Lisanne Hut-Mossel

In Chapter 1 of this dissertation, a general introduction is provided on the main topics (namely types of audits, the effectiveness of audits, and the role of residents in quality improvement strategies) and the issues addressed. We explain that quality and safety issues have become increasingly important in hospital care over recent decades because they directly influence both clinical outcomes and patient satisfaction and experiences. However, a gap remains between ideal care, based on the best available scientific evidence, and the care actually delivered to patients. To bridge this gap, health authorities and organizations currently prioritize quality improvement strategies. A frequently used strategy within hospitals for quality improvement is the audit. Audits are seen as a systematic and continuous approach aimed at addressing healthcare problems, improving service delivery, and ultimately delivering better patient outcomes. Many audits, however, are developed without explicitly building on previous research or being supported by theory. This dissertation aims to gain more insight into how and why audits may or may not lead to improved quality of hospital care, how residents develop quality awareness and leadership in quality improvement, and how hospitalists evolve in their role as 'champions' of quality care.

Which mechanisms ensure that audits deliver their intended results, and which contextual factors determine whether the identified mechanisms result in the intended outcomes?
In Chapters 2 and 3, we examined, based on a systematic literature review, how and why audits do or do not lead to improved quality of hospital care. Chapter 2 describes the study protocol for our systematic realist review. Chapter 3 addresses the execution of the proposed realist review. This realist review goes beyond simply describing specific audits and their outcomes (O); we also emphasize context (C) and underlying mechanisms (M) in so-called CMO configurations (CMOcs). This means we analyze how healthcare professionals use the intervention's resources (M-resource), how they respond to them (M-reasoning), and what intended or unintended outcomes (O) result. We identify seven CMOcs that explain the mechanisms and contextual factors determining why audits may or may not lead to improved quality of hospital care: 1. Externally initiated audits increase quality awareness, but the effect on quality improvement decreases over time. 2. A sense of urgency among healthcare professionals stimulates their involvement in an audit. 3. 'Champions' are crucial for healthcare professionals to make an audit valuable. 4. Audits started by healthcare professionals themselves ('bottom-up') have a higher chance of leading to lasting changes. 5. Knowledge sharing within externally mandated audits promotes participation by healthcare professionals. 6. Audit data support healthcare professionals in raising issues in discussions with management. 7. Audits make providing feedback to colleagues legitimate, reducing the sense of hierarchy and fostering constructive collaboration. These CMOcs provide policymakers and practice leaders with a solid conceptual foundation for designing context-sensitive audits in diverse environments and promote research on audits in various contexts.

How do residents develop quality awareness and leadership in quality improvement during a clinical audit as part of their postgraduate training, and how does the learning environment influence this development?
In Chapter 4, we examined how residents develop quality awareness and leadership in quality improvement by performing a clinical audit during their training, and what role the learning environment plays in this process. During clinical audits, residents collect data and systematically evaluate delivered care based on established standards, guidelines, or work agreements within their clinical setting. Residents develop quality awareness and leadership by gaining knowledge through their experiences. They do this by presenting audit results and motivating colleagues to implement changes. They also promote a sense of shared responsibility for quality improvement and demonstrate leadership in quality, supported by the results of the clinical audit. Furthermore, residents show leadership by ensuring that the Plan-Do-Check-Act (PDCA) cycle is completed after performing a clinical audit. However, the successful implementation of clinical audits in postgraduate training faces various challenges. These challenges include: 1. Residents recognizing the value of clinical audits and taking shared responsibility for conducting audits and improving patient care. 2. Support from department leadership in ensuring the involvement of all healthcare professionals in clinical audits as a strategy for quality improvement. 3. Role modeling by staff physicians that aligns with the vision of department leadership, where quality improvement is seen as an integral part of daily clinical practice. 4. The effort of healthcare professionals to promote collaboration and team-based learning. Clinical audits can be a meaningful strategy for residents to develop their quality awareness and leadership in quality improvement. Developing these skills requires a supportive clinical learning environment in which medical staff recognize the importance of clinical audits and integrate them as part of the department's clinical governance.

How do hospitalists in training develop their role as 'champions' within the framework of quality improvement projects in hospital care, and why are some more effective in leading a quality improvement project than others?
In Chapter 5, we investigated the experiences of a specific group of residents, namely hospitalists in training, during their quality improvement project. We expected these doctors, after identifying care processes needing improvement in their own practice, to take ownership and responsibility for implementing improvement actions. This study allowed us to explore the challenges residents face in their development as 'champions,' particularly in building credibility. Credibility is crucial for gaining the trust of other healthcare professionals and achieving successful, sustainable quality improvements. We found that four characteristics of credibility are essential for hospitalists in training to be successful as 'champions': 1. Showing persuasiveness regarding the need for change, supported by clinical evidence. 2. Demonstrating competence in their clinical work and dedication to their tasks. 3. Creating shared ownership of the quality improvement project with other healthcare professionals. 4. Acting as a team player to promote collaboration during the quality improvement project. Two contextual factors are crucial for the hospitalist in training to move the quality improvement project forward: Choosing a subject perceived as urgent by all stakeholders involved, and gaining support from the Board of Directors and informal leaders, so the hospitalist can successfully lead the quality improvement project. We believe that many of the necessary traits identified in this study, such as communication and collaboration skills, can be learned. Our findings can help healthcare organizations prepare professionals to effectively lead quality improvement strategies. Credibility seems to build gradually over time, just as trust must be built with supervisors who determine to what extent they can trust residents to perform patient care independently. We observe that hospitalists in training are considered credible by other professionals when they act as team players, emphasizing the importance of each team member's contribution and valuing all stakeholders as such in the quality improvement process. This collaborative approach is essential for building trust and realizing successful quality initiatives.

DISCUSSION AND CONCLUSIONS
In Chapter 6, we discuss our main findings and place them in a broader scientific and practical perspective. We mention the limitations of our research and describe the implications for practice and future research. Overall, we have been able to state that audits in hospital care can be useful for improving care quality. Nevertheless, change in practice often proves difficult, especially in an educational setting. These insights, combined with suggestions from literature, emphasize that quality initiatives are a learning process. In an ideal world, it would be standard for healthcare professionals to engage in quality improvement, collaborating interprofessionally and sharing responsibility for care quality. However, our research shows that it is a challenge to get everyone 'on board' and to implement lasting improvements in daily practice. To make quality improvement an integral part of the daily work of all healthcare professionals, a supportive context is needed that stimulates a shared vision of quality and promotes collaborative learning. Our research emphasizes that collaboration between healthcare professionals is crucial during quality initiatives. The positive impact of teamwork, the importance of credibility, and navigating between different professional groups play a central role. By focusing on these aspects, organizations can make quality care an integral part of daily practice, ultimately benefiting patient care.