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Implementing a network for electronic surveillance reporting from public health reference laboratories: an international perspective.

Electronic data reporting from public health laboratories to a central site provides a mechanism for public health officials to rapidly identify problems and take action to prevent further spread of disease. However, implementation of reference laboratory systems is much more complex than simply adopting new technology, especially in international settings. We describe three major areas to be considered by international organizations for successful implementation of electronic reporting systems from public health reference laboratories: benefits of electronic reporting, planning for system implementation (e.g., support, resources, data analysis, country sovereignty), and components of system initiation (e.g., authority, disease definition, feedback, site selection, assessing readiness, problem resolution). Our experience with implementation of electronic public health laboratory data management and reporting systems in the United States and working with international organizations to initiate similar efforts demonstrates that successful reference laboratory reporting can be implemented if surveillance issues and components are planned.

Clinical Laboratory Information Systems↗

PubMed2001

Employees' perceptions of the implementation of affirmative action in the health sector in the Standerton District in South Africa.

Since the inception of a fully democratic government in South Africa in 1994, government and trade unions have been placing increasing pressure on government departments and public institutions to introduce steps to correct racial discrimination through the implementation of affirmative action (AA). This study, which was carried out in the Standerton Health District, assesses employees' perceptions of and attitudes towards the implementation of AA. A quantitative design was used. Data was gathered from a total population of 360 employees by means of a questionnaire. The study revealed the following major themes: Respondents feel that if AA were effectively implemented, there would be an increase in productivity. There is strong support for the implementation of AA appointments. The implementation of AA will fail if the goals of AA are not properly and effectively communicated to all employees.

Adult↗

PubMed2001

Successful hazard analysis critical control point implementation in the United Kingdom: understanding the barriers through the use of a behavioral adherence model.

Hazard analysis critical control point (HACCP), a system of risk management designed to control food safety, has emerged over the last decade as the primary approach to securing the safety of the food supply. It is thus an important tool in combatting the worldwide escalation of foodborne disease. Yet despite wide dissemination and scientific support of its principles, successful HACCP implementation has been limited. This report takes a psychological approach to this problem by examining processes and factors that could impede adherence to the internationally accepted HACCP Guidelines and subsequent successful implementation of HACCP. Utilizing knowledge of medical clinical guideline adherence models and practical experience of HACCP implementation problems, the potential advantages of applying a behavioral model to food safety management are highlighted. The models' applicability was investigated using telephone interviews from over 200 businesses in the United Kingdom. Eleven key barriers to HACCP guideline adherence were identified. In-depth narrative interviews with food business proprietors then confirmed these findings and demonstrated the subsequent negative effect(s) on HACCP implementation. A resultant HACCP awareness to adherence model is proposed that demonstrates the complex range of potential knowledge, attitude, and behavior-related barriers involved in failures of HACCP guideline adherence. The model's specificity and detail provide a tool whereby problems can be identified and located and in this way facilitate tailored and constructive intervention. It is suggested that further investigation into the barriers involved and how to overcome them would be of substantial benefit to successful HACCP implementation and thereby contribute to an overall improvement in public health.

Consumer Product Safety↗

PubMed2004

Monitoring the degree of implementation of an integrated delivery system.

INTRODUCTION: The aim of the study was to develop a method to measure the implementation of specific components of an Integrated Service Delivery system for the frail elderly. The system includes six mechanisms and tools: (1) coordination of all organizations involved in delivering health and social services, (2) a single entry point, (3) case management, (4) a single assessment tool with a case-mix classification system, (5) an individualized service plan, and (6) a computerized clinical chart. METHOD: Focus groups of researchers, clinicians, managers and policy-makers identified quantitative indicators for each component. The six components were weighted according to their relative importance in order to generate a total score. Data were collected every six months over 30 months to establish the implementation degree in the three experimental areas: Sherbrooke, Granit and Coaticook in the Province of Quebec, Canada. RESULTS: After 30 months, coordination is the most developed component in the three experimental areas. Overall, in July 2003, the Integrated Service Delivery system was implemented at the rate of 73%, 71% and 70% in Sherbrooke, Granit and Coaticook, respectively. DISCUSSION: This type of quantitative assessment provides data for managers and researchers to monitor the implementation. Moreover, when there is an outcome study, the results of the outcome study can be correlated with the degree of implementation, thus allowing for dose-response analyzes and helping to decrease the "black box" effect.

Journal Article↗

PubMed2005

Association between the implementation of a laboratory information system and the revenue of a general hospital.

CONTEXT: A laboratory information system (LIS) is a useful tool for the management of laboratory processes and data, as well as for improving quality. OBJECTIVE: To examine the association between the implementation of a LIS with the outpatient and inpatient revenues of a general hospital. DESIGN: This study analyzed the outpatient and inpatient revenue data of all 212 general hospitals in South Korea; data were obtained from the Korean National Health Insurance Corporation during the period from 1996 through 1999. The mixed model was used for the repeated measure data. The following listed variables were used in the analysis: LIS implementation status, the population size, the state of competition, average local income, the hospital location, the hospital size, whether or not the hospital was a teaching hospital, whether the hospital was private or public, and the effect of the implementation time. RESULTS: The revenues from both the outpatient and inpatient departments were significantly higher 1 year after implementing a LIS, even after controlling for confounding variables. CONCLUSIONS: Although the causality needs to be clarified, the implementation of a LIS was found to be significantly associated with higher outpatient and inpatient revenues.

Financial Management, Hospital↗

PubMed2005

Effect of increasing the intensity of implementing pneumonia guidelines: a randomized, controlled trial.

BACKGROUND: Despite the development of evidence-based pneumonia guidelines, limited data exist on the most effective means to implement guideline recommendations into clinical practice. OBJECTIVE: To compare the effectiveness and safety of 3 guideline implementation strategies. DESIGN: Cluster-randomized, controlled trial. SETTING: 32 emergency departments in Pennsylvania and Connecticut. PATIENTS: 3219 patients with a clinical and radiographic diagnosis of pneumonia. INTERVENTIONS: The authors implemented a project-developed guideline for the initial site of treatment based on the Pneumonia Severity Index and performance of evidence-based processes of care at the emergency department level. Guideline implementation strategies were defined as low (n = 8), moderate (n = 12), and high intensity (n = 12). MEASUREMENTS: Effectiveness outcomes were the rate at which low-risk patients were treated on an outpatient basis and the performance of recommended processes of care. Safety outcomes included death, subsequent hospitalization for outpatients, and medical complications for inpatients. RESULTS: More low-risk patients (n = 1901) were treated as outpatients in the moderate-intensity and high-intensity groups than in the low-intensity group (high-intensity group, 61.9%; moderate-intensity group, 61.0%; low-intensity group, 37.5%; P = 0.004). More outpatients (n = 1125) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 60.9%; moderate-intensity group, 28.3%; low-intensity group, 25.3%; P < 0.001); more inpatients (n = 2076) in the high-intensity group received all 4 recommended processes of care (high-intensity group, 44.3%; moderate-intensity group, 30.1%; low-intensity group, 23.0%; P < 0.001). No statistically significant differences in safety outcomes were observed across interventions. LIMITATIONS: Twenty percent of eligible patients were not enrolled, and data on effectiveness outcomes were not collected before the trial. CONCLUSIONS: Both moderate-intensity and high-intensity guideline implementation strategies safely increased the proportion of low-risk patients with pneumonia who were treated as outpatients. The high-intensity strategy was most effective for increasing the performance of the recommended processes of care for outpatients and inpatients.

Aged↗

PubMed1996

Views of implementation approaches by top managers in health service organizations.

This study examined how top managers view the prospects of success and resistance when using four implementation approaches in participative and control cultures that foster climates more or less conducive to change. An accommodation approach was viewed as having the best prospect of success and of lowering resistance in a participative culture. Bargaining and incentive approaches were thought to have successful and low resistance outcomes, which were just below those of accommodation, in a control type of culture. A persuasion approach was thought to be the least effective implementation approach in a control-oriented culture. These preferences differ from prescriptions found in the implementation literature. Assuming that preferences influence behavior, implementation success could be improved if managers selected an implementation approach according to the demands of the situation. More research is needed to appreciate fully the rationale that lies behind the preferences uncovered in this research.

Analysis of Variance↗

PubMed1980

The effects of group decision-making process and problem-situation complexity on implementation attempts.

The effects of group problem-solving method and problem-situation complexity on attempts at implementing group solutions were investigated in a laboratory-field setting. Group members were supervisory nurses from various organizations, who were randomly assigned to three groups in a balanced research design which included three group decision-making processes and three levels of problem-situation complexity in implementation. The dependent variable was the number of attempts at implementing group-derived solutions in home organizations. The results showed that structure in group decision-making processes led to increased rates of implementation attempts at all levels of problem-situation complexity. There was a significant complexity-by-process interaction effect among the decision-making processes, which supports the conclusion that the type of group decision-making process and the problem-situation complexity should be considered in order to optimize the number of implementation attempts.g

Analysis of Variance↗

PubMed1999

A framework for strategic information systems implementation in the United Kingdom health sector.

The implementation of information technologies in the United Kingdom health sector is a relatively recent phenomenon. Many of the developments have followed the patterns in the United States. One such example is that of Case Mix, introduced strategically as part of the Resource Management Initiative and aimed at the facilitation of both clinical and financial audit. Moreover, Case Mix was implemented alongside significant changes in hospital structure and culture, requiring clinicians to get involved in management tasks and decision making within the structure of the hospital, supported by a new information infrastructure. The success of such systems has varied significantly. A number of lessons can be learned from the way that the implementation was approached. This article stems from a research project focusing longitudinally on the implementation of Case Mix in four UK hospitals. It draws a number of findings from the cases, and importantly, explicates a framework for strategic information systems implementation, as generated from the cases and supported by the extant literature. Such a framework has implications for both theory and practice, and assists in the understanding of what is often a dynamic and poorly understood situation.

Capital Financing↗

PubMed1999

[Resident Assessment Instrument (RAI): a review of international research on the psychometric qualities and effects of implementation in nursing homes].

This article is a review of the available literature on psychometric qualities and effects of implementation of the Resident Assessment Instrument (RAI) on quality of care and health of nursing homes residents. The RAI was developed in the USA to assess the needs of nursing home residents. It consists of a comprehensive assessment of the resident (the Minimum Data Set) and 18 protocols (Resident Assessment Protocols) for further analysis of major problem areas. RAI is implemented in nursing homes in the United States, Canada, Japan and several European countries. The interrater reliability was adequate for clinical use in several studies. The validity is good for the appraisal of ADL- and cognitive functions, but moderate for mood and behaviour. In Japan and the United States positive effects were found after implementation of the RAI, especially on the care process. Implementation of RAI has shown to have positive effects on the physical and cognitive function of the resident, but there were negative effects on a number of psychosocial domains. Fourteen Dutch nursing homes have recently implemented the RAI. Studies concerning reliability, validity and effects on quality of care and quality of life are underway.

Adult↗

PubMed2000

The effect of clinical pathway implementation on total hospital costs for thyroidectomy and parathyroidectomy patients.

Clinical pathways have long been used to guide the delivery of patient care in varied practice settings. There is little information in the literature to document the effectiveness of pathway implementation in general surgical populations. This study reports the effect of clinical pathway implementation in two general surgical patient groups, thyroidectomy and parathyroidectomy. Clinical pathways were implemented to serve patients undergoing thyroidectomy and parathyroidectomy surgery. The effects of both clinical pathways on total hospital costs, length of hospitalization, variances, and outcomes were collected and evaluated from July 1998 through July 1999. These data were compared to data from the previous year. The average length of stay for parathyroidectomy patients decreased from 2.4 to 1.5 days (P = 0.26) for pathway patients as compared to prepathway patients. The average cost per case decreased from $5071 to $4291 (P = 0.50) for parathyroidectomy pathway versus prepathway patients. The average length of stay decrease for thyroidectomy patients was 1.4 to 1.2 (P = 0.16) for the pathway to prepathway comparison. The average cost per case decrease was minor at $4117 to $4111. Pharmacy costs and laboratory utilization were effectively reduced. Perioperative costs rose dramatically during this period, operating room/central sterile supply cost per case rose 12 per cent, anesthesia supply cost per case rose 15 per cent, and surgical pathology costs increased 110 per cent overall for both patient groups. Clinical pathway implementation has allowed us to reduce or maintain total hospital costs in the face of rising perioperative costs. We conclude that implementation of these clinical pathways has allowed us to improve consistency with which we deliver care while maintaining the quality of patient outcomes and reducing the costs of care and length of hospital stay.

Adolescent↗

PubMed2000

The process of implementation.

After the selection of an information system (either a HIS or a NIS) the process of implementation is of vital importance to get the system up and running. This paper describes how an implementation process can be prepared and in which way skillful implementation can contribute intensively to the pleasure of right use of the system. The author has carried the final responsibility of very different implementation processes for about 10 years in a quite a number of hospitals. Based on this experience success factors and pitfalls are given. The paper addresses in the first place hospital- and nursing managers and is written to stimulate professional implementation. A process that can cause real pleasure and fine results when it is carried out on the right way.

Computer User Training↗

PubMed2000

The implementation of clinical guidelines in a managed care setting: implications for children with special health care needs.

OVERVIEW: The project tracked the development and implementation of a pediatric asthma guideline to determine its usefulness as a quality assurance mechanism for children with special health care needs. METHODS: Interviews were conducted with clinic staff to gather descriptive information about guideline implementation at owned clinics within a large HMO. RESULTS: Providers developed multiple implementation strategies emphasizing patient/family education. Service coordination within the health plan was well established, while coordination of services beyond the health plan was less clearly related to guideline implementation. CONCLUSION: Guideline implementation appeared to be a highly variable process. Clinical guidelines alone may not be sufficient tools of quality assurance for children with chronic or complex conditions.

Adolescent↗

PubMed2000

Assessing the implementation process.

A Computerized Patient Record System (CPRS) has many benefits and could improve health care outcomes. Reaping these benefits, however, is dependent on successful implementation of a provider order entry system. The literature supports substantial evidence that even systems that are usable, effective and reliable have not been adopted by the intended users. A successful implementation may be substantially a function of the degree to which the processes of care have changed to adapt to the new system. To ensure successful implementation we suggest monitoring the implementation process itself. The purpose of this paper is to report the methodology we developed for assessing how successfully a provider order entry system is being implemented. We adopt a model of diffusion of information technology developed by Fichman (1994) and expanded by Ash (1997). In this model, diffusion is characterized be three categories, "breadth" (infusion) and "depth" (diffusion) and "quality" (appropriateness of use). In this paper we discuss the typology of diffusion and describe specific measures designed to measure infusion and diffusion of a hospital information system.

Diffusion of Innovation↗

PubMed2001

Optimal methods for guideline implementation: conclusions from Leeds Castle meeting.

BACKGROUND: Quality problems in medical care are not a new finding. Variations in medical practice as well as actual medical errors have been pointed out for many decades. The current movement to write practice guidelines to attempt to correct these deviations from recommended medical practice has not solved the problem. OBJECTIVE: In order to gain greater acceptance of these guidelines and to change the behavior of health care providers, the science of guideline implementation must be understood better. RESEARCH DESIGN: A group of experts who have studied the problem of implementation in Europe and the United States was convened. This meeting summary enumerates the implementation methods studied to date, reviews the theories of behavioral change, and makes recommendation for effecting better implementation guidelines. RESULTS: A research agenda was proposed to further our knowledge of effective evidence-based implementation.

Europe↗

PubMed2002

Automated transport and sorting system in a large reference laboratory: part 2. Implementation of the system and performance measures over three years.

BACKGROUND: Our laboratory implemented a major automation system in November 1998. A related report describes a 4-year process of evaluation and planning leading to system installation. This report describes the implementation and performance results over 3 years since the system was placed into use. METHODS: Project management software was used to track the project. Turnaround times of our top 500 tests before and after automation were measured. We compared the rate of hiring of employees and the billed unit per employee ratio before and after automation by use of linear regression analysis. Finally, we analyzed the financial contribution of the project through an analysis of return on investment. RESULTS: Since implementation, the volume of work transported and sorted has grown to >15,000 new tubes and >25,000 total tubes per day. Median turnaround time has decreased by an estimated 7 h, and turnaround time at the 95th percentile has decreased by 12 h. Lost specimens have decreased by 58%. A comparison of pre- and post-implementation hiring rates of employees estimated a savings of 33.6 employees, whereas a similar comparison of ratios of billed units per employee estimated a savings of 49.1 employees. Using the higher figure, we estimated that the $4.02 million cost of the project would be paid off approximately 4.9 years subsequent to placing the system into daily use. CONCLUSIONS: The overall automation project implemented in our laboratory has contributed considerably to improvement of key performance measures and has met our original project objectives.

Automation↗

PubMed2002

[Results from a general training hospital for the implementation of a diagnostic workup for pulmonary embolism according to the Dutch Institute for Health Care Improvement].

OBJECTIVE: To evaluate the active implementation of the Dutch Institute for Healthcare Improvement's guideline for the diagnostic work-up for pulmonary embolism in a general training hospital, and to analyse reasons for not following the guideline strategy. DESIGN: Partly retrospective and partly prospective. METHOD: The diagnostic strategy was analysed for all consecutive patients with clinically suspected pulmonary embolism who underwent a perfusion lung scintigraphy. The extent to which the guideline was followed was investigated in the year before (July 1999-June 2000; n = 384) and the year after (July 2000-June 2001; n = 380) its active implementation. The possible reasons for not completing the strategy in the prospective cohort of the study were also analysed. RESULTS: Following a non-high-probability perfusion-ventilation scan, the guideline was completed in 23/117 (20%) patients prior to the implementation and in 50/109 (46%) patients after the implementation of the guideline. In 27% and 60%, respectively, an additional duplex ultrasound of the legs was made to check for deep vein thrombosis, and in 65% and 70% respectively, pulmonary angiography was performed after a normal ultrasound result. The main reasons for not following the diagnostic work-up included low clinical probability (41%, without a proper alternative diagnosis), an alternative diagnosis (36%; pneumonia, heart failure, malignancy) and a reluctance to perform angiography. The mean age of the patients for whom the guideline was completed was lower (51 years) compared to patients for whom the guideline was not followed (65 years; p < 0.001). The risk of not completing the diagnostic workup in accordance with the guideline was six-fold higher for patients > or = 80 years compared with patients < 40 years of age, whereas an alternative diagnosis was not more prevalent in patients > or = 65 years. CONCLUSION: Although active implementation of the guideline-based diagnostic work-up for pulmonary embolism increased the number of adequate diagnoses, the diagnostic work-up was not completed in half of the patients with inconclusive lung scans. The main reasons for this were the advanced age of the patient, alternative diagnoses, and a reluctance to perform pulmonary angiography.

Adult↗

PubMed2002

Correction of partial-volume effect for PET striatal imaging: fast implementation and study of robustness.

UNLABELLED: PET imaging of D(2) receptors or (18)F-L-dopa metabolism are reference protocols to follow and study neurodegenerative diseases, but the accuracy of striatal PET imaging is limited by the partial-volume effect (PVE). For such studies, the geometric transfer matrix (GTM) method has been proposed to correct the regional mean values for PVE and is now widely used. METHODS: The GTM method models the geometric interactions induced by the PET system between the anatomic regions in which PVE correction is performed. This implies estimation of the corresponding regional spread function (RSF). The literature describes 2 implementations for the RSF calculation; they differ in the way the point spread function (PSF) of the imaging system is modeled, but no comparison or discussion has been given. The first and reference implementation uses an accurate intrinsic detector PSF that is applied in the sinogram space. The second uses a global PSF that is applied in the image space. In this work, we compared the 2 GTM implementations for 3-dimensional (3D) PET striatal imaging using Monte Carlo simulations and a phantom study. We studied the robustness of the GTM correction with respect to residual registration errors between PET and anatomy and with respect to residual segmentation errors. RESULTS: Despite the differences in RSF calculation and computation cost between the 2 implementations, similar recovery results were obtained (between 95% and 100%). The study of robustness of the GTM correction yielded 2 results. A realistic residual misregistration between the anatomic and PET images did not modify the algorithm accuracy but decreased its precision. Conversely, a realistic residual missegmentation of the anatomic regions submitted to GTM correction decreased the correction accuracy. CONCLUSION: A simple but efficient implementation in the image space of the GTM method yields accurate PVE correction in striatal regions in studies with 3D PET and enables clinical use. The method is less sensitive to residual misregistration errors between PET and anatomy than to residual missegmentation of the anatomy. Special care should be taken with segmentation of the regions to correct for PVE.

Corpus Striatum↗