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PubMed2006

Implementation examined in a health center-delivered, educational intervention that improved infant growth in Trujillo, Peru: successes and challenges.

Process evaluation was used to examine the implementation of a randomized, controlled trial of an education intervention that improved infant growth in Trujillo, Peru. Health personnel delivered the multi-component intervention as part of usual care in the government health centers. Quantitative and qualitative methods were used to examine process indicators, which included the extent of delivery (dose), fidelity to intervention protocol, barriers to implementation and context. Results demonstrated that most intervention components were delivered at a level of 50-90% of expectations. Fidelity to intervention protocol, where measured, was lower (28-70% of expectations). However, when compared with existing nutrition education, as represented by the control centers, significant improvements were demonstrated. This included both improved delivery of existing educational activities as well as delivery of new intervention components to strengthen overall nutrition education. Barriers to, and facilitators of, implementation were explored with health personnel and helped to explain results. This study demonstrates the importance of examining actual versus planned implementation in order to improve our understanding of how interventions succeed. The information gained from this study will inform future evaluation designs, and lead to the development and implementation of more effective intervention programs for child health.

Caregivers↗

PubMed1995

Training health professionals to implement quality improvement activities. Results of a randomized controlled trial after one year of follow-up.

STUDY OBJECTIVE: To test the advantages of training and of a trainee-centered educational strategy for the implementation of quality evaluation and improvement (QI) activities in Health Centres (HCs). DESIGN: Experimental, with random assignment of HCs to three different groups, two for two different training methods and one as control group. Each group had 10 HCs. SETTING: HCs network of the region of Murcia (Spain). STUDY SUBJECTS: Selected PHC personnel, grouped by study groups. INTERVENTIONS: One of the groups (GI) received trainee-centered training on QI methods with problem-solving oriented methodology. A second group (GII) received more traditional training. The third group (GIII) received no training. MEASUREMENTS: 1. Knowledge test before and after the seminars. 2. Post-seminar survey to assess trainees' appraisal of the seminar experience and attitudes towards implementation of QI activities. 3. One year follow-up survey to assess actual implementation of QI activities and attitude towards more training. RESULTS: GI showed significantly higher scores than GII regarding both their subjective appraisal of the training experience, and actual implementation of activities. No QI activity was found in any GIII Center. We conclude that the importance of training in the implementation of QI activities has been confirmed, and also that training method does matter.

Adult↗

PubMed2003

Implementation of evidence-based practices in state mental health systems: implications for research and effectiveness studies.

There is a huge gap between knowledge and practice, and between what is known through research and what is actually implemented in public mental health systems. In the past 2 decades, rigorous research has demonstrated the effectiveness of various treatments and interventions but these findings have not resulted in broad-based implementation. A major contention of this article is that while there is a growing body of knowledge related to evidence-based practices, there is a lack of understanding and research related to factors critical for implementation. This article reviews the current status of implementation of evidence-based practices in the public mental health system and identifies challenges and barriers related to their dissemination. Based on this analysis, this article proposes a research agenda that promotes the development of a science of implementation of evidence-based practices.

Evidence-Based Medicine↗

PubMed2004

Implementation of standards for individual monitoring in Europe.

A large number of standards are available for radiation protection and individual monitoring purposes. They are published by various organisations, international and national. Moreover, the increasing policy of "Quality" applied to individual monitoring requires the implementation of standards on Quality Assurance (QA) both in technical and management aspects of a dosimetric service. Implementation of standards is not mandatory; therefore, varying degrees of implementation can be found in different European countries. However, for a number of good reasons, a degree of harmonisation within the European Union (EU) of the requirements and procedures for individual monitoring would be desirable. Harmonisation as applied to dosimetric services does not mean that they should all follow exactly the same procedures, but that they should aim to meet the same general requirements, and their results should be comparable. This article aims to compile information on the use of all standards applied within individual monitoring practices, be it on the calibration of dosemeters or on the QA procedures to be applied to the overall dose evaluation process. Both "technical standards" and "quality standards" will be discussed. A list of documents of relevance to subjects such as recommendations and requirements in the field of individual monitoring, whose application could help in the harmonisation of procedures, will also be given. As it is agreed that implementation of quality standards is a relevant framework within which harmonisation can be achieved, guidance on the implementation of quality standards in a dosimetric service is given. Accreditation and approval of dosimetric services will be of relevance in the process of harmonisation of individual monitoring within the EU. In this article, a discussion of various procedures and the meaning of both forms of recognition is also provided. Although most of the text applies to the monitoring of internal and external exposure to ionising radiation, the emphasis of this practical guidance is on monitoring for external radiation with passive dosemeters.

Body Burden↗

PubMed1999

Implementation of a clinical pathway decreases length of stay and cost for bowel resection.

OBJECTIVE: To examine the effect of a clinical pathway for small and large bowel resection on cost and length of hospital stay. SUMMARY BACKGROUND DATA: Clinical pathways are designed to streamline patient care delivery and maximize efficiency while minimizing cost. Theoretically, they should be most effective in commonly performed procedures, in which volume and familiarity are high. METHODS: A clinical pathway to assist in the management of patients undergoing bowel resection was developed by a multidisciplinary team and implemented. Data about length of stay and cost was collected for all patients undergoing bowel resection 1 year before and 1 year after pathway implementation. Three groups were compared: patients undergoing bowel resection in the year prior to pathway implementation (prepathway), patients in the year after pathway implementation but not included on the pathway (nonpathway), and patients included in the pathway (pathway). RESULTS: The mean cost per hospital stay was $19,997.35 +/- 1244.61 for patients in the prepathway group, $20,835.28 +/- 2286.26 for those in the nonpathway group, and $13,908.53 +/- 1113.01 for those in the pathway group (p < 0.05 vs. other groups). Mean postoperative length of stay was 9.98 +/- 0.62 days (prepathway), 9.68 +/- 0.88 days for (nonpathway), and 7.71 +/- 0.37 days (pathway) (p < 0.05 vs. other groups). CONCLUSIONS: Implementation of the pathway produced significant decreases in length of stay and cost in the pathway group as compared to the prepathway group. These results support the further development of clinical pathways for general surgical procedures.

Costs and Cost Analysis↗

PubMed2002

Mission aligned management and allocation: a successfully implemented model of mission-based budgeting.

In response to declining funding support and increasing competition, medical schools have developed financial management models to assure that resource allocation supports core mission-related activities. The authors describe the development and implementation of such a model at the University of Wisconsin Medical School. The development occurred in three phases and included consensus building on the need for mission-based budgeting, extensive faculty involvement to create a credible model, and decisions about basic principles for the model. While each school may encounter different constraints and opportunities, the authors outline a series of generic issues that any medical school is likely to face when implementing a mission-based budgeting model. These issues include decisions about the amounts and sources of funds to be used in the budgeting process, whether funds should be allocated at the department or individual faculty level, the specific metrics for measuring academic activities, the relative amounts for research and teaching activities, and how to use the budget process to support new initiatives and strategic priorities. The University of Wisconsin Medical School's Mission Aligned Management and Allocation (MAMA) model was implemented in 1999. The authors discuss implementation issues, including timetable, formulas used to cap budget changes among departments during phase-in, outcome measures used to monitor the effect of the new budget model, and a process for school-wide budget oversight. Finally, they discuss outcomes tracked during two years of full implementation to assess the success of the new MAMA budget process.

Budgets↗

PubMed2003

Implementing a problem-based learning curriculum in an Argentinean medical school: implications for developing countries.

The authors review the difficulties that Argentina's medical schools, particularly the public ones, are likely to face when implementing a problem-based learning (PBL) curriculum, describe the barriers that were faced by their medical school as it implemented PBL, and point out the implications for medical education in developing countries with conditions and education programs similar to those in Argentina. Specifically, they (1) outline the basic requirements for successful implementation of a PBL curriculum, (2) describe the training contradiction in Argentina between a complex and heterogeneous health care system that forces specialization and medical schools' attempts to train generalists, and (3) review the effects on curriculum change of the size and the training levels of the student population and the availability of human and financial resources. This information indicates the context in which the Rosario University School of Medicine designed a new PBL curriculum and implemented it in 2002. The authors close by suggesting that schools in developing countries that are in circumstances similar to that of Rosario should consider whether a PBL curriculum is even appropriate for them, and should realize the difficulties (discussed in the article) they will have to overcome. Also, uncertainties about the efficacy of PBL create a case for exploring alternatives to PBL, including hybrid curricula. Considering the available research on curricular innovations such as PBL and the particular situations of their countries may help schools anywhere avoid wrong decisions about what curricula to implement.

Argentina↗

PubMed2002

National program for preventing mother-child HIV transmission in Thailand: successful implementation and lessons learned.

OBJECTIVE: To describe the development, components, and initial uptake of Thailand's national program for preventing mother-child HIV transmission. DESIGN: Historical review, interpretation of experience, national program monitoring. SETTING: Public health system, Thailand. PARTICIPANTS: Policymakers, clinicians, HIV-infected pregnant women. INTERVENTION: Voluntary counseling and HIV testing of pregnant women; short-course zidovudine for HIV-infected women and their infants and formula feeding for infants. MAIN OUTCOME MEASURES: Program components implemented and program uptake. RESULTS: Research, monitoring and evaluation of pilot projects, training, and policy-making provided the information, experience, infrastructure, and guidance to develop a program for preventing mother-child HIV transmission that was implemented in all Ministry of Public Health hospitals in Thailand in 2000. A national system was established to monitor program implementation. Monitoring reports were received from 669 hospitals in 65 provinces for the period October 2000 through July 2001. During this period, 93% of 318 721 women who gave birth were tested for HIV; 69% of 3958 HIV-infected women giving birth received zidovudine; and 86% and 80% of the 3865 children born to HIV-infected women received zidovudine and infant formula, respectively, through the program. CONCLUSIONS: A national program for preventing mother-child HIV transmission was successfully implemented in Thailand. Early monitoring indicates good program uptake. Lessons learned from implementing this program include the importance of paying attention to counseling, communication, and training in the program, and using pilot projects and focused monitoring and evaluation data to guide the program development, expansion, and improvement.

AIDS Serodiagnosis↗

PubMed1989

The relationship between knowledge about acquired immunodeficiency syndrome and the implementation of universal precautions by registered nurses.

The relationship between the level of knowledge of registered nurses (RNs) concerning acquired immunodeficiency syndrome (AIDS)-related issues and the practical observance of universal precautions was studied. It was hypothesized that the more knowledge a nurse has concerning AIDS the more likely he or she is to implement universal precautions. All registered nurses who have direct patient contact (N = 400) and are employed at a Northeastern teaching medical center, were provided a packet of three questionnaires and encouraged to participate. Two hundred thirteen (53%) RNs returned completed questionnaires. Subgroups were examined for trends relating such parameters as age and the amount of AIDS knowledge, using analysis of variance. The major hypothesis was tested by correlating the overall scores for AIDS knowledge and the implementation score. Results indicated no relationship between knowledge and the implementation of universal precautions (r = -0.12). When evaluating scores according to work areas, those subjects with higher knowledge scores had lower practice scores. Other demographic variables showed no influence on either knowledge or implementation scores as measured by this study. Further study is needed to understand what factors will motivate RNs to implement universal precautions.

Acquired Immunodeficiency Syndrome↗

PubMed2000

Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels.

OBJECTIVE: Because of around-the-clock activities, environmental noise and light are among the many causes of sleep disturbance in an intensive care unit (ICU). The implementation of guidelines may potentially change behavior rules and improve sleep quality. DESIGN: A prospective interventional study, observing the effects of simple nighttime guidelines on light and noise levels in an ICU. SETTING: A modern surgical ICU, subdivided into six identical three-bed rooms. PATIENTS: Critically ill adult patients. INTERVENTION: Between two observation periods, five guidelines were implemented to decrease both light and noise during the night shift in the patient's room. MEASUREMENT: Light levels and noise levels were obtained using a luxmeter and a sound level meter [A-weighted decibels (dB) scale] and were monitored continuously from 11 pm to 5 am both before (period P1) and after (period P2) the implementation of guidelines. MAIN RESULTS: Similar patient's gravity and nursing workload scores were observed between P1 and P2. A low mean (<5 Lux) and maximal light level were measured during both P1 and P2. The implementation of guidelines lowered mean light disturbance intensity with a greater variability of light during P2. All noise levels were high and corresponded more to a quiet office for noise level equivalents and to a busy restaurant for peak noise levels during both P1 and P2. Guidelines decreased the noise level equivalent (P1, 51.3 dB; P2, 48.3 dB), peak noise level (P1, 74.9 dB; P2, 70.8 dB), and the number of acoustic identified alarms (P1, 22.1 dB; P2, 15.8 dB) during P2. CONCLUSION: The night light levels were low during both periods, and lowering the light levels induced a greater variation of light, which may impair sleep quality. All measured noise levels were high during both periods, which could contribute to sleep disturbance, and the implementation of guidelines significantly lowers some important noise levels. The background noise level was unchanged.

Adult↗

PubMed2006

Implementing and complying with the Smoke-free Hospitals Project in Catalonia, Spain.

The objective of the study was to describe the implementation of measures for preventing tobacco consumption developed in the Catalan Network of Smoke-free Hospitals. Information from 25 hospitals that are actively involved in the Catalan Network of Smoke-free Hospitals (April 2004) was used. The degree of implementation of the Smoke-free Hospitals Project was analysed by means of the Self-Audit Questionnaire of the European Network for Smoke-free Hospitals; each hospital was analysed globally and according to the duration of its Network membership (<1 year: implementation stage; > or =1 year: consolidation stage). In terms of global indicators, there were high levels of commitment (64.8%), communication (74.7%), tobacco control (77.4%) and implementation of smoke-free environments (81.0%). A lower degree of implementation (<50%) was found in education and training, health promotion and healthy workplaces. According to the duration of Network membership, significant differences were observed for communication, environment, healthy workplaces and follow-up. Deficits were observed in areas such as specialist training and cessation support, and further input is required here. By identifying areas needing attention, providing a guide for policy development and by administering it periodically, one can ensure that progress is kept on track.

Guideline Adherence↗

PubMed2001

Developing and implementing measures of quality of care in the intensive care unit.

As consumers, payers, and regulatory agencies require evidence regarding quality of care, the demand for intensive care unit (ICU) quality measures will likely grow. ICU providers and professional societies may need to partner with experts in quality measurement to develop and implement quality measures. This essay outlines the steps for developing and implementing quality measures and provides examples of potential ICU quality indicators. Outcome measures, in particular mortality rates, require risk adjustment, making data collection burdensome and broad implementation unlikely. On the other hand, structure and process measures may be feasible to implement broadly. Given the steps for developing quality measures outlined in this essay and the growing evidence in the literature regarding the impact of ICU care, the future should realize the development and implementation of ICU quality indicators that are rigorously developed and provide insights into opportunities to improve the quality of ICU care.

Humans↗

PubMedDate not supplied

Put Prevention into Practice implementation model: translating practice into theory.

Put Prevention into Practice (PPIP), a national initiative promoting evidence-based clinical preventive services, was atheoretical in its approach to change. In 1994, the Texas Department of Health began demonstration projects to implement PPIP in grantee primary care sites across the state. They funded implementation and evaluation projects that resulted in eight years of experience with the process. Gathering both qualitative and quantitative data, the Texas Department of Health and the University of Texas researchers found action research essential to learning how to successfully support clinical sites in the implementation of PPIP. The researchers also found the need for on-site consultative assistance and a participatory problem-solving approach in order to produce desired systems change. A complex adaptive systems' perspective gave theoretical justification for action research, the composition of the PPIP Implementation Model, and the importance of specific adaptation by clinics. Thus, the eight-year action research project found that a state health department desiring to implement and institutionalize quality health care should focus on: (1) context-specific consultation, (2) recognition of complexity and system-level constructs, and (3) the requirement for participatory change.

Delivery of Health Care↗

PubMed1997

Evidence-based clinical guidelines--implementation plans in Scotland.

Presents a study which investigates how it was planned to implement guidelines from the Scottish intercollegiate guidelines network (SIGN). The study aimed to describe the activity in planning the implementation of SIGN guidelines in Scottish Health Service Trusts in 1996, and to provide a baseline for evaluation. A postal questionnaire was sent to the Clinical Audit lead person in 46 Scottish Health Service Trusts. The response rate after two reminders ranged from 60-72 per cent across different categories of Trust. The questionnaire asked for plans to implement individual guidelines, adaptation, professions involved, timeframes, dissemination, and evaluation methods. Reveals that local consensus was the main factor in deciding priorities. Most Trusts wished to see other local versions of guidelines produced, and to evaluate implementation collaboratively. Most expected to have reviewed baseline practice before implementation.

Evidence-Based Medicine↗

PubMed2006

An analysis of international health care logistics: the benefits and implications of implementing just-in-time systems in the health care industry.

PURPOSE: The primary purpose of this study is to undertake a diagnostic investigation of the international health care logistical environment and determine whether regulatory policies or industry procedures have hindered the implementation of just-in-time (JIT) systems and then to recommend operational improvements to be achieved by implementing JIT Systems. DESIGN/METHODOLOGY/APPROACH: The analysis was conducted in a systematic manner and compared the anticipated benefits with benefits validated in other industries from the implementation of JIT. An extensive literature review was conducted. FINDINGS: In this particular study the cost and benefit outcomes achieved from a health care JIT implementation were compared with those achieved by the manufacturing, service, and retail industries. Chiefly, it was found that the health service market must be restructured to encourage greater price competition among priorities. A new standardization process should eliminate duplication of products and realize substantial savings. ORIGINALITY/VALUE: The analysis was conducted in a systematic manner and compared the anticipated benefits with benefits validated in other industries from the implementation of JIT.

Efficiency, Organizational↗

PubMed2003

Measuring implementation intentions in the context of the theory of planned behavior.

The usefulness of measuring implementation intentions in the context of the theory of planned behavior (TPB) was explored among 112 Norwegian college students. They responded to a questionnaire measuring past behavior, perceived behavioral control, behavioral intentions, implementation intentions, and actual performance of regular exercising and recycling of drinking cartons. Implementation intentions were measured using five items relating to recycling and four items relating to exercise, which showed satisfactory internal consistencies. Consistent with the main prediction, the presence of implementation intentions was related to performing the two behaviors, although behavioral intentions were the strongest determinant for both behaviors. The results suggest that the TPB may benefit from inclusion of the concept of implementation intentions to provide a more complete understanding of the psychological process in which motivation is translated into action.

Exercise↗

PubMed2004

Achieving early surgery for undescended testes: quality improvement through a multifaceted approach to guideline implementation.

BACKGROUND: Surgery for undescended testes is recommended before the age of 2 years. However, boys are still undergoing surgery for undescended testes at a much later age than recommended. METHODS: An initial audit reviewed all orchidopexies performed at Northampton General Hospital between 1992 and 1994. This demonstrated that only 19% of boys had surgery by the age of 2 years, and the key reason for late surgery was late referral. Guidelines for referral of undescended testes were established in which referral to a surgeon was advised following the 8-month child health surveillance check if undescended testis was suspected. This would enable surgery before the age of 2 years. Audit results were disseminated and we implemented a package of measures based on evidence based change management techniques. These included written advice to general practitioners (GPs), a parent information leaflet and an amended personal child health record advising timing of referral. A reminder to the GP to refer following the 8-month check was generated using computer recall from the Child Health System records. Guideline implementation was monitored by annual audit and feedback. RESULTS: The baseline audit for the years 1992-94 found a median age at surgery of 4 years. Implementation of the new policies in 1998 resulted in a reduction in median age at surgery to 2.0 years in the 12 months ending September 2001. CONCLUSIONS: While concern about the age at orchidopexy has been highlighted in many previous studies, this is the first to show that improvement in the age at orchidopexy can be achieved. Implementing locally agreed guidelines with written information to GPs and parents combined with computerized recall from Child Health System records achieved the target within 3 years. Similar systems could be implemented nationally at minimal cost.

Age Factors↗

PubMed1985

'The more things change the more they stay the same': factors affecting the implementation of the nursing process.

One of the biggest problems currently facing the nursing profession is that of implementing the nursing process. Innovations in health care often elicit obstructions, and objective data which might help us to understand and overcome these implementation problems are lacking. The present study considered these problems by contrasting two groups of psychiatric nurses both of whom had received an in-service course in behaviour therapy. One group went on to implement this training by conducting behavioural nursing care plans with their patients, whereas the second group did not do so. A retrospective analysis of 25 variables associated with these groups of nurses indicated that neither subject variables, test scores nor learning during the course were good predictors of the nurses' implementations of the nursing process. An alternative basis for predicting and facilitating implementation is discussed. This focuses on institutional variables which may exert more control over the use of the nursing process than the personal characteristics of individual nurses. The implications of this analysis are important for the selection, training and motivation of nurses.

Adult↗