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PubMed2006

Compliance and efficiency before and after implementation of a clinical practice guideline for laryngeal carcinomas.

We evaluated whether the implementation of a nationwide clinical practice guideline for diagnosis, treatment and follow-up of laryngeal carcinomas led to changes in hospital costs, balanced against clinical changes observed following the guideline's implementation. Charts of 822 patients with larynx carcinoma (459 treated before the introduction of the guideline and 363 thereafter) in five hospitals were retrospectively investigated. In all phases, no differences in total hospital costs were observed after the guideline's implementation. Total mean costs were Euro 3,207 (95%CI 3,091-3,395) for diagnosis, Euro 3,169 (2,153-4,182), Euro 5,026 (3,996-6,057), Euro 6,458 (5,579-7,337), Euro 8,037 (7,469-8,606), Euro 12,765 (10,763-14,769), Euro 19,227 (16,848-21,605) for treatment of dysplasia, carcinoma in situ, T1, T2, T3 and T4 carcinoma, respectively, and Euro 1,856 (1,491-2,220) for 1 year disease-free follow-up. In an earlier study, we observed several positive changes after the guideline's implementation. Balanced against the equal costs before and after the guideline's implementation, we conclude that the efficiency of the care process improved.

Adult↗

PubMed2002

Practical implementation of good practice in health, environment and safety management in enterprise in the Lodz region.

OBJECTIVES: Good practice in health, environment and safety management in enterprise (GP HESME) is the process that aims at continuous improvement in health, environment and safety performance, involving all stakeholders within and outside the enterprise. The GP HESME system is intended to function at different levels: international, national, local community, and enterprise. METHODS: The most important issues at the first stage of GP HESME implementation in the Lodz region are described. Also, the proposals of future activities in Lodz are presented. RESULTS: Practical implementation of GP HESME requires close co-operation among all stakeholders: local authorities, employers, employees, research institutions, and the state inspectorate. The WHO and the Nofer Institute of Occupational Medicine (NIOM) are initiating implementation, delivering professional consultation, education and training of stakeholders in the NIOM School of Public Health. The implementation of GP HESME in the Lodz region started in 1999 from a WHO meeting on criteria and indicators, followed by close collaboration of NIOM with the city's Department of Public Health. 'Directions of Actions for Health of Lodz Citizens' is now the city's official document that includes GP HESME as an important part of public health policy in Lodz. Several conferences were organized by NIOM together with the Professional Managers' Club, Labor Inspection, and the city's Department of Public Health to assess the most important needs of enterprises. The employers and managerial staff, who predominated among the participants, stated the need for tailored sets of indicators and economic appraisal of GP HESME activities. Special attention is paid to GP HESME in supermarkets and community-owned enterprises, e.g., a local transportation company. A special program for small- and medium-size enterprises will be the next step of GP HESME in the Lodz region. CONCLUSION: The implementation of GP HESME is possible if the efforts of local authorities; research institutions and state inspectorate are combined with the support of employers' organizations.

Environment Design↗

PubMed2006

Self-regulatory strategy and executive control: implementation intentions modulate task switching and Simon task performance.

Two tasks where failures of cognitive control are especially prevalent are task-switching and spatial Simon task paradigms. Both tasks require considerable strategic control for the participant to avoid the costs associated with switching tasks (task-switching paradigm) and to minimize the influence of spatial location (Simon task). In the current study, we assessed whether the use of a self-regulatory strategy known as "implementation intentions" would have any beneficial effects on performance in each of these task domains. Forming an implementation intention (i.e., an if-then plan) is a self-regulatory strategy in which a mental link is created between a pre-specified future cue and a desired goal-directed response, resulting in facilitated goal attainment (Gollwitzer in European Review of Social Psychology, 4, 141-185, 1993, American Psychologist, 54, 493-503, 1999). In Experiment 1, forming implementation intentions in the context of a task-switching paradigm led to a reduction in switch costs. In Experiment 2, forming implementation intentions reduced the effects of spatial location in a Simon task for the stimulus specified in the implementation intention. Results supported the prediction that the need for high levels of cognitive control can be alleviated to some degree by making if-then plans that specify how one responds to that critical stimuli.

Adult↗

PubMed2006

Training and motivational factors as predictors of job satisfaction and anticipated job retention among implementers of a school-based prevention program.

Despite increasing dissemination of prevention programs, little is known about program implementers, including factors that promote satisfying job roles. Using Self-Determination Theory as a conceptual framework, we surveyed 128 implementers of the widely disseminated Primary Mental Health Project. Implementers reported 7.1 years average experience on the job (range 1-25 years), and 55% had two or more years of college. In a multivariate regression model, predictors of higher job satisfaction were: lower education level; positive perceptions of supervision and continuing education opportunities; and satisfaction at work of needs for autonomy and competence. For implementers with </=3 years experience, satisfaction of competence needs predicted job satisfaction; for implementers with >3 years experience, satisfaction of needs for autonomy and for relatedness predicted job satisfaction. Contrary to expectations, job satisfaction was unrelated to anticipated job retention.

Adult↗

PubMed2006

School predictors of the intensity of implementation of school-based prevention programs: results from a national study.

Research has indicated that the effectiveness of school-based prevention programs is affected by the implementation quality of these programs. As the importance of implementation has become clearer, researchers have begun to examine factors that appear to be related to implementation quality. Data from a nationally representative sample of 544 schools were used to examine structural equation models representing hypothesized relationships among school and program factors and implementation intensity, controlling for exogenous community factors. Significant relationships were found between implementation intensity and several school and program factors, including local program development process, integration into school operations, organizational capacity, principal support, and standardization. Implications of these findings are discussed.

Models, Theoretical↗

PubMed1991

Optimal distance from the implement to the axis of rotation in hammer and discus throws.

It is a well-known fact that a dramatic improvement in the range of any projective throw can be achieved by increasing the release velocity. In this paper a simple model of a competitor with an implement (hammer or discus) in the turns is considered. The thrower is regarded as a rigid body, and the implement as a point mass. The transverse velocity component of the implement at the release moment is maximized. For finding the optimal distance of the implement from the axis of rotation optimal control theory is applied. According to the proposed model, the optimal hammer throwing technique requires constant and maximal distance of the implement from the axis of rotation, followed by the rapid shortening of the distance immediately prior to the release. In the discus throw, however, this shortening is useless.

Acceleration↗

PubMedDate not supplied

Evaluating risk assessment implementation in child protection: issues for consideration.

The use of systematic risk assessment models by Child Protective Services is a rapidly growing phenomenon. Despite their popularity, we know little about the effect of implementation on casework practice. This article examines some issues that agencies might consider when evaluating the impact of risk assessment implementation on service delivery. The authors recommend an approach that includes the use of qualitative and quantitative measures in a process and an outcome evaluation to determine the degree to which the model has been implemented as intended and the impact of implementation on the case work process. Though this approach is likely to provide agencies with detailed information of the impact of risk assessment implementation, caution is recommended when interpreting the results from an evaluation of a risk assessment model in a field setting.

Child↗

PubMed2005

Barriers to effective implementation of guideline recommendations.

Cardiovascular disease (CVD) is the leading cause of death worldwide, and its prevention and treatment are important healthcare aims. Hypercholesterolemia is among the most important modifiable risk factors for CVD, and numerous guidelines exist for the treatment of this condition. Nevertheless, despite the existence of well-established and safe pharmacologic therapy for lowering cholesterol and preventing CVD, surveys in the United States and Europe have revealed that many patients have elevated cholesterol levels. There is a clear gap between what is known about treating CVD and the implementation of that knowledge. A survey assessing patients' knowledge about CVD observed that many patients are unaware of the disease prevalence and have little knowledge about the main risk factors, including the importance of cholesterol. Another survey demonstrated that many physicians overestimate patients' awareness of CVD and that physicians also overestimate the extent to which guidelines are implemented in clinical practice. Guideline implementation may be improved by narrowing the discrepancies between what patients and physicians believe and the reality. Many physicians claim that lack of time hinders guideline implementation and improvement of patient education. Physicians also appear to lack the motivation to implement lipid-lowering interventions. A multifactorial approach to improving use of guidelines in clinical practice may improve the treatment and prevention of CVD.

Cardiovascular Diseases↗

PubMed2006

Improvement of diabetic foot care after the Implementation of the International Consensus on the Diabetic Foot (ICDF): results of a 5-year prospective study.

The aim of this prospective study was to evaluate the efficacy of the implementation of the International Consensus on the Diabetic Foot (ICDF) in the area of Pistoia (Tuscany, Italy), in terms of percentage of population screened, reduction of hospitalization, and reduction of lower extremity amputations. The study was carried out over a 5-year period (1999-2003) in a district general hospital covering a clearly defined and relatively static population. The implementation of ICDF was performed at district health care level, in collaboration with general practitioners, and at the hospital with the establishment of a multidisciplinary care team. The database for this study was extracted from the DRG Tuscany database, and the diabetes foot lesion data source was taken from the Data Elaboration Centre of the Health Care District of Pistoia, cross-checked with the clinical records of the Diabetes Unit. In the period of the study, there was an increase in both the total number of diabetic foot lesions observed and the number of patients with diabetes referred for evaluation to the Diabetes Unit of Pistoia. Following implementation, the total number of hospitalizations for diabetic foot lesions and the duration of clinical stay were reduced. The total incidence of amputations per 100,000 inhabitants decreased from 10.7 in 1999, to 10.1 in 2000, 2.7 in 2001, 6.3 in 2002 and 6.24 in 2003. In particular, while the incidence of major amputations decreased over time, the relative number of minor amputations increased in the first years, stabilizing at a higher rate in later years. Finally, while before 1999 most people from the Pistoia area were referred to various hospitals in Tuscany for diabetic foot problems, during the implementation period almost all were referred to the Diabetic Unit of Pistoia. This study shows the advantages of prospective data collection, demonstrating that the implementation of the International Consensus on the Diabetic Foot can improve foot care in diabetes.

Amputation, Surgical↗

PubMed2004

Reduced readmission rate for alternating diagnoses of heart failure and pulmonary disease after implementation of B-type natriuretic peptide testing.

BACKGROUND: Patients with heart failure (HF) or pulmonary diseases (PD) present with similar symptoms. Effective disease management requires an accurate diagnosis. B-type natriuretic peptide (BNP) is increased in patients with HF and is normal in PD patients without cardiac involvement. OBJECTIVE: To determine if the readmission rate for patients with either HF or PD who later present with the alternate diagnosis (PD or HF) is decreased with the implementation of BNP testing at one hospital. METHODS: We retrospectively determined the impact of BNP testing on reducing diagnostic ambiguities for patients admitted to an emergency department (ED) with these diseases. We compared a HF DRG (Diagnostic Related Group) (#428) and PD DRGs (#480-496) before vs. 1 and 2 y after implementation of BNP testing. RESULTS: In a 12-month period before BNP, there were 42 total visits (15 cases) where a patient presented with a HF DRG and returned within 6 months with a PD DRG, and 41 visits (14 cases) where there was a PD-->HF readmission. One year after BNP implementation, the corresponding number of visits decreased 52% to 20 visits (15 cases) for HF-->PD, and 73% to 11 visits (8 cases) for PD-->HF readmissions. A similar reduction in readmissions was observed in the second year after BNP testing. The total number of HF and PD cases in 1999 (1029 patients) was similar to 2001 (985), and was higher in 2002 (1350) during these time intervals. The ED length-of-stay (LOS) was slightly higher for the HF-->PD cases with BNP testing, whereas there was no change in LOS for the PD-->HF cases. CONCLUSION: We hypothesize that prior to BNP implementation, there may have been diagnostic ambiguities in the initial diagnosis of HF or PD, which contributed to a repeat visit for the alternate diagnosis (PD or HF). With BNP testing, the apparent number of inappropriate visits decreased. Reducing unnecessary ED admissions helps justify the costs for implementing BNP testing in the hospital.

Biomarkers↗

PubMed2004

Implementation of the project 'Support and Consultation on Euthanasia in The Netherlands' (SCEN).

OBJECTIVE: In the project 'Support and Consultation on Euthanasia in The Netherlands' (SCEN), general practitioners (GPs) receive training in formal consultation and in giving expert advice to colleagues who have questions about euthanasia and physician-assisted suicide (EAS). This study describes the way in which this project was implemented in The Netherlands and how it was received by GPs. METHOD: In the period from April 2000 to December 2002, all GPs in the districts in which SCEN had been implemented received a written post-test questionnaire a year and a half after the start of the project. Registration forms were also filled in by the SCEN physicians and the GPs who contacted SCEN. The post-test questionnaire was returned by 60% of the GPs (n = 3614), and registration forms were returned by 86% (n = 3337) of the GPs who contacted SCEN. RESULTS: The gradual nation-wide implementation of SCEN was completed within the 4-year study period. Almost all GPs were familiar with the project (99%) and most GPs knew what they could contact SCEN for. Most GPs felt supported by the presence of SCEN, and most GPs also had a positive attitude towards consultation and SCEN. GPs who had received an explicit request for EAS, or had performed EAS, often consulted SCEN physicians (71 and 85%, respectively). Reasons for contacting SCEN were: independence (60%), expertise (58%), and accessibility/availability of a consultant (45%). Reasons for not contacting SCEN were: enough other possibilities for counselling and consultation (48%) only at the beginning of the decision-making process (36%), and sufficient knowledge about EAS (22%). Most GPs intended to use SCEN in the future (96%). CONCLUSION: The implementation of SCEN has been successful, according to the four steps for successful implementation: awareness, attitude, use and future use. In this respect, linking up with existing networks and good organisation may play an important role. Furthermore, GPs consider it important to have a facility like SCEN which they can contact concerning EAS.

Attitude of Health Personnel↗

PubMed2003

Grounding a new information technology implementation framework in behavioral science: a systematic analysis of the literature on IT use.

Many interventions to improve the success of information technology (IT) implementations are grounded in behavioral science, using theories, and models to identify conditions and determinants of successful use. However, each model in the IT literature has evolved to address specific theoretical problems of particular disciplinary concerns, and each model has been tested and has evolved using, in most cases, a more or less restricted set of IT implementation procedures. Functionally, this limits the perspective for taking into account the multiple factors at the individual, group, and organizational levels that influence use behavior. While a rich body of literature has emerged, employing prominent models such as the Technology Adoption Model, Social-Cognitive Theory, and Diffusion of Innovation Theory, the complexity of defining a suitable multi-level intervention has largely been overlooked. A gap exists between the implementation of IT and the integration of theories and models that can be utilized to develop multi-level approaches to identify factors that impede usage behavior. We present a novel framework that is intended to guide synthesis of more than one theoretical perspective for the purpose of planning multi-level interventions to enhance IT use. This integrative framework is adapted from PRECEDE/PROCEDE, a conceptual framework used by health planners in hundreds of published studies to direct interventions that account for the multiple determinants of behavior. Since we claim that the literature on IT use behavior does not now include a multi-level approach, we undertook a systematic literature analysis to confirm this assertion. Our framework facilitated organizing this literature synthesis and our analysis was aimed at determining if the IT implementation approaches in the published literature were characterized by an approach that considered at least two levels of IT usage determinants. We found that while 61% of studies mentioned or referred to theory, none considered two or more levels. In other words, although the researchers employ behavioral theory, they omit two fundamental propositions: (1) IT usage is influenced by multiple factors and (2) interventions must be multi-dimensional. Our literature synthesis may provide additional insight into the reason for high failure rates associated with underutilized systems, and underscores the need to move beyond the current dominant approach that employs a single model to guide IT implementation plans that aim to address factors associated with IT acceptance and subsequent positive use behavior.

Attitude to Computers↗

PubMed2005

Promoting adherence to antibiotics: a test of implementation intentions.

OBJECTIVE: This prospective study tested whether implementation intentions increased adherence to short-term antibiotics in a patient sample. Implementation intentions specify exactly when and where an individual will undertake an activity. They may help people achieve health behaviours, such as taking medicines. METHODS: A total of 220 patients with an antibiotics prescription were randomly assigned to four groups (control, Theory of Planned Behaviour (TPB) questionnaire, TPB questionnaire+formed own implementation intention for taking the medicine, TPB questionnaire+researcher formed implementation intention). Participants were telephoned at the end of the course to record adherence. Two hundred and seven participants completed the study. RESULTS: At follow-up, adherence was high (75.8% reported no tablets left). Analysis revealed no significant difference in adherence between groups. CONCLUSION: High adherence to antibiotics was achieved, but not improved by implementation intentions. PRACTICE IMPLICATIONS: Providing information and telephone follow-up may have been the unintended effective intervention in this study.

Adult↗

PubMed2006

Primary health care professionals' views on barriers and facilitators to the implementation of the Ottawa Decision Support Framework in practice.

OBJECTIVE: To describe primary health care professionals' views on barriers and facilitators for implementing the Ottawa Decision Support Framework (ODSF) in their practice. METHODS: Thirteen focus groups with 118 primary health care professionals were performed. A taxonomy of barriers and facilitators to implementing clinical practice guidelines was used to content-analyse the following sources: reports from each workshop, field notes from the principal investigator and written materials collected from the participants. RESULTS: Applicability of the ODSF to the practice population, process outcome expectation, asking patients about their preferred role in decision making, perception that the ODSF was modifiable, time issues, familiarity with the ODSF and its practicability were the most frequently identified both as barriers as well as facilitators. Forgetting about the ODSF, interpretation of evidence, challenge to autonomy and total lack of agreement with using the ODSF in general were identified only as barriers. Asking about values, health professional's outcome expectation, compatibility with the patient-centered approach or the evidence-based approach, ease of understanding and implementation, and ease of communicating the ODSF were identified only as facilitators. CONCLUSION: These results provide insight on the type of interventions that could be developed in order to implement the ODSF in academic primary care practice. PRACTICE IMPLICATIONS: Interventions to implement the ODSF in primary care practice will need to address a broad range of factors at the levels of the health professionals, the patients and the health care system.

Adult↗

PubMed2004

Implementing the UK Medical Research Council (MRC) RT01 trial (ISRCTN 47772397): methods and practicalities of a randomised controlled trial of conformal radiotherapy in men with localised prostate cancer.

BACKGROUND AND PURPOSE: Radiotherapy is the most frequently used treatment for men with localised prostate cancer. Conformal radiotherapy (CFRT) is a relatively new development. MRC RT01 was set-up to explore optimum CFRT dose. PATIENTS AND METHODS: RT01 was an international multi-centre randomised controlled trial for men with T1b-T3a, N0, M0 prostate cancer that evolved from a single-centre pilot trial of similar design. All men received at least 3 months of pre-radiotherapy hormone treatment, before randomisation to standard (64 Gy) or high dose (74 Gy) radical CFRT. Accrual was completed in December 2001 with 843 men randomised from 25 centres in less than 4 years. RT01 has been a catalyst for implementing CFRT across UK. In addition to the Trial Management Group, independent Data Monitoring and Ethics Committee and independent Trial Steering Committee, a Quality of Life and Health Economics (QL/HE) group, a radiotherapy Quality Assurance (QA) Group and a Radiography Trial Implementation Group were set up. The QL/HE group ensured implementation, compliance, analysis and interpretation of the QL and HE data in the trial. The inauguration of QA and Radiography groups facilitated inter-centre collaboration. The QA Group ensured procedures were in place before and during trial participation, and monitored quality and consistency with systems including a physics questionnaire, a clinical examples exercise, a standard operating procedure document, designing and building a phantom, and convening a complications modelling subgroup. The Radiography group agreed and implemented technique improvements. RESULTS: More centres participated than initially predicted, enabling recruitment better than scheduled. The trial expedited the implementation of CFRT in many UK radiotherapy centres. Additionally, the QA and Radiography groups helped ensure smooth initiation and established consistency in planning, dosimetry and delivery of prostate CFRT services at participating UK centres. Considerable data has been collected; a series of papers will be produced, although mature clinical trial results are not anticipated until 2006-2008.

Humans↗

PubMed2002

Development and implementation of the Clinical Privileges for Dietitian Nutrition Order Writing program at a long-term acute-care hospital.

A patient nutrition care plan is of little value unless it is quickly and efficiently implemented. Recognition of the value of appropriate and timely medical nutrition intervention in improving patients' nutritional status led to the development of the Clinical Privileges for Dietitian Nutrition Order Writing (CPD NOW) program at a long-term, acute-care hospital. CPD NOW is a formalized approach specifying the types of nutrition care orders that may be written by a registered dietitian (RD), allowing nutrition recommendations to be implemented immediately. More than 95% of the facility's primary attending physicians participate in this optional program. Development included an initial evaluation of physician use of RD recommendations, identification of problems in implementing these recommendations, formulation of an efficient nutrition order writing system, and adoption of this system by the medical staff. In the first 5 years of implementation, the benefits achieved by this program were: expedited order implementation, improved patient nutritional response, and increased RD responsibility. A survey demonstrated physician support of this new RD role. CPD NOW may be applicable as a model to develop similar systems in other hospitals.

Critical Care↗

PubMed2001

Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia.

PURPOSE: We developed a pneumonia guideline at Intermountain Health Care that included admission decision support and recommendations for antibiotic timing and selection, based on the 1993 American Thoracic Society guideline. We hypothesized that guideline implementation would decrease mortality. SUBJECTS AND METHODS: We included all immunocompetent patients > 65 years with community-acquired pneumonia from 1993 through 1997 in Utah; nursing home patients were excluded. We compared 30-day mortality rates among patients before and after the guideline was implemented, as well as among patients treated by physicians who did not participate in the guideline program. RESULTS: We observed 28,661 cases of pneumonia, including 7,719 (27%) that resulted in hospital admission. Thirty-day mortality was 13.4% (1,037 of 7,719) among admitted patients and 6.3% (1,801 of 28,661) overall. Mortality rates (both overall and among admitted patients) were similar among patients of physicians affiliated and not affiliated with Intermountain Health Care before the guideline was implemented. For episodes that resulted in hospital admission after guideline implementation, 30-day mortality was 11.0% among patients treated by Intermountain Health Care-affiliated physicians compared with 14.2% for other Utah physicians. Analysis that adjusted by logistic regression for age, sex, rural versus urban residences, and year confirmed that 30-day mortality was lower among admitted patients who were treated by Intermountain Health Care-affiliated physicians (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.49 to 0.97; P = 0.04) and was somewhat lower among all pneumonia patients (OR: 0.81; 95% CI: 0.63 to 1.03; P = 0.08). CONCLUSION: Implementation of a pneumonia practice guideline in the Intermountain Health Care system was associated with a reduction in 30-day mortality among elderly patients with pneumonia.

Aged↗

PubMed1996

Guidelines for cost-effective implementation of Picture Archiving and Communication Systems. An approach building on practical experiences in three European hospitals.

This paper describes a comprehensive approach for the assessment of the impact of (partial) Picture Archiving and Communication Systems (PACS). The approach is developed, based on actual clinical experience in three European hospitals and tested in these environments. The approach departs from a thorough analysis of the working procedures and information flows before implementation, both descriptive and quantitative. On the basis of this analysis, quantitative (and hence testable) objectives of the implementation are defined. The implementation strategy is defined after comparison of various scenarios, taking costs and effects for both the final and the transition phases into account. The approach is supported by a comprehensive evaluation protocol and a software package (PACER). The approach is demonstrated in this paper by applying it on a hypothetical PACS implementation for CT, ultrasound and for the part of the radiology department serving ICU. The objectives of this PACS are: (1)--to shorten the turn around time between the radiology department and ICU from 4 h to 30 min, (2)--to save 2000 m2 of film per year and (3)--to save personnel time. In this case the PACS is introduced in three phases and completed after three years. The cost analysis shows that, if started in 1995, a financial break even point is reached after 6 years, when comparing costs for the film-based system with those of the PACS. Experiences in the three sites show that the approach helps to harvest potential benefits, allowing a cost-effective implementation of PACS.

Cost-Benefit Analysis↗