Recently, the issue of how to involve actual service users in the service designs for Smart cities has grown in importance, as this is a key factor in determining the serviceability and sustainability of developed services. Reckless participation of users can make the service design process inefficient and cause a cost increase. So, in this study, we propose the needs map which can be applied to various stages of service development and help service designers to make efficient and reasonable decisions without being too time-consuming. The proposed needs map is a schematization of theoretical concepts for Smart city planning in accordance with the framework of service-technology-infrastructure-management (STIM). Through the needs map, various urban problems, statistical data, and users' needs in a smart city are classified and analyzed concept by concept, and these focused analysis results suggest a proper direction to researchers in the service development plan. To demonstrate experimentally the feasibility of the needs map, we applied it in practice to a service design for the Smart city experience zone located in Daejeon, South Korea. The smart city is a future high-tech city in which various information services can be provided through devices whenever and wherever by using Information Communication Technology (ICT), and is a concept that has gradually evolved from Information Cities and U-Cities. When the term “Smart city” is mentioned, rather than a simple compound of two words “Smart” and “City” in some sense it means a process of making existing cities smart. PAS 180 announced by BSI (British Standards Institution) defines “Smart city” as the effective integration of physical, digital, and human systems in the built environment to deliver a sustainable, prosperous, and inclusive future for its citizens  announced the “3rd Comprehensive Plan on Smart Cities (2019~2023)” which integrated policies and projects from government departments. It is a mid-to long-term master plan for the construction and proliferation of smart cities and the creation of innovative ecosystems, and the enhancement of global initiatives. In this period, the Korean Ministry of Public Administration & Security (MOPAS) also held a Smart City Joint Workshop with the World Smart Sustainable Cities Organization (WeGO), the World Bank, and the International Telecommunications Union (ITU), and 19 countries including India, Malaysia, and Kyrgyzstan participated in the workshop. Furthermore, local authorities and central government departments are continuing the efforts for new projects for smart cities.Technology adoption is indispensable in developing Smart cities and there are two approaches to applying cutting-edge technologies to making existing cities smart. One is the tech-driven method (TDM) and the other is the human-driven method (HDM) . This needs map can help designers to analyze and confront urban issues from various essential perspectives and find some insight either in the Living Lab process or before it starts. Through such common insight about interested issues, co-creation between users, service designers, government officials, etc. would be possible. Also, the users' needs within various social fields with urban issues can be closely understood through the needs map and reflected in the service development. That is to say, the proposed needs map is a methodology not for user participation but for smart city-tailored filtering and efficient utilization of a variety of users' needs in actual cities. To demonstrate the feasibility of the proposed needs map, we will provide an application of a Needs Map to the service design for the Smart city experience zone located in Daejeon, South Korea.In this study, we will form the conceptual framework for the needs map from the viewpoint of services for the Smart city, and it will be utilized to develop services for the Smart city experience zone to verify its necessity for the Smart city service design. The study method and scope are organized as follows.We will take three steps in this study. In the first step, key concepts for the needs map framework are considered through the literature study. In particular, we will seek to understand essential notions or entities for the Smart city service design using previous works that contain ISO SMART CITY CONCEPT MODEL GUIDELINE, and by consulting experts. In the second step, the needs map, which will consist of four layers, will have key entities appropriately located on it, with each layer being divided into four sides of service, technology, infrastructure, and management. This needs map provides useful information about what should be considered in designing specific services. Finally, the proposed needs map will be experimentally applied to service designs for the smart city experience zone to demonstrate the usability or feasibility of the needs map.Indeed, the needs map is quite utilizable in the discovery step of the service design process based on Design Thinking, in which user's surveys and studies on the situation are performed. Service completeness can also be improved by double-checking concepts missed in the service realization process. By using the needs map, researchers can thoroughly investigate extensive urban issues or users' needs in a relatively short time through cooperation with interested parties. Eventually, the needs map will help planners to survey vastly diverse urban experiences and develop sustainable services to reflect the purpose of the user-centered smart city.The eventual purpose of this study is to develop services suitable for Smart cities by finding refined needs, not from the simple classification of users and operation managers, but from the analysis of a variety of raw needs from interested parties. We hope that the proposed needs map will play such a methodological role. We organized the needs map on the basis of the STIM framework. U-City emphasized technology-based infrastructure planning . In order to reflect these needs to the service design development for Smart cities, they should be interpreted and categorized in a standard manner. Going outward from the center, the terms on the tiers become specific and detailed in the perspective of the STIM embedded model. For the needs map shown in , a roundLayer 1 is based on the STIM embedded design model. It is a promotion process for planning, designing, and operating a Smart city and is a multi-layer design model with Service-Technology-Infrastructure-Management layers which are on four rectangular sides of Layer 1, respectively.Layer 2 is for the functional aspect of the STIM embedded design model. The service sector of Layer 2 is composed of Contents and Interaction. The technology sector represents Interface and Interaction. The infrastructure sector includes Function and Interface. The management sector consists of Function and Contents. Entities on Layer 2 are defined as follows: Contents are a variety of information and details realized ultimately in the perspective of the software; Interaction is the entity for realizing the user-centered design in terms of interaction between service environment and user; and Interface is the medium and protocol for communication between thing to thing or thing to human, and should be considered for practical realization of technology models for the Smart city. Function is to help physical Infrastructure and systematic Management to play a consistent and efficient role.While Layer 2 is for functional approach of the STIM model, Layer 3 represents practical entities for design and realization in the real space. Each entity on Layer 3 can be used as the detailed goal which should be solved to realize the service.Layer 4 is composed of the data indicators that will be used to draw miscellaneous insights required for the service development of the Smart city. Sixteen statistical indicators and their details appear on Layer 4. In fact, these indicators are used in national annual surveys as statistical social indicators. Each indicator will become a region and survey subject to which practical services for the Smart city should be provided. For instance, the field of residential transportation is an important indicator which the future housing or urban model should provide as a service for the Smart city, and furthermore the supply and demand of housing, the residential status, the convenience of transportation, etc., should be checked.In this study, the needs map is defined as a visualized output on which essential entities for the Smart city service are linked into the STIM framework according to their functional meanings. In fact, before obtaining these functional entities on the layers, many important concepts for the Smart city were discussed and extracted through several expert advisory councils in line with the advent of the Smart city over the U-city see . To deriIn this paper, on the basis of these fundamental concepts for the Smart city, we discreetly selected functional entities through careful literature studies which are arranged on the layers in accordance with their practical functions. These entities are chosen to accomplish the purpose of the user-centered Smart city, and so their physical and systematic perspectives are continuously deliberated to incarnate them in sustainable services on (smart city) experience zones. Quantitative social indicators or statistical indicators also are considered to address various urban issues. These entities are distributed on layers of the needs map which form in stratum. Entities on a higher layer are more specific than those on a lower one.To reflect the various needs of users, the service sector in the needs map can show reasons or purposes for why users require and use the service. So the service sector should contain contents, their role and goal, and communication and cooperation with various related parties. In particular, contents for the Smart city should include “living” (for supporting the living convenience and safe life of the citizens), “work” , “entertainment” , and “mobility” .As described earlier, technology supports two-way communication with citizens as users in the urban space and management. So, contents for the technology sector should include sensing and interface technologies for motion detection and network processing and security for information exchange.Infrastructure includes physical facilities to realize services into the real space, and so the infrastructure sector should consider contents which are related to terms such as “built,” “movable,” and “variable.”Management implies the concreteness and realizability of the business model for sustainable services, and so the management sector should include contents such as governance establishment, private cooperation, public participation, facility operation-management, and maintenance of contents and information.The needs map in The classification of such large-scale data requires several filtering processes of data sets. In algorithms for Big Data Analysis, a filter or kernel is given in the form of a matrix and, in fact, the filtering process is a convolution of the filter with a data set. So to design filters appropriate to the purpose is very important in data classification. A needs map should permeate these filter matrixes. This filter design for the need map will be one of our future studies see .In this section, we show the feasibility of the needs map in In this step, as services developed for smart cities are intrinsically used by a large number of citizens in public places, the environment issue in the experience zone is considered. According to statistics of social indicators released by Daejeon Metropolitan City  25.1% ofThe Doan district is an area in Doan New Town and Spa Tourist Site  in Yuseong-gu, Daejeon. Yuseong Spa Station of Daejeon Metro Line 1 is located at the Doan district and two avenues (Doan-daero and Gyeryong-daero) cross on this district so that accessibility through public transportations is quite convenient. Also, the Doan district is close to accommodations, shopping towns, and large-scale apartment complexes. Since the user experience elements can be maximized, the Doan district with many infrastructures was finally selected as the experience zone after an advisory board discussion.In this study, image analysis devices  were used for the behavior analysis of the users visiting the Doan district. The field investigation was conducted on November 19, 2017, from 16:30 p.m. to 18:30 p.m. for 2 h. The user behavior survey was conducted only to check the frequency of behaviors and did not infringe on personal portrait rights see .In the behavior analysis, user's behaviors were separated into 11 pedestrian activity types and the frequency of each behavior type was counted. The behavior types are classified into essential activity , selective activity , and social activity . Peculiar features which can be identified visually such as gender, age group, vehicle possession, riding on a motorcycle or bicycle, carrying out a criminal act, or using a mobile phone, or other smart devices were also recorded  ServiceBased on items in the service sector of the needs map, the Smart View service was carefully planned. To reflect various needs for user groups we considered the content component, the communication and cooperation within diverse interested parties, and the concept of their role and goal. The content component includes living (supporting the living convenience and safe lives of the citizens), work , entertainment , and mobility , etc.Smart view is a smart streetlight which is modularized to have an assembled structure. It plays a basic role of not only a streetlight but also a security camera. Additionally, it has the environmental monitoring function to measure temperature, humidity, micro dust, and ultraviolet light, and provides public and local information through a kiosk see , 4.2) TechnologyBased on items in the technology sector of the needs map, the technological components of Smart view were carefully planned. To support the two-way communication and management with the citizens in the urban space, sensing and interface technologies were adopted to detect human movement and state, network, and processing for various information exchanges, and security. In particular, the connectability with other hardware, software, and services already used in the city was taken into consideration see .3) InfrastructureSince Infrastructure includes the physical form to realize services into the real space, Smart View was designed in the consideration of the fixed, movable, or variable functional elements. Through modularization, it can be designed into an independent kiosk according to the purpose of necessity, and it can also be designed in the application form to be connected to existing public facilities, such as a streetlight or a bus stop see .4) Operation ManagementManagement means not just the service operation, but also the concreteness and possibility of the business model for sustainable services. Thus, the governance establishment for private cooperation and citizen participation, and the management, operation and maintenance of various contents and information were considered. The integrated control to operate all information is important in the view of management, and so the role of the integrated control center is quite essential to information operation for providing the Smart View service and actual management of Smart View see , 8.In this paper, we recognized the problems of Smart city planning focused on fragmentary technology developments and proposed the needs map as a schematization of theoretical concepts for the Smart city planning in accordance with the framework of the service-technology-infrastructure-management (STIM). This study has important implications for architects, designers, planners, and policy makers who seek to develop creative Smart city services. We confirmed that researchers can thoroughly investigate extensive urban issues or users' needs in a relatively short time through cooperation with interested parties by using the needs map. Researchers can develop or analyse Smart city services through each of the layers and entities on the need map. In other words, service completeness can be improved by double-checking concepts missed in the service realization process.Furthermore, the users' needs within various social fields with urban issues can be closely understood through the needs map and reflected to the service development. Applying the needs map to not local but whole smart cites requires the management of an immense amount of data which is constantly updated. Needs from variously interested people who are men, women, residents, visitors, officials, etc. are also complicated and extensive. This demonstrates another reason why the needs map is necessary. The needs map proposes a new methodology through which user behaviors are classified, managed, and utilized for needs extraction and further service development creation for Smart cities. The classification of such large-scale data requires several filtering processes of data sets. In algorithms for Big Data Analysis, a filter or kernel is given in the form of a matrix and, in fact, the filtering process is a convolution of the filter with a data set. So, to design filters appropriate to the purpose is very important in data classification. The needs map should permeate these filter matrixes. This filter design for the need map will be our future study. Through our future study, we can analyse the current status of smart services in urban spaces and suggest directions for improving the Smart city services.To demonstrate the feasibility of the proposed needs map, we provided an application of the needs map to the service design for the Smart city experience zone located in Daejeon, South Korea. We propose the necessity of Smart View on this experience zone see . Smart VAll datasets generated for this study are included in the article/supplementary material.SA conceived of the presented idea and developed the theory. SA and SoK performed the computations and verified the analytical methods. SuK helped carry out the Mathematical concepts for analyzing associations between 4 layers of Needs Map. All authors provided critical feedback and helped shape the research, analysis, and manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


National studies on food waste quantification in EU countries present highly discrepant results due to the different quantification approaches adopted. The European Commission has published a delegated act establishing a common methodology and minimum quality requirements for the uniform measurement of food waste generated in Member States. Nevertheless, as EU countries are at different levels of development and implementation of national strategies for food waste quantification, there is a need to develop a harmonized modelling system that enables the estimation of food waste generated by Member States to assess the amounts reported by each country. The aim of this paper is to fulfil this need by presenting two modelling approaches to estimate food waste in EU countries. One approach is based on Material Flow Analysis (MFA) and combines statistical information on the production and trade of food products with food waste coefficients. The other approach is based on the estimation of food waste based on waste statistics. Three EU countries are used to illustrate the two approaches and compare the results obtained thereby. Food waste estimates from waste statistics are generally lower than those obtained using MFA, in particular at the early stages of the food chain. The MFA model presented in this article is the first of its kind developed to estimate food waste across Member States in a consistent way and through time. Crucially, this could support the definition of a baseline and binding targets to reduce food waste across the EU, as announced in the EU Farm to Fork Strategy.  The knowledge of the amounts of food wasted at each step of the value chain is key for the design of efficient food waste prevention strategies. Up to now, studies quantifying food waste have been developed using different approaches and data sources, mainly relying on secondary data, resulting in high uncertainties in the existing global food losses and waste database . CorradoTo contribute to the harmonization of food waste quantification in the EU the EC has published a Delegated Decision (EU) 2019/1597 of 3 May 2019 establishing a common methodology and minimum quality requirements for the uniform measurement of food waste generated in MSs . The delThe first modelling approach uses statistics on food production and trade combined with food waste coefficients to estimate food and food waste flows across the food chain. Examples of this approach are the works by Using a combination of statistical data sources and scientific literature, which included estimates of food waste coefficients, The second modelling approach uses waste statistics to estimate food waste generated across the food supply chain. Examples of this approach are the works by Building on the works of 2Two alternative methodological approaches to estimate food waste at national level are presented in this article. The first builds on the work done by The second approach estimates the amount of food waste based on waste statistics (WS) (hereafter designated as “WS approach”).The models can be used to estimate food waste for all MSs; as an illustrative example, three MSs were chosen to present the results: Italy, Germany, and Denmark. These countries were selected as they present different production and consumption patterns, and due to the availability of country-specific coefficients to calculate the share of food waste in household waste. A comparison between the results of the two approaches is presented for the year 2012. The choice of the reference year is related to the availability of food consumption data , which i2.1This approach is based on the model developed by In the original model , food waste was defined as: ‘food and inedible parts of food removed from the food supply chain’ to be recovered or disposed  .Instead, in the current model (version 1.0) the food waste definition has been aligned with the EU food waste definition see , which dFood waste amounts are calculated at the different stages of the food chain, i.e. primary production, manufacturing, retail and distribution, and consumption (including food services and households), and are reported in wet mass. The model follows a territorial approach in which food waste embedded in the net imports of raw and manufactured products is not accounted for.•FAOSTAT: production of crops, processed crops, livestock, livestock products, trade of crops and livestock products, commodity balance sheets (CBS) . The FAO•Eurostat: production of crops, livestock products, manufactured food products, trade of crops and livestock products .•Industry association (e.g. European Potato Processors' Association): Inputs/outputs of food manufacturing by country and products.•Scientific literature providing food waste coefficients (i.e. waste as a percentage of the input flow) based on direct measurement ).The model uses multiple sources of data, namely:The original modelling approach is presented in At both primary production and processing stages, an estimation is provided of the streams generated that are used for animal feed or other processing purposes, hence classified as by-products, and of those that are wasted.The amounts of food entering the distribution phase are taken from a range of statistical data sources and reports  No 178/2002 of the European Parliament and of the Council  that has become waste” , including both edible and inedible parts of food.•primary production corresponds to NACE activity A: Agriculture, forestry and fishing;•processing and manufacturing corresponds to NACE activities C10-C12: Manufacture of food products; beverages and tobacco products;•retail and food services correspond to NACE activities G-U_X_G4677: Services ;•households correspond to NACE activity EP_HH: Households.Food waste was quantified for the different stages of the food supply chain for specific NACE (Nomenclature statistique des Activités économiques dans la Communauté Européenne) activities i.e.those expected to generate food waste. The correspondence between the NACE activities considered and the stages of the food supply chain is the following:The main underlying data source used are the EU waste statistics, reported by each MS and collected by Eurostat based on EU Commission regulation on waste statistics (No. 2150/2002) . The was•Animal and mixed food waste (EWC-Stat W091);•);Vegetal waste (EWC-Stat W092•Household and similar wastes (EWC-Stat W101).As the waste statistics do not explicitly report food waste, the following European Waste Catalogue for Statistics (EWC-Stat) codes potentially containing food waste were identified in Eurostat (2017):The calculations of the total amount of food waste per country is obtained by means of equation 1.Equation 1Where:101β), when no country-specific coefficient was available. This was obtained by multiplying the average share of food waste in mixed municipal waste  by the average share of mixed municipal waste in W101 . These coefficients were obtained from . However, finding country-specific data sources to model this stage proved particularly challenging, and, therefore, in most cases, average EU coefficients are used for all countries. Consequently, the model might not be representative of the specific countries or specific products. This could entail that the share of food waste generated by the model is overestimated (and the share of by-products underestimated), which might explain the higher values obtained with the MFA compared to the WS at this stage. Additionally, it is quite common that the treatment of residues generated from food manufacturing takes place on site  and therefore would not be captured by waste statistics. Hence, also in this case, the waste reported in the statistics is expected to be lower than the waste estimated by the model, which includes all streams that become waste (both on- and off-site).At retail and distribution, the differences in the results obtained with the two approaches are generally less significant. The WS method provides a 13% lower value than the MFA for Germany and a 17% higher value for Denmark. However, in the case of Italy, the value reported by the WS is 99% lower than the value obtained with the MFA approach. Contributing to this difference is the fact that, for Italy, the amount reported under waste code W101, for all NACE activities except for EP_HH, is equal to zero. At retail and distribution, the MFA approach estimates the amount of food waste potentially generated by the three countries based on the amounts of food products entering this stage and on average (i.e. non country-specific) food waste coefficients extracted from the literature. However, in some contexts part of such food might be collected for animal feed production or for value added products (e.g. rendering of meat to produce fats)  and ther91 and β92 are not country specific and β101 might not be representative of the entire country. At household level, the MFA approach estimates food waste generated regardless its destination, including food waste disposed of via the sink, home composted or fed to pets. In some countries, these destinations resulted to be a significant component of household food waste. For instance, according to  a significant variation in the food waste weight might occur due to water evaporation. For example, in a study developed by The estimation of food waste on a macro scale is not trivial. There are disadvantages with respect to data availability and related uncertainty. Both approaches use data from national statistics published by FAO or Eurostat, affected by a degree of uncertainty. It is difficult to determine the level of uncertainty as the data is reported from multiple sources and it is inherently of varying quality.According to , the EU A major difference between the two methods is related to how food waste is defined. In the MFA approach, food waste is estimated using a standard definition specifying the system boundary. This is not the case for food waste estimated from waste statistics, where food waste is not reported as a separate category and it was assumed to be a portion of the waste reported in specific categories that contain food waste.In addition, there is a temporal disparity in the availability of data, as waste statistics are reported every two years by Eurostat , while tBenefits of the MFA approach are that: (i) it includes all food waste generated regardless of its destination, (ii) it provides an estimation of the consumed amounts of different food products, enabling to perform a plausibility check of the results , and ii.However, this approach presents some drawbacks. One is that it largely relies on the use of food waste coefficients, which are available for few countries and may not be representative enough due to limited sample for data collection and biases in the methods used to collect data (e.g. surveys very often lead to an underestimation of food waste generation). Furthermore, due to the inherent cost of collecting such data, it is very rare that this is done periodically, enabling to establish a temporal trend (e.g. a reduction in food waste generation). This means that a coefficient collected in one MS might be used to model household food waste generation in the remaining MSs, and that such coefficients are static (if not updated regularly), meaning that the model would not able to capture changes in waste generation patterns caused by e.g. awareness campaigns or national programs to tackle food waste. Furthermore, this approach is affected by gaps in statistical data caused by e.g. confidentiality issues. This aspect is particularly relevant when the model is applied at MS level, as aggregated values at EU level are generally provided even when they are not provided at national level for all MSs. Consequently, for countries not reporting the production or trade of certain products, the amounts of food entering the distribution phase might be underestimated (if either the production or imports are not reported) or overestimated (if exports are not reported) and subsequently, the accuracy of food waste estimation in the following stages is affected.3.1.1Very few studies can be found in the literature quantifying food waste in EU MSs. Regarding the total amount of food waste reported in the different studies, for Germany, the total values reported in The values of food waste estimated with the MFA approach at the different stages of the supply chain are generally higher than the values reported in the studies from the literature. A major discrepancy is observed between the values reported in 3.2The MFA approach allows to derive food waste generated at food group level. The food groups presenting the largest amount of food waste at primary production are fish for Denmark, and vegetables for Germany and Italy. This is partly influenced by the food waste coefficients used at primary production that are significantly higher for these three food groups compared to the remaining ones, but also by the specific production profile of each country. For instance in the case of Denmark, the production of fruit and vegetables is relatively small compared to the production in Germany and Italy. Instead, fish production is larger, which explains the higher amount of food waste generated by this food group.Similarly to what is observed for the primary production, Italy presents larger amounts of food waste at manufacturing than the remaining two countries, mostly deriving from fruit and vegetables.To enable a better comparison of food waste calculated for retail and consumption stages across the three countries, per capita results were calculated , as bothThe waste profile of the different countries  at distribution and consumption is similar . The hig3.2.1Aside the amount of food waste and by-products generated along the food supply chain, the MFA approach provides as additional output the amount of food consumed. This was compared with the average food consumption data reported in EFSA (2015) to perform a plausibility check of the output of the MFA model. The rationale followed is that, as the consumed amounts are an output of the model, if those cannot be justified, this might be caused by errors in the model. In general, the amounts of food consumed obtained with the MFA approach are higher than the ones reported by EFSA. The food groups for which the food consumed reported in EFSA is higher than the consumed amounts estimated with the MFA approach are cereals for all the countries and fruit for Denmark and Germany. As pointed out in previous work of the authors , the amoAdditionally, another issue with this comparison is that certain products, such as sugar or vegetable oil, are incorporated into processed food products at the processing stage. As this is not captured by the MFA approach, this model overestimates the amount of e.g. sugar or vegetable oils eaten as such, whilst, in the food consumption surveys on which EFSA data is based, these products would not result as they would be “hidden” under the consumption of processed food products. This makes the estimation of e.g. sugar and fats consumed very difficult, as consumers are rarely aware of the content of the processed products they eat. Therefore, the comparison between the eaten amounts according to the MFA approach and to the food consumption statistics can provide useful insights and enable a plausibility check of the results of the MFA approach only for certain food groups .4This paper presents two methodological approaches to estimate food waste in EU countries. One approach is based on material flow analysis (MFA) and combines statistical information on the production and trade of food products with food waste coefficients. The other approach estimates food waste based on waste statistics (WS). The two approaches are illustrated by means of case studies based on three EU countries , and the results obtained are compared. The added value of performing such a comparison is that it enables to identify potential anomalies as the two approaches rely on different data sources.Food waste estimates obtained with the MFA approach are generally higher than those obtained using the WS approach. These differences are more significant for early stages of the food chain i.e. primary production and food processing. Such discrepancies are very likely caused by an underreporting of waste collected by waste statistics, as waste flows generated at these stages can be treated on site  and might, therefore, not be reported. Other issues that affect food waste estimates based on waste statistics that can explain the differences obtained are: the influence of the water content on the food waste weight, the fact that countries have their own waste codes and there might be discrepancies between national classification systems and the one adopted by Eurostat, and the uncertainty associated with statistical data used, as such data is reported from multiple sources and it is inherently of varying quality. The latter issue also influences the MFA model as this as well uses statistical data. Nevertheless, this model presents a comprehensive picture of the food system, providing a breakdown of food waste estimates per stage of the food supply chain and per food group that allows the identification of critical food groups and stages. This is particularly relevant, as it can support the design of tailored food waste prevention actions, after combining its findings with environmental considerations to ensure that the food groups presenting highest embedded impacts are given priority. Although country-specific coefficients should be collected to improve the robustness of the MFA approach, the model developed has the potential to be used to assess the data on food waste that will be reported by MSs in the coming years. Crucially, this could support the definition of a baseline and binding targets to reduce food waste across the EU as announced in the Farm to Fork Strategy.Carla Caldeira: Writing - original draft, Writing - review & editing, Formal analysis, Methodology, Investigation, Visualization. Valeria De Laurentiis: Formal analysis, Methodology, Investigation, Writing - review & editing. Agneta Ghose: Investigation, Writing - review & editing. Sara Corrado: Methodology, Writing - review & editing. Serenella Sala: Conceptualization, Methodology, Validation, Writing - review & editing.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


In 2017, the European Association of Nuclear Medicine, the Society of Nuclear Medicine and Molecular Imaging, the European Thyroid Association, and the American Thyroid Association established an intersocietal working group on differentiated thyroid cancer (DTC). The mission statement summarizes the purpose, prioritization of discussion topics, and goals of the working group.The mission of the intersocietal working group is to provide a forum to discuss our differences in an open, honest, data-driven, respectful manner. Discussion should focus on areas of agreement and those disagreements which result in meaningful differences in clinical management. The group will propose potential solutions and strategies to address those differences.The intersocietal working group continues to demonstrate a constructive spirit in which a rotating group of the world’s top-level specialists on the management of patients with DTC from the fields of nuclear medicine and endocrinology have committed to ongoing discussions, which will include meeting on a yearly basis. As set out in the “Martinique Principles” , this meDuring the 2019 meeting, in addition to discussions on specific management issues, there was an extensive discussion on how to proceed with future interdisciplinary collaboration. Therefore, a steering committee of representatives from each society was assigned to investigate the topics for future meetings. To secure fresh input and ideas, it was decided that delegates from each society will be chosen on the basis of the topics of discussion, achieving a rotation of delegates to provide continuity while avoiding redundancy. We also acknowledge that the medical care for patients with DTC is multidisciplinary, involving other specialties beyond the current groups represented. However, in the interest of fostering intensive and open exchange, we feel that the number of participants must be limited for the time being. In order to gain the perspective of relevant sister society expertise while maintaining a manageable and facile group, it was agreed that representatives from other societies would be invited as dictated by the needs for the topics to be discussed. Potential expansion of permanent sister society representation within the group will be reconsidered at a future time once the effort has matured and is on more solid footing. However, the working group is certainly open to receive suggestions for discussion topics from patients, clinicians, and other thyroid cancer-related organizations. In 2019, topical discussions included the following: (1) the criteria for success of I-131 therapy, (2) whether there are variations in peri-therapeutic diagnostics which may lead to differences in treatment, (3) the optimal tests to include for post-surgical diagnostic imaging to guide the decision on whether or not to pursue I-131 therapy and (4) the arguments in favour of and against empirical and dosimetry-based approaches for determining the activity of I-131 required to treat iodine-avid DTC metastatic disease.Although there was wide agreement on these topics amongst the participants, as expected there were also differences of opinion. Despite extensive efforts to review the literature, the available evidence was found to be insufficient to provide any definitive guidance. Furthermore, while the meeting initiated very productive discussions of each of the topics, we could not arrive at consensus opinions on these important topics. Therefore, the unanimous decision was made to pursue more narrowly defined questions to allow for more in-depth discussion during future meetings of the intersocietal working group.Designing a study to assess practice differences between centers regarding peri-operative risk-stratification. Parameters to be reviewed include specific tests and procedures performed before, during and after surgery which might impact the decision about whether or not to treat with radioiodine.Providing a series of cases of DTC with increasing disease severity to appropriate experts in the working group and associated thyroid experts. Each clinician will be asked to recommend for or against I-131 therapy in each case and to recommend an appropriate therapeutic activity. This study should help better understand where disagreements in approach to therapy exist between the four societies members.Providing a protocol for a trial on the benefit of dosimetry in metastatic, I-131-avid DTC will be considered. This likely would be a two arm randomized prospective trial comparing empiric fixed dosing to whole body/blood dosimetry guided activity selection. Preliminary calculations indicate that a sufficiently and relevantly powered two-arm, randomized trial comparing a dosimetry-based activity as high as safely administrable (AHASA) to a fixed activity appears to be feasible depending on the choice of primary endpoint.Suggesting that the four societies cooperate to establish an international committee to address the evolving definition and management options for radioiodine refractory thyroid cancer.In accordance with the mission statement, the working group decided to consider several actions to further resolve points of discussion addressed during both the 2018 and 2019 meetings. These efforts are to be coordinated by designated members of the working group. Actions agreed upon include the following:The results of these efforts are expected to contribute to the group’s stated mission and to establish a solid foundation for continued fruitful collaboration. Ultimately, it is hoped that these deliberations will promote the societies developing a level of consensus that will result in the long-term benefit for our patients by achieving unified, optimized care.


The aim of the study was to evaluate the job satisfaction of official veterinarians working in the field of animal welfare control and identify both positive features and challenges of their work. An electronic questionnaire was designed to evaluate job satisfaction. The questionnaire was responded to by 73 of the 98 Finnish official veterinarians working in the field of animal welfare control. The Spearman's rank correlation coefficient was used to evaluate the relation between stress and different work-related factors. More than half of the respondents reported work-related stress or fatigue. Threatening situations, disturbed work–private life balance and a high amount of overtime work were found to be frequent underlying causes of stress. Fieldwork, especially when working alone, was perceived as the most challenging part of the work. Of the respondents, three out of four performed animal welfare inspections mainly alone. Although the respondents reported getting additional help to perform an inspection most of the times they needed it, a wish to work in a pair was highlighted. The results of the present study indicate that official veterinarians often experience work-related stress and fatigue. By testing interventions shown to be beneficial, such as providing adequate support within the work community, decreasing the workload and enabling inspections to be done in pairs, job satisfaction could be improved. A wide range of legislative provisions concerning animal welfare have been established over the last 30 years in the European Union (EU). The Member States are obligated to implement official controls in order to monitor and verify that animal welfare standards are complied with . The demIn Finland, the implementation of animal welfare control is organized at four administrative levels : the MinAccording to the Finnish Animal Welfare Act  the animOfficial veterinarians work in a demanding environment–animals must be protected from unnecessary pain and suffering, yet they have to respect the basic rights of a person to own property, including animals, and to earn a living, including through livestock production. Lepistö  called tThere are several studies on the well-being of veterinarians and it has been shown that the rates of suicidal behavior [see for review ], stressThe previous studies have mainly concentrated on clinical veterinarian practitioners, and according to the authors' knowledge there are no studies on the well-being of veterinarians working mainly in the field of animal welfare control. To bridge the gap, this study focuses on the special characteristics of these veterinarians with the aim of evaluating their working conditions and job satisfaction.An electronic questionnaire was developed together with the Finnish Veterinary Association to acquire information on working conditions of the Finnish official veterinarians and their well-being at work. The questionnaire included a cover letter in which the purpose of the study, voluntary participation, and confidentiality were explained. In addition, it was indicated that by completing the questionnaire a respondent consents to participate the study. The questionnaire was sent by the Finnish Veterinary Association after obtaining from the Regional State Administrative Agencies an email address list of the official veterinarians currently working, or that have recently worked, in the field of animal welfare control. A hyperlink to the questionnaire was sent by email to 98 recipients during autumn 2017. It was open for 3 weeks and a reminder was sent 10 days before the closing of the questionnaire. The Finnish Veterinary Association collected the responses electronically and deleted all identifying data before sending the data to the authors. No follow-up study to investigate the reasons for not responding was performed.Ethical review was not applied for as the study did not meet any of the criteria defined by the Finnish Advisory Board on Research Integrity Ethical .The questionnaire included closed, multiple choice, and open-ended questions covering the following topics: (1) background information including work experience, current position, and work content, (2) positive features and challenges of the work, (3) job satisfaction and negative side effects of the work, (4) experiencing work-related stress, (5) support from and cooperation with different partners, and (6) use of enforcement measures and educational needs .U-test and the Kruskal–Wallis H test for ordinal variables, and the Fisher's exact test for nominal variables were used to evaluate the differences between the variables. Non-parametric analysis was chosen as the Kolmogorov-Smirnov-test of normality showed that the data were not normally distributed .The respondents were categorized based on their work history as a veterinarian, an official veterinarian, and on their current position. The Spearman's rank correlation coefficient was used to evaluate the strength, and direction of a relationship between different variables. Only correlations with coefficients over 0.30 are reported. The Mann–Whitney To deepen the information gained through the closed and multiple-choice questions, some of the open-ended questions were analyzed by using content analysis , in whicp < 0.05). The data were analyzed using SPSS statistical software .The “Don't know” answers were categorized as “missing,” and ambiguous answers in open questions that could not be interpreted were excluded from the analysis. Statistical significance was accepted at a confidence level of 95% . All the respondents worked in the field of animal welfare control. In addition, the job description of most respondents included animal health and disease control and/ or by-product control. Some of the respondents also worked in the field of food control. The respondents' background information including work history and current position, and parameters related to their work are presented in The respondents ranked fieldwork, including inspections and sampling, as the most challenging part of their work . This wap < 0.01 for both). The most used means of coping in the threatening situations were “discussing,” “fleeing from the situation,” and “calling the police.”More than half of the respondents estimated that they experience work-related stress or fatigue at least weekly . The higr = 0.55 and r = 0.31, respectively, p < 0.01 for both). When the respondents perceived their commitment to work as too high, they also more often experienced sleeping disorders and disturbed work–private life balance .The more the respondents were working overtime and participating in animal welfare control outside office hours, the more often they perceived the commitment to work as too high . The impact of the work, i.e., the possibility to help animals, was ranked as the best element of the work , the less they suffered from loneliness , and sleeping disorders , and the better they perceived their job satisfaction to be . The most desired forms of support were possibility to work in a pair, supervision of work and legal advice. Two thirds of the respondents (48/73) expressed their wish to use enforcement measures together with a colleague at least in difficult cases. The respondents listed legislative education, education on animal welfare and husbandry, and training in interaction skills as the most important educational needs.The respondents reported receiving support mostly in the form of the exchange of views with colleagues, guidance from the Regional State Administrative Agencies, and support given by a supervisor. The more easily the respondents received support, the more often they perceived themselves to be suitably committed to their work . Cooperation with the work community was perceived to be better functioning and the respondents felt less lonely when it was easy to obtain a partner for performing an inspection . The respondents reported that they performed inspections most often with an official veterinarian working either as a practitioner or in the field of animal welfare control, the police or a health inspector. The respondents who performed animal welfare inspections in a pair perceived their work to be more meaningful than those working alone (p = 0.01).The respondents perceived cooperation with different partners to be mostly well-functioning . If the The Finnish official veterinarians working in the field of animal welfare control perceive their work as meaningful because they can influence the welfare of animals, but at the same time, they often experience work-related stress and fatigue. The underlying causes of stress were identified as threatening situations, such as death threats, assaults, and disturbance of domestic peace, high frequency of overtime work, disturbed work–private life balance, and the inconvenience of working alone. Long working hours have also previously been recognized as a stress factor among veterinarians , 16. AltMost of the veterinarians performed animal welfare inspections alone, most likely due to resource and financial reasons, though they perceived it inconvenient and wished to work in pairs. If the usual inspection tasks, such as observing, taking measurements, and photos, writing notes, and at the same time communicating with the client(s), were divided between two persons, it would decrease the workload of an individual veterinarian and safeguard the veterinarians', and animal owner's legal protection. The veterinarians were worried about their safety at work, and their feeling of insecurity is justified as most of them had already encountered a threatening situation at work. Clients' physical assaults are significant stressors also for human health care workers . The impWorking alone, communication problems and too high a workload were reasons why fieldwork was experienced as the most challenging part of the work of official veterinarians. Performing inspections at the homes of clients and animal facilities even against the client's will and enforcing animal welfare legislation exposes the veterinarians to challenging interactions with the clients. The impact of a client's gender on the interaction was not examined in this study; however, we previously showed that female Finnish farmers perceive animal welfare inspections more positively than male farmers and that a client's positive attitude toward inspection is associated with better interaction . The levVeterinarians may also face social and health-related human factors as these are often behind animal welfare problems , 24. OffIn this study, most official veterinarians wished to use the enforcement measures together with a colleague at least in difficult cases. The enforcement measures most often applied in animal welfare control are orders to perform correct actions within a specific time period and prohibitions for continuing or repeating an illegal procedure . FurtherThe support received from the supervisor and the work community was shown to be very important for official veterinarians. When performing inspections alone and making decisions independently on issues open for interpretation, the role of the working community as provider of support becomes highly relevant. The importance of support and the opportunity to meet and reflect on the experiences with colleagues has been recognized also by Anneberg et al.  and DeviOne of the strengths of this study is high response rate (74%). The current position of the responding veterinarians corresponded well with the overall distribution of official veterinarians in Finland. No gender or demographic information were collected as this information would have disclosed the identity of some respondents. The distribution by gender of all veterinarians in Finland is ~1:3, female veterinarians being in the majority. The confidentiality was also secured by letting the respondents respond anonymously, and by deleting all possible identifying data on the responses of the open-ended questions before sending the data to the authors.This study provides novel, valuable information about the well-being of official veterinarians whose job content differ considerably from veterinarians conducting clinical veterinary practice; enforcing animal welfare legislation may result in difficult interaction with a client, and even to threatening situations. By providing adequate support within the work community, decreasing the workload, and enabling inspections to be done in pairs, job satisfaction of official veterinarians could be improved.There are, however, also weaknesses of the study. First, only the frequency of stress was inquired about, not the severity. Second, the number of respondents in some groups, such as groups categorized based on the current position, was significantly smaller than in others, making a comprehensive comparison between the groups not possible. Thirdly, bias caused by social desirability is also possible and strong dissatisfaction with work might have been a motivation to respond.Animal welfare control work is often experienced as stressful. Having the possibility to work in a pair, adequate resources to minimize overtime work, and a well-managed, supportive work community were shown to be beneficial to the workplace well-being of official veterinarians. The findings support the testing of these interventions when aiming at improving working conditions. To be prepared for threatening situations, veterinarians should receive more training in interaction skills and cooperate well with the police.The datasets generated for this study are available on request to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent was not provided because the participants were informed that by returning the completed questionnaire they would be considered to have given consent to participate in this study.SV analyzed the data, interpreted the results, and wrote the first draft of the manuscript. LH helped with drafting the manuscript and supervised. MN participated in the drafting of the questionnaire, supervised, and helped draft the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone.This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs , guided by a participatory ‘Theory of Change’ process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases—(1) pre-implementation, (2) intervention implementation , and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention’s effectiveness For improving nursing in this pilot setting.We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone.Protocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021.The online version contains supplementary material available at 10.1186/s40814-021-00768-5. Over 5 billion people in the world do not have access to safe, affordable, and timely surgical and anaesthesia care when needed . While sMortality after surgery in Africa is two times higher than the global average, despite patients being younger, having a lower-risk profile, and developing fewer complications . The risHigh-quality surgical care requires effective communication across a multidisciplinary team –10. A baDespite wide recognition of the importance of good nursing documentation practices, the quality of such documentation in LMICs remains poor. There are many facets to the problem including missing, insufficient, and unclear information in clinical records; poor completion of forms; incorrectly recorded patient identifiers with missing signatures, dates, and times; and insufficient use of discharge summaries and provision of care plans , 17–21.In recent years, numerous efforts aiming to improve the quality of nursing documentation have been undertaken. Evidence-based approaches to improving documentation include interventions such as national clinical audits with data feedback , 22, theOf these interventions for the improvement of nursing documentation, only some are suitable for implementation in LMIC health care settings. For example, electronic data record systems are not easily implementable in many LMICs due to unreliable computer networks and equipment, low computer literacy level amongst health care staff (HCS), and high costs . As a reThis pilot aims to assess the feasibility of delivering and assessing a set of evidence-based interventions to improve paper-based nursing documentation for surgical patients in the surgical wards of one hospital in Sierra Leone , 30. TheThis is the feasibility pilot  of a proThe study was co-developed and co-designed during 2019 by hospital HCS and UK-based global health researchers in close collaboration with local experts in the field and Ministry of Health and Sanitation of Sierra Leone staff (MoHS). During the co-development process of this project, emphasis was put on the assessment of the needs, identification of contextual determinants to implementation, and careful selection of interventions appropriate for the local context. This process was guided by the Theory of Change (ToC) approach that can facilitate the development of complex theory-driven interventions . To ensuImplementation science is a research methodology that uses theoretical approaches  to understand the components and implementation strategies necessary to promote context-relevant adoption of evidence-based interventions, to increase their effectiveness . The impIn addition, to support the delivery of the QI process within a complex health care environment that changes over time in predictable and unpredictable ways, improvement methods can be used . Plan-DoTo optimise the evaluation of the outcomes of this project, two formal evaluation frameworks will be used, the Kirkpatrick Learning Evaluation Model  and the Acceptability: perception amongst stakeholders that the new intervention is agreeable.Adoption: intention to apply new intervention.Appropriateness: perceived relevance of the intervention for the setting and problem.Feasibility: extent to which an intervention can be applied.Fidelity: the proportion of management protocol components completed as intended.Coverage: the proportion of eligible patients who actually receive the intervention.Cost: costs of the intervention, including the delivery strategy.Sustainability: extent to which a new intervention becomes routinely available/is maintained post-introduction.The implementation outcomes taxonomy proposed by Proctor and colleagues  proposesTo ensure consistent defining and reporting of the study, Standard Protocol Items: CONSORT Extension to pilot and feasibility studies and Recommendations for Interventional Trial (SPIRIT) checklists adapted to protocols of pilot and feasibility studies, have been applied –45.This pilot study will last for one year (planned start-end date: Jan-Dec 2021)The study will take place within the surgical department of Connaught Hospital, the main referral hospital in Sierra Leone for both adult and paediatric surgery (excluding obstetrics).There are 6 surgical wards that are included in this study .Nursing documentation forms currently being used at Connaught Hospital include the Green registration card which is completed at registration by administration staff, and in triage by triage nurses and doctors; the Yellow admission folder which is completed by ward nurses during admission onto a surgical ward; vital sign recordings on the Sierra Leone Early Warning Score (SLEWS) form; and Nurses Daily Report form (daily written notes) that are both completed by ward nurses on a daily basis Fig. , Table 1The project consists of three distinct parts: pre-implementation, intervention implementation, and evaluation Table Table 2PThe pre-implementation phase has been completed and included the following activities.The QINDT consists of a working group and nursing champions who will support the delivery of the project. The QINDT (working group and nursing champions) will be provided with training and support by the research team for the duration of this project, through regular meetings, workshops, presentations, and written reference materials. Further details on composition and remit of the QINDT are available in Appendix One of the barriers that were identified during the intervention development process was lack of equipment on the wards to measure vital signs, such as blood pressure machines, oximeters, and thermometers. To address this structural gap, all six wards that are part of this project were provided with a set of equipment to enable the nurses to measure vital signs.Another structural barrier that was identified and explored during the intervention development process was the need to review and update current policies and forms related to the nursing hospital documentation practices. As a result, members of the hospital medical records department, matron’s office, and the surgical department, with support from the research team, have reviewed and updated the current nursing documentation policies and forms. One of the main changes to be introduced as part of this project will be use of a nursing documentation framework that will be recorded on nursing daily reporting forms. The updated forms will be used in the intervention implementation phase.The intervention consists of three components. Each is delivered by use of a PDSA cycle and is focused on a specific element: raising awareness of high-quality documentation (PDSA1); improving knowledge, skills, and attitudes around documentation (PDSA2); and finally, introducing an audit and feedback mechanism to support sustainable implementation (PDSA3). These are described in more detail below.To introduce simple and cheap educational interventions that will raise awareness amongst HCS of the importance of quality clinical documentation in all groups of HCS within the surgical department.Deliver, assess, and adjust the awareness drive .The awareness drive will consist of two parts—WhatsApp texts and educational posters that will be implemented simultaneously. The content and design of WhatsApp texts and posters will be co-developed by the research team and QINDT using infographics.WhatsApp communications will be sent to all staff within the surgical department on a weekly basis, using existing WhatsApp groups. Educational posters will be displayed in all clinical areas  to act as a visual aid reminder. Educational posters will be regularly checked to make sure they are in suitable places and in good condition. These activities will be undertaken by the research team.After 3 weeks from the beginning of the awareness drive, several outcomes to assess feasibility of delivering the intervention and capturing learning, process, and implementation will be collected and analysed as detailed in Tables Based on the results from the analysis, changes or adjustments will be made to make improvements to the awareness drive (e.g. to WhatsApp text and posters). Findings of the awareness campaign will be disseminated through departmental meetings, QINDT, Hospital Newsletter, and WhatsApp.To introduce a training package for the nursing staff which will increase adherence to the hospital documentation standards.Deliver, assess, and adjust a training package for improved nursing documentation.Ninety percent of nursing staff of surgical department will have attended a training workshop.Ninety percent of nursing staff will have had a minimum of two 1-to-1 support sessions.The training package for nurses to improve the quality of nursing documentation in the surgical department will consist of two parts—a training workshop and ward-based 1-to-1 support sessions. The content, design and evaluation tools of this package will be co-developed by the research team, QINDT, and educational experts, using adult learning theories. To ensure the training package is culturally and contextually appropriate, and the workshop design and delivery methods used are effective, it will be piloted to a small group of staff who were not involved in the development process. The results of the pilot will be analysed, and the changes and adjustments to context and delivery of the training package will be made before finalising and approving the training package by the matron’s office.The training package will be delivered by the members of matron’s office and educational experts and coordinated by the research team. The entire process will be overseen by NB.A 1-day workshop will be delivered to surgical nurses currently on the payroll including the matron’s team and nurses covering five general surgical wards and the trauma ward, as a mixture of didactive, interactive, and practical sessions. Each nurse will be required to have at least two 1-to-1 sessions that will be delivered on the ward by champions. During these sessions, three to four nursing daily notes from ward patients will be assessed on the application of the implemented nursing documentation framework for daily reporting, using a nursing documentation framework evaluation checklist and evaluation form (to be designed). Nurses will receive verbal and written clarification of any queries that arise during this session related to nursing documentation in general and nursing process framework in particular. There are 120 surgical nurses currently on the payroll. All will be invited to take part in the training workshop and 1-to-1 supportive supervision sessions.After 3 weeks from delivery of the training package, several outcomes to assess feasibility of delivering the intervention and capturing learning, process, and implementation will be collected and analysed as detailed in Tables Based on the results from the analysis, any changes and adjustments will be made to the training package before being incorporated into regular new nursing staff induction sessions and continuing professional development programs. Findings of the training package assessment will be disseminated through presentations to the MoHS, surgical departmental meetings, QINDT, Hospital Newsletter, and WhatsApp.To co-develop and co-introduce an audit and feedback (A&F) process for nursing documentation by the research and clinical staff that is culturally and contextually appropriate and sustainable after the end of the intervention.To co-introduce, assess, and adjust an audit and feedback (A&F) process, which reports results of quality of nursing documentation to the hospital QI committee and takes action to make improvements based on these results.Development includes the identification and training of the staff by the matron’s office, development of the audit forms and a database to record the results, and determining frequency and sampling strategies of audit and feedback. A simple user-friendly ward-based audit form will be designed by QINDT that will be used for regular nursing documentation assessments. The A&F process will be structured around existing hospital/surgical department routine and changes that have been introduced during this project.All staff assigned to participate in the A&F (i.e. champions) will be provided with a one half-day training session, to ensure they understand how to use the new tool and the whole audit process.The A&F process will be undertaken within PDSA1 and PDSA2 cycles as part of the ‘study’ component and led by the research team in collaboration with the QINDT. During this time, the process will be evaluated for appropriateness for long-term use and any changes made as necessary. After the end of PDSA1 and PDSA2 cycles, the A&F process will continue to be undertaken but now led by the matron team independently from the research team, according to the developed and agreed plan.After 2–3 audit and feedback cycles undertaken and led by the matron team (independently of the research team), several outcomes to assess feasibility of delivering the intervention and capturing process and implementation will be collected and analysed as detailed in Tables Based on the results from the analysis, any changes or adjustments will be made if needed. Findings will be disseminated through departmental meetings, Hospital QI Committee meetings, Hospital Newsletter and WhatsApp.The evaluation phase will include three types of evaluation. First, we will assess the feasibility of delivering the intervention and capturing the outcomes needed to evaluate the implementation and effectiveness of this intervention. If feasible, second, we will evaluate the implementation and the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation and process outcomes related to training. Third, we will evaluate the intervention’s effectiveness to improve quality of nursing documentation in this limited setting. All outcomes that will be collected as part of the pilot are described below.For each PDSA, we will assess the feasibility of delivery of the intervention and of assessing the outcome. As an implementation science project, PDSA cycles enable adjustment of the intervention if it is not delivered as intended. Each PDSA can stand alone; hence, progress to the next one is not contingent on delivery and assessment of outcomes being feasible in the preceding one. Issues in data capture will inform assessment methods for wider roll out of the project in multiple hospital settings. We will also assess feasibility of capturing data to evaluate the effectiveness of the project. If these data are feasible to collect, we will continue to collect to sample size to inform whether the intervention is effective and therefore should be tested in multiple hospital settings, in different contexts, and for different specialties.All outcomes that will be collected to evaluate the impact of implementation and implementation strategies are detailed in Table The effectiveness outcome is a composite measure of the number of nursing daily report forms that was compliant and completed. Compliance is defined as the % of times a nursing daily report had been completed as required by the current hospital policy, and completeness is defined as % of nursing daily reports that have all compulsory fields completed . All process outcomes that are required to calculate effectiveness outcomes are listed in Table All data will be collected using RedCap software .Details of proposed sample sizes for all the outcomes are given below and captured in Fig. A purposive sample of 80 doctors and nurses, as they enter the hospital, will be asked to take part in a survey capturing responses to the awareness drive WhatsApp messages and posters that are displayed. There are approximately 450 doctors and nurses present at the hospital during daytime shift. A sample of 80 will represent just under 20% of the total number of doctors and nurses, which is within a recommended sample size for pilots and feasibility assessments.Up to a maximum of 16 health care staff will participate in two focus group discussions (FGDs) to assess their reactions to the awareness drive exercise, an equal number of nurses and doctors will form the two focus groups.There are 120 nurses on the payroll in the surgical department. All nurses will be invited to participate. If we assume a 70% participation rate, we expect 84 nurses to take part. Approximately 20 nurses will be interviewed using qualitative semi-structured interviews after completing the training package. We will use quota sampling to ensure that we have surgical ward representation across all six wards. We will continue interviewing until thematic saturation has been reached, which we anticipate will be achieved after interviewing 20 nurses.There will be approximately 30 hospital staff involved in the audit and feedback co-delivery phase. All of them will be invited to complete the implementation outcome questionnaires. Ten staff members will be interviewed using semi-structured interviews. We will use quota samplings to capture information from health care staff from the hospital at all levels and will include the following members: matron, hospital manager, working group members, two nurses in-charge, and five ward nurses.effectiveness outcome, 10 surgical patient files from each of 6 wards will be selected at various time points  giving 60 files in total. Assuming that the average in-patient time of a surgical patient at Connaught Hospital is 7 days, it will provide 420 days of nursing notes for analysis at each time point. Assuming nurses’ daily notes are recorded on 50% of the days at baseline, the sample size of 210 provides 85% power to detect as significant (at the 5% level), an increase of 15% from baseline, in completion and compliance rate of nurses daily notes, including a set of four compulsory fields  and application of a Nursing Documentation Framework (criteria to be defined).For the The feasibility outcomes will be used to understand what changes needs to be made to the protocol in order to successfully deliver this study and replicate in other hospitals. The data on implementation  of the interventions and implementation strategies piloted in this study will be captured and used to make changes to each component of the intervention  that are needed for successful implementation. Any modifications that are required during this pilot will be monitored and described. The results will be discussed with the stakeholders who will be required to help with the interpretation of findings in the context and agree to any proposed changes .t test) statistical testing will be used as appropriate [For the effectiveness outcome, the change from baseline in the percentage of compliance and completeness rates will be calculated and formally tested using non-parametric  and parametric  Team.