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PubMed1992

Implementing practice guidelines through a utilization management strategy: the potential and the challenges.

Although there is currently much enthusiasm for practice guidelines, far more energy and resources have been expended on their development than on their implementation. A prospective interventional trial was performed using a previously validated explicit practice guideline (decision aid) to decrease the hospital length of stay for selected "low-risk" patients with chest pain. Utilization management (UM) coordinators (RNs) and physicians were chosen to implement the guideline since these resource people are available in most hospitals, allowing for generalization of the experience. With explicit review criteria used for 624 patients, it was found that when the guideline was applied by UM coordinators, it had a sensitivity of 0.85, a specificity of 0.90, a positive predictive value of 0.76, and a negative predictive value of 0.94. The attending physicians failed to override falsely classified low-risk patient recommendations 51% of the time. Implicit review judged that outcome might have theoretically been worsened in two of these patients. Follow-up at 30 days after admission, however, revealed no untoward sequelae in falsely categorized patients discharged according to the guideline. Utilization management appears to be a promising mechanism for guideline implementation that is available in most institutions. However, the accuracy with which UM coordinators implement guidelines should be assessed rigorously. Guidelines should be implemented in an environment of checks and balances in which physicians have the ultimate responsibility for their patients' care.

Adult↗

PubMed2006

Absorptive capacity and disbursements by the Global Fund to Fight AIDS, Tuberculosis and Malaria: analysis of grant implementation.

BACKGROUND: The Global Fund to Fight AIDS, Tuberculosis and Malaria was launched in 2002 to attract and rapidly disburse money to fight these diseases. However, some commentators believe that poor countries cannot effectively use such resources to increase delivery of their health programmes-referred to as a lack of absorptive capacity. We aimed to investigate the major determinants of grant implementation in developing countries. METHODS: With information available publicly on the Global Fund's website, we did random-effects analysis to investigate the effect of grant characteristics, types of primary recipient and local fund agent, and country attributes on disbursements that were made between 2003 and 2005 (phase one of Global Fund payments). To check the robustness of findings, regression results from alternative estimation methods and model specifications were also tested. FINDINGS: Grant characteristics--such as size of commitment, lag time between signature and first disbursement, and funding round-had significant effects on grant implementation. Enhanced political stability was associated with high use of grants. Low-income countries, and those with less-developed health systems for a given level of income, were more likely to have a higher rate of grant implementation than nations with higher incomes or more-developed health systems. INTERPRETATION: The higher rate of grant implementation seen in countries with low income and low health-spending lends support to proponents of major increases in health assistance for the poorest countries and argues that focusing resources on low-income nations, particularly those with political stability, will not create difficulties of absorptive capacity. Our analysis was restricted to grant implementation, which is one part of the issue of absorptive capacity. In the future, assessment of the effect of Global Fund grants on intervention coverage will be vital.

Acquired Immunodeficiency Syndrome↗

PubMed2003

The precautionary principle within European Union public health policy. The implementation of the principle under conditions of supranationality and citizenship.

The present study examines the precautionary principle within the parameters of public health policy in the European Union, regarding both its meaning, as it has been shaped by relevant EU institutions and their counterparts within the Member States, and its implementation in practice. In the initial section I concentrate on the methodological question of "scientific uncertainty" concerning the calculation of risk and possible damage. Calculation of risk in many cases justifies the adopting of preventive measures, but, as it is argued, the principle of precaution and its implementation cannot be wholly captured by a logic of calculation; such a principle does not only contain scientific uncertainty-as the preventive principle does-but it itself is generated as a principle by this scientific uncertainty, recognising the need for a society to act. Thus, the implementation of the precautionary principle is also a simultaneous search for justification of its status as a principle. This justification would result in the adoption of precautionary measures against risk although no proof of this principle has been produced based on the "cause-effect" model. The main part of the study is occupied with an examination of three cases from which the stance of the official bodies of the European Union towards the precautionary principle and its implementation emerges: the case of the "mad cows" disease, the case of production and commercialization of genetically modified foodstuffs. The study concludes with the assessment that the effective implementation of the precautionary principle on a European level depends on the emergence of a concerned Europe-wide citizenship and its acting as a mechanism to counteract the material and social conditions that pose risks for human health.

Animals↗

PubMed2006

Implementation of recommendations on hypertension: the Canadian Hypertension Education Program.

The diffusion of research evidence or practice guidelines does not, by itself, lead to changes in practice behaviour or patient outcomes. The Canadian Hypertension Education Program (CHEP) was specifically structured to have an explicit process to improve the ability of primary care professionals to use CHEP recommendations. The key features of this process are reviewed in the present report. The responsibility for implementation of recommendations is divided between the executive committee of CHEP and the Implementation Task Force (ITF). The executive develops an extensive array of summaries and implementation tools for the recommendations, and encourages and facilitates other organizations to develop educational materials and programs. The ITF creates further implementation tools, tailors the tools to specific health care disciplines and creates discipline-specific dissemination strategies. Currently, CHEP recommendations are disseminated through updated full scientific manuscripts, short scientific and clinical summaries, one-page handouts, wall posters, pocket cards, advertisements, extensive slide kits, textbooks, didactic lectures and workshops. A Web site with the recommendations in different formats is maintained to allow easy access. More recently, media releases have been used to alert the public and health care professionals to important recommendations. The transparent and interactive annual process of developing the recommendations by most of Canada's clinical hypertension experts is also viewed as critical to providing uniform educational messages to health care professionals from national and local opinion leaders. The CHEP ITF includes primary care disciplines and specialties important to blood pressure control. The CHEP process for the implementation of recommendations is very extensive and continues to evolve. There is early evidence for improvement in the management of hypertension in Canada that coincides with the initiation of CHEP, suggesting that CHEP could serve as a model for disease management recommendations.

Advisory Committees↗

PubMed2000

Clinical practice guidelines: the need for improved implementation strategies.

Although substantial resources have been spent developing clinical practice guidelines, little effort has been made to evaluate the effectiveness of their implementation. In the absence of effective implementation, CPGs will have minimal impact on changing behaviours. This article critically reviews the literature and identifies a number of reasons why these guidelines have not been implemented successfully. If CPGs are to have a positive impact upon clinical behaviour and practice, then more aggressive and positive implementation strategies are indicated. Five key ingredients for successful implementation of quality CPGs are identified and recommended.

Guideline Adherence↗

PubMed1999

Development, implementation, and evaluation of a ketoconazole practice guideline for ARDS prophylaxis.

PURPOSE: The purpose of this study was to develop, implement, and evaluate a practice guideline using ketoconazole for the prevention of the adult respiratory distress syndrome (ARDS) in critically ill patients. MATERIALS AND METHODS: In hospital A (study hospital), we developed a guideline for ketoconazole prophylaxis in patients at high risk of ARDS using evidence from two randomized trials. We prospectively implemented the guideline using intensive care unit (ICU) teaching sessions, in-services, informational posters, and patient-specific individual audit and feedback. ICU caregivers in hospital B (concurrent control hospital) did not participate in the guideline development or implementation and were unaware of the conduct of the study. RESULTS: Patients at risk of ARDS were similar in hospitals A and B. Implementation of the guideline was associated with a significantly higher use of ketoconazole use for ARDS prevention (P < .0001) and a significantly lower rate of ARDS (P < .05) in hospital A compared with hospital B. Mortality, duration of ventilation, and ICU stay were similar. CONCLUSION: Development and implementation of a prophylactic ketoconazole practice guideline for ICU patients at high risk of ARDS was associated with a higher prescription of ketoconazole and a lower rate of ARDS in the study hospital than in the control hospital.

APACHE↗

PubMed2003

Implementing good practice in epilepsy care.

Examples of evidence-based guidelines for epilepsy care exist. However, guidelines are of little use if they are not recognised, implemented and supported. The object of this study was to establish the degree to which good practice guidelines for epilepsy have been implemented and to identify positive and negative factors that affect their implementation. Semi-structured questionnaires were sent to 750 randomly selected health professionals working in primary and secondary care in England. The sample comprised nurses (200), adult consultants (including learning disability consultants) (300), paediatric consultants (150) and general practitioners (100). Aspects of good practice are being implemented in some areas, but not generally, therefore service provision is likely to remain fragmented until this is addressed. Professionals have been prevented from successful implementation of guidelines to sustain good practice due to a number of factors, most notably lack of time, workload, competing priorities and staffing levels. Factors that have promoted and encouraged the successful adoption and application of good practice include inputs from epilepsy specialist nurses (ESNs), appropriate, timely and accessible professional development opportunities and the support and enthusiasm of colleagues.

Data Collection↗

PubMed1994

Implementing TQM in a military hospital in Saudi Arabia.

BACKGROUND: Health care services in the Kingdom of Saudi Arabia are unique not only in the varied patient population served and multinational staff recruited to provide services, but also because they are not driven by financial or medicolegal constraints. As part of a five-year plan (carried out in four phases) to improve the quality of health care provided in the Kingdom, the North West Armed Forces Hospitals (NWAFH) in Tabuk became the first health care facility in the Kingdom to implement total quality management (TQM). This was not an implementation de novo, but a well-coordinated transition from quality assurance (QA) to TQM. The hospital leadership believe that TQM is best implemented when there is a strong foundation of QA to provide a pre-existing process for data collection and performance measurement. METHODS: Using the eight-step model for implementing TQM adapted from Joint Commission standards and The Health Care Manager's Guide to Continuous Quality Improvement, the QA staff identified the customers of the QA department, their needs, and professional requirements; implemented changes to meet these needs; identified internal monitors to evaluate the effectiveness of the operational changes and monitor performance; reported results and identified opportunities for improvement; and problem solved with FOCUS-PDCA. RESULTS: These efforts yielded a customer satisfaction survey in the form of a report card. In addition, three case studies launched by the QA department to address abstract data accuracy and completion, nosocomial infection rates in cesarean-section patients, and receipt of hospital laboratory reports by peripheral clinics are described in detail. CONCLUSION: The NWAFH Program leadership believes that TQM is a pancultural concept and that these first successful efforts can provide a model for the expansion of TQM not only in Saudi Arabia but throughout the rest of the Middle East.

Cesarean Section↗

PubMed1995

Think globally, act locally: an approach to implementation of clinical practice guidelines.

BACKGROUND: In an environment of concern about the rising costs of medical care, the Vermont Program for Quality in Health Care (VPQHC; the program) was incorporated in 1988 as a nonprofit organization and in 1989 was made a peer review organization by the state legislature. The program acts a resource center for health care in Vermont, coordinating three functions: implementation and maintenance of a statewide database for healthcare quality; training for health care providers in continuous quality improvement (CQI) methods and support for their CQI projects; and focusing clinical study group work on specific diagnoses or procedures. METHODS: The program uses a seven-step process for implementing CQI: pick a process (modify a nationally developed guideline or develop a new guideline); select a team of people involved in doing the work; establish goals and key quality factors; document the clinical process; determine what and how to measure; measure and analyze data; and modify the process to improve. GUIDELINE: This article describes the implementation of a guideline from the American College of Obstetricians and Gynecologists (ACOG) on cesarean section (C-section). Except for a few specific contraindications, the ACOG paper states that it is reasonable to encourage vaginal birth after C-section. A related set of criteria from ACOG states that the benchmark for emergency C-section should be 30 minutes from the decision to proceed with an emergency C-section until the baby is born. CASE STUDY: State C-section rates from 1985-1990 showed wide variation by hospital. Such wide variation is based as much on practice style as on sound science. C-section rates (primary and repeated) were measured, plotted, and shared with Vermont hospitals. Successful vaginal birth after C-section (VBAC) rates from the statewide data-base also were shared. Based on these data, one hospital, Hospital A, developed a plan to lower its repeated C-section rate and improve its VBAC rate. Hospital A collected and reviewed local data, which showed interesting variations. The time from decision to birth became the focus of the overall project; Hospital A designed its project to study events during the time from decision to birth. RESULTS: Most recent data (1992-1993) from Hospital A shows improvement in three areas. First, 89% of patients having emergency C-sections met the goal of a 30-minute time frame from decision to incision. Second, the VBAC success rate for the same time period increased to 85.7% from 69% in the previous year, and from a mere 7% before the implementation of the project. Third, the percentage of total C-sections that were repeat C-sections fell to 36% from a high of 51%. In a follow-up evaluation, one-third of the C-section performed from October 1, 1993, to July 31, 1994 were performed because of patient refusal to attempt VBAC, suggesting that there is a communitywide culture that influences behavior. A major effort at patient education on VBAC is underway. CONCLUSIONS: Think globally, act locally, might be the motto for the program. Implementing guidelines starts with obtaining national guidelines and literature but needs the use of local data to sharpen the focus on narrow areas to address. Specifically, it is unrealistic to tackle the entire problem at once. Success comes from finding specific opportunities for improvement.

Cesarean Section↗

PubMed1995

A model for practice guideline adaptation and implementation: empowerment of the physician.

The Medical Center model of practice guideline adaptation and implementation uses local clinical leaders to evaluate nationally endorsed guidelines, adapt those guidelines for use in the local setting, work with support staff to develop and apply methods for guideline implementation, and assist the evaluation of clinical practice and outcomes data. The model described here combines the guideline dissemination techniques of clinical leadership, implementation, and data support and feedback. This model overcomes the failures of previous models by incorporating local physician involvement during every step of practice guideline selection, adaptation, implementation, and evaluation, and by supporting the physician leaders with quality data, resources to support guideline implementation, and outcomes assessment and feedback.

Feedback↗

PubMed2006

The Inner-City Asthma Intervention: description of a community-based implementation of an evidence-based approach to asthma management.

BACKGROUND: In 2000, the Centers for Disease Control and Prevention funded a 4-year project to implement the Inner-City Asthma Intervention (ICAI)-an asthma treatment and management project based on the protocol developed for the National Cooperative Inner-City Asthma Study (NCICAS) funded by the National Institutes of Health, National Institute of Allergy and Infectious Disease. OBJECTIVE: To describe the ICAI's major components and implementation issues. METHODS: Information contained in this article is based on project activity and management reports, site client tracking and data collection reports, site visit and other program oversight activity, and general subject matter knowledge. The site client tracking data collection process varied among sites during the intervention. Common definitions and processes were developed and implemented as needed. RESULTS: Three of the 24 original sites discontinued participation. The remaining sites enrolled 4,174 children into the intervention. Although the project ended earlier than originally scheduled, 1,035 children completed the entire intervention. Of the 3,139 children who did not complete the entire protocol, 1,355 children and their families completed the core activities or the core activities plus one or more follow-up activities. CONCLUSION: The ICAI project demonstrated that although there were a number of implementation issues to overcome, it is possible to implement effectively a proven National Institutes of Health protocol in the community setting.

Asthma↗

PubMedDate not supplied

Implementation of the care coordinator role: a grounded theory approach.

The purpose of this study was to explore the process of implementing a new care coordinator role on a medical-surgical unit. Qualitative data were collected from employees and patients during a 3-month period; data analysis occurred concurrently. Using the constant comparative method, a grounded theory was developed to explain the initial process of implementation of the clinical nurse III (CNIII) role. The basic social psychological problem associated with implementation was role ambiguity. The basic social psychological process used to resolve this problem was "making the role of the CNIII". Making the role involves the following four strategies, which may occur simultaneously: communicating the vision, gaining new knowledge, accessing resources, and defining boundaries. Communicating the vision refers to efforts to articulate the role before and during the implementation process. Gaining new knowledge includes participating in educational workshops and acquiring new skills. Accessing resources refers to development of new relationships and acquisition of office space and equipment. Defining boundaries includes determining the scope of responsibilities and differentiating the role from other roles. This theory may be useful to researchers, educators, and administrators interested in role implementation.

Communication↗

PubMed1998

Implementing early warning messages on emerging health technologies.

The purpose of this study was to determine how horizon-scanning organizations can encourage the implementation of recommendations contained in their early warning messages about emerging health technologies. We reviewed the conclusions of the EUR-ASSESS Project Subgroup report on dissemination and impact, an overview of systematic reviews of interventions to promote implementation of research findings by health care professionals, and various Cochrane Effective Practice and Organisation of Care Group protocols and reviews. The evidence on the effectiveness of different implementation strategies aimed at distinct target groups is of variable quality. There is some evidence from rigorous study designs on the effectiveness of strategies designed to influence the behavior of health care professionals; the quality of the evidence relating to policy makers and the general public is more limited. Horizon-scanning organizations can improve the likelihood of their recommendations being acted upon by developing active implementation strategies based on the best available evidence, establishing links with key groups, and directing early warning messages at specific target audiences. Given the relative lack of good quality evidence, it is important that implementation strategies be rigorously evaluated to determine their effectiveness.

Diffusion of Innovation↗

PubMed2006

Cost-effectiveness of implementing national guidelines in the treatment of acute otitis media in children.

OBJECTIVES: Acute otitis media (AOM) is one of the most common diseases of childhood, representing a major disease burden on the society. New evidence-based guidelines for AOM, focusing on children under 7 years of age, were introduced in Finland in 1999. The aim of this study was to evaluate the cost-effectiveness of implementing those guidelines in Finland. METHODS: A 5-year prospective trial was conducted in thirty community primary healthcare centers in Finland. All AOM patients between 0 and 6 years of age visiting the study health centers for the first time, for this episode of illness, during 1 week in November 1998 (n = 579) and November 2002 (n = 369) were included in this study. The outcome measure was the percentage of symptom-free patients. RESULTS: The mean direct cost of an AOM episode per patient stayed almost the same after implementing the guidelines, euro152 in 1998 and euro150 in 2002. After implementing the guidelines, the percentage of symptom-free patients was 10 percentage points higher than before the guidelines. The treatment after the implementation of the guidelines, thus, was a dominant strategy. CONCLUSIONS: Implementing the guidelines to the treatment of AOM in children was associated with extra health benefits at slightly lower direct costs and, thus, is a dominant strategy. The focus of this study was on the short-term effects of the treatment; including long-term effects in the analysis might affect the results.

Acute Disease↗

PubMedDate not supplied

Developing and implementing clinical guidelines: lessons from the NICE schizophrenia guideline.

This paper describes the development of the clinical practice guideline on schizophrenia from the National Institute for Clinical Excellence (NICE) and outlines its main recommendations. It reviews the evidence on effective implementation of guidelines generally and examines issues specific to the schizophrenia guideline. It describes NICE's approach to supporting implementation alongside that developed by the National Collaborating Centre for Mental Health (NCCMH) and looks at local implementation examples for schizophrenia. The paper highlights key considerations for the forthcoming revision of the NICE schizophrenia guideline. It makes recommendations concerning the scope of the guideline and the quality and type of data available to the guideline developers: the lack of data on outcomes such as quality of life and social functioning, the challenges presented by unpublished papers and areas where evidence is limited. Since publication of the schizophrenia guideline, the NICE development process has undergone significant methodological improvements. The grading of evidence has been refined and more recently NICE proposed that grading of recommendations be dropped. Consensus methods are increasingly and more effectively used to deal with areas where the evidence-base is limited. NICE and the NCCMH have developed a more implementation-ready range of guideline products. The initial NICE guideline on schizophrenia was positively received nationally and internationally. This paper highlights challenges that will be involved in updating the guideline and ways to refine the methodology of development. Ultimately the impact of the guideline will be measured not in its methodological rigor but in how its successful implementation improves patient care.

Academies and Institutes↗

PubMed1997

Implementation of a patient charting system: challenges encountered and tactics adopted in a burn center.

The rapid movement of information technologies into health care organizations has raised managerial concern regarding the capability of today's institutions to satisfactorily manage their introduction. Indeed, several health care institutions have consumed huge amounts of money and frustrated countless people in wasted information systems implementation efforts. Unfortunately, there are no easy answers as to why so many health informatics projects are not more successful. In this light, the aim of this study is to provide a deeper understanding of how clinical information systems are being implemented by emphasizing research efforts on the dynamic nature of the process, that is, the "how" and "why" of what happened. Using a case study methodology, we examined the implementation of a patient charting system in the Burn Center of a large, not-for-profit, teaching hospital. Based on an in-depth examination of this implementation, several insights are offered to those who have responsibility for managing complex and risky clinical information system implementation projects.

Burn Units↗

PubMed2001

Implementation intentions and efficient action initiation.

Implementation intentions ("If I encounter Situation X, then I'll perform Behavior Y!") are postulated to instigate automatic action initiation. In 4 studies, the hypothesis was tested that implementation intentions lead to immediate action initiation once the specified situation is encountered, even under conditions of high cognitive load. First, individuals whose action control is known to be hampered by disruptive cognitive business, such as opiate addicts under withdrawal (Study 1) and schizophrenic patients (Study 2), benefited from forming implementation intentions. Second, the beneficial effect of implementation intentions was also found in 2 experiments with university students (Studies 3 and 4) in which cognitive load was experimentally induced by using dual task paradigms. Results of the 4 studies suggest that forming implementation intentions instigates immediate action initiation that is also efficient.

Adolescent↗

PubMed2006

Evidence that implementation intentions promote transitions between the stages of change.

A dietary change intervention based on Gollwitzer's (1993) concept of implementation intentions was used to see whether transitions between transtheoretical model stages could be induced in a field experiment. Participants (N=554) were randomized to receive either questionnaire-only or questionnaire-plus-implementation intention. Results showed that, controlling for variables from the theory of planned behavior, implementation intentions helped a significantly greater number of people to progress through the stages of change than did receiving the questionnaire alone. However, the implementation intention intervention did not prevent regression from the stages of change. The discussion focuses on the importance of targeting implementation intention interventions and on the future use of health professional-led analyses of critical situations and precise identification of appropriate responses to prevent regression.

Adaptation, Psychological↗