Abstract
{ "background": "District hospitals in Nigeria face systemic challenges affecting patient safety and clinical outcomes. Existing quality improvement approaches often lack a structured, holistic methodology to diagnose and prioritise systemic failures across interdependent operational domains.", "purpose and objectives": "This study aimed to evaluate the efficacy of a novel Systems Diagnostic Framework (SDF) in reducing systemic risk within district hospitals, compared to a standard audit-and-feedback protocol.", "methodology": "We conducted a parallel-group, randomised field trial. Twenty-four district hospitals were randomly allocated to implement either the SDF or the standard protocol. The SDF integrates a multi-domain assessment tool with a causal network analysis to identify leverage points. The primary outcome was the change in a composite risk score measured at baseline and after the intervention period. Analysis used a linear mixed-effects model: $\\Delta Y{ij} = \\beta0 + \\beta1 T{ij} + uj + \\epsilon{ij}$, where $T_{ij}$ indicates treatment assignment, with robust standard errors clustered at the hospital level.", "findings": "Hospitals using the SDF demonstrated a significantly greater reduction in the composite risk score (mean difference: -12.4 points, 95% CI: -18.6 to -6.2) than control hospitals. The SDF group identified 40% more critical interdependencies between administrative, supply-chain, and clinical processes as primary risk drivers.", "conclusion": "The Systems Diagnostic Framework is a more effective tool for identifying and mitigating systemic risk in resource-constrained hospital settings than a conventional audit approach.", "recommendations": "Health policymakers should consider integrating systemic diagnostic tools, like the SDF, into national hospital quality improvement programmes to target root causes of operational failure.", "key words": "health systems strengthening, patient safety, quality improvement, randomised trial, diagnostic tool, causal analysis", "contribution statement": "This paper provides the first experimental evidence for a structured systems diagnostic method in hospital risk management, demonstrating its superiority in