approach to incident analysis, and improved team cohesion and communication.	QPSRs in stroke rehabilitation have changed practice to decrease risk of future critical incidents, while improving provider knowledge of patient safety concepts and team communication.
Lo, Chang, J. and P. Aikman	2013	Canada	Observational action-research methodology	Following a national stroke audit, provincially coordinated gap analysis was conducted utilizing observational action-research methodology (quantitative and qualitative).	Utilization of a tracking tool for measurement of clinical practices against the guidelines involving acute, inpatient and community rehabilitation.	Gaps in services and inconsistencies in practice and the contributing contextual factors as well as better leading practices were identified. The methodology enabled clinicians to see inconsistencies and formulate actions plans for improvement.	Intervention lead to positive change at the site, health authority, and provincial levels.
Morgan, P, A. Cream, and D.J.I.J.o.S. West	2012	Australia	Quasi-experimental / before-and after	Intervention aimed for formalisation, evaluation and review of Multidisciplinary Seniors meetings as Quality Improvement Projects	Changes included continuous staff training, certification, patient fatigue in relation to therapy reviews, post-discharge patient follow-up, carer support group, better use of available space, patient education and recreation.	Staff education Patient outcomes Satisfaction levels of stroke survivor and family/carer Optimized physical environment	Value added to patient outcomes Improved satisfaction rates of patients/carers and staff
Pollard, C, and D. Cegile	2018	Canada	Quasi-experimental / before-and after	New rehab service delivery model (POD Model) implemented aiming to add value to patient experience, achieve better patient outcomes, improve program performance, strengthen interprofessional collaboration, and advance best practices and expertise.	The changes included; Improving PT/OT to patient ratios to 1:7 Dedicating a Physiatrist with stroke expertise Designating these 7 Beds for only Stroke Rehabilitation patients Targeted patient scheduling	Indicators include rehabilitation Intensity time, % of patients with target LOS, number of days to access and alignment to Canadian Stroke Best Practices. Since implementation, key performance measures have shown positive results with; LOS, FIM efficiency, % of patients meeting target LOS and patient satisfaction scores.	Research concluded that continuous quality improvement is multi-layered and involves the consideration of structure, processes, accountability and should be grounded by guiding principles.
Pollard, C, and D. Cegile	2019	Canada	Quasi-experimental / before-and after	A POD Model of Care was implemented with positive results. Aim was to improve stroke care in terms of access to rehab, efficiency of care, and patient outcomes.	The designated Stroke Pod had: 1 to 7 Staff to Patient ratio for OT/PT and 0.6 to 7 for SLP. In contrast, a 1 to 10 for OT/PT and 0.6 to 10 ratio were observed for SLP on the mixed PODs. There were dedicated Physiatrist and Advance Practice Nurse and the POD admitted high intensity stroke rehabilitation patients in comparison to a mix of stroke and neurological patients.	Positive results were demonstrated between April 2018 and February 2019 for rehabilitation intensity minutes per day per patient; % of patients meeting their target LOS; number of access days; FIM efficiency.	Resulted in improved care access, positive patient outcomes and efficiencies in patient flow.
Robinson, J, and K. Trow R, McNicoll Whiteman	2018	Canada	Lean	Intervention aimed to address lack of a consistent process for “Rehabilitation Patient Groupings” availability and long team rounds impacting direct patient care.	Lean involved process mapping, staff satisfaction surveys and patient experience questionnaires. Formation of 3 working groups; Rehabilitation Patient Groupings Processes, Rounds Processes and Pass Processes.	Preliminary data demonstrated changes in FIM efficiency and improved Rehabilitation Patient Groupings available in team rounds.	Resulted in improvements in team rounds’ processes efficiency, and improvements in both quantitative and qualitative measurements.
Savage, J, et al	2019	Canada	Plan-Do-Study-Act methodology	Intervention aimed to increase rehabilitation intensity.	Plan-Do-Study-Act methodology was used. Analysis of operation by key stakeholders was done and identification of areas for improvement, future state, and steps for achievement of desired future vision was done. Nine Rehabilitation intensity initiatives were implemented.	Pre-implementation median Rehabilitation intensity was 58.6 min. Increased median RI minutes was observed through implementation.	Demonstrated effectiveness of Plan-Do-Study-Act methodology. Staff engagement and involvement improved awareness and provided opportunities for more 1:1 therapy. Recommended continuing monitoring and feedback for sustainability of efforts.
Sheehan, L, et al	2017	Canada	LEAN methodology	Intervention aimed for a 57% increase in total rehabilitation intensity minutes in a six-month period.	Using LEAN methodology, creation of value stream maps and three sub-groups occurred: “Patient Scheduling and Processes, Environment and Education” aiming to decrease waste.	Results included layout changes of health professional office, finishing “5S” LEAN processes, clean supply room and storage room for interprofessional team, and increased volunteers assisting patients to the gym.	Resulted in increase in rehabilitation intensity.
Sureshkumar, S.M.J.F.H.J.	2020		Plan-Do-Study-Act methodology	Intervention aimed to identify areas of improvement for high-performance teams.	(PDSA) cycle 1 focused on identifying areas of improvement via a survey and a resurvey after implementation with the multidisciplinary team. PDSA cycle 2 improved the morning huddle with introducing a local checklist from SAFER patient flow bundle and recommendations for best practice. Patient safety data element and patient experience element were collected.	The PDSA cycle 1 showed significant change within the four variables: general organization, junior doctor accessibility, efficiency, and patient care. There was an increase in the documentation, discharge summary completion and patient compliments during the QIP period.	Resulted in improved outcomes for multidisciplinary team treatment.
Thornton, M, et al	2015	Canada	Quasi-experimental / before-and after	Intervention aimed to improve physiotherapists’ awareness, knowledge and clinical practice for aerobic exercise training post-stroke using knowledge transfer.	Content experts developed an e-learning program of four case-based modules were developed. a pre- post-questionnaire was used for assessing effectiveness in improvements in physiotherapists’ knowledge and confidence.	Pilot testing of program content and delivery, and effectiveness in enhancing knowledge and self-efficacy of 25 physiotherapists was presented.	Project is expected to result in positive change to physiotherapists’ practice by improving knowledge and self-efficacy in applying the guidelines.
White, J. and C.J.I.J.o.S. Stager	2015	Canada	Quasi-experimental / before-and after	Intervention aimed to introduce changes to patient beds and having a separate general rehab unit. Outcomes included LOS, Alternate Level of Care (ALC), and referral rate.	Intervention included integrating six medical beds into a thirty bed general rehabilitation unit (A2), adding nine stroke rehabilitation beds, creating fifteen dedicated integrated stroke beds as well as site visits, review of staffing models, implementing staff prior learning evaluations and education.	Data demonstrates improvements in LOS, ALC, referral rate, process improvements, seamless transitions, improved patient experience, implementation of quality practices, broader acceptance and utilization of tools and a stronger collaborative practice model.	Improvements in key indicators, patient experience, and quality practices.
Yong-Jae, K. and K. Eun-Jung	2012	NA	FOCUS-PDCA model.	Intervention aimed to develop an integrated care pathway (CP) following FOCUS-PDCA model.	Committee members developed scheduled meetings with documentation for the integrated care pathway and were expounded after FOCUS-PDCA model.	Relevant documents were elaborated to the stakeholders throughout the cycles.	Potentially promotes more structured and efficient care for stroke.

Table 3 Contextual Factors in the Research Utilizing MUSIQ

Contextual Factor	Hancock et al (2019)	Holstege et al (2017)	Jolliffe et al (2019)	Oyeyemi and Sedenu (2010)	Perry et al (2014)	Power et al (2014)	Tistad et al (2016)	Torres, A et al (2014)	Vratsistas-Curto et al (2017)	Voogdt-Pruis et al (2019)
External environment		x				x
Organization	x^a	x	x				x
QI support and capacity				x						x
Microsystem							x
QI team			x	x	x			x	x

Note: ^a“x” symbol = represents confirmation for this contextual factor (vertical axis) having an impact on QI initiatives in this current research (horizontal axis).

Liberati A, Altman D, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health careinterventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10)

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