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At least 487 records · Page 27Linked to original sources

PubMed2006

Are health interventions implemented where they are most needed? District uptake of the integrated management of childhood illness strategy in Brazil, Peru and the United Republic of Tanzania.

OBJECTIVE: To describe geographical patterns of implementation of the Integrated Management of Childhood Illness (IMCI) strategy in three countries and to assess whether the strategy was implemented in areas with the most pressing child health needs. METHODS: We conducted interviews with key informants at the national and district levels in Brazil, Peru and the United Republic of Tanzania, and an ecological study of factors associated with health worker training in IMCI. Explanatory factors included district population, distance from the capital, human development index, other socioeconomic indicators and baseline mortality rates in children younger than five years. FINDINGS: In line with recommendations by WHO, early implementation districts were characterized by proximity to the capital and suitable training sites, presence of motivated health managers and a functioning health system. In the expansion phase, IMCI tended to be adopted by other districts with similar characteristics. In Brazil, uptake by poor and small municipalities and those further away from the state capital was significantly lower. In Peru, there was no association with distance from Lima, and a non-significant trend for IMCI adoption by small and poor departments. In the United Republic of Tanzania, the only statistically significant finding was a lower uptake by remote districts. Implementation was not associated with baseline mortality levels in any country studied. CONCLUSION: Whereas clear and reasonable guidelines are provided for selection of early use districts, no criteria for promoting IMCI expansion had been issued, and areas of greatest need were not prioritized. Equity analyses based on the geographical deployment of new programmes and strategies can contribute to assessing whether they are reaching those who need them most.

Brazil↗

PubMed1999

Implementation of substance use screening in prenatal clinics.

BACKGROUND AND OBJECTIVES: To reduce women's consumption of alcohol and other drugs during pregnancy, the Department of Epidemiology for the Aberdeen Area Indian Health Service (AAIHS) promoted a maternal substance use screening program for prenatal clinics in 1992. This report describes the adherence to the screening protocol at AAIHS facilities and barriers to such screening. METHODS: Prenatal clinic staff members at 20 AAIHS health care facilities were surveyed to determine the extent of prenatal substance use screening and the barriers to its implementation. The medical records of a random sample of 235 women who sought prenatal care at five hospitals were reviewed to determine whether prenatal clinic staff adhered to the screening protocol. RESULTS: Of the 20 health care facilities, 13 (65%) had implemented the screening. The major barriers to implementing screening were lack of training in prenatal substance use screening and lack of clinic staff designated to administer the screening protocol. Though not statistically significant, our data suggest that women not administered the screening questionnaire were more likely to be multiparous (prevalence ratio = 2.1; 95% confidence interval = 0.9, 4.5). CONCLUSIONS: To improve screening of pregnant women for substance use, prenatal clinic staff members should address administrative barriers and assess adherence of health care providers and patients to the screening protocol. Training of prenatal clinic personnel is essential to implement optimal maternal substance use screening in prenatal clinics.

Female↗

PubMed2003

Implementing potentially better practices for multidisciplinary team building: creating a neonatal intensive care unit culture of collaboration.

OBJECTIVE: Part of the process of deriving and refining the CARE (communication, accountability, respect, empowerment) focus group's potentially better practices (PBPs) for multidisciplinary teamwork was to evaluate and experience the PBPs through implementation. METHODS: The 4 neonatal intensive care units (NICUs) in the CARE focus group each worked with implementation of the PBPs. The choice of initial PBP and method of implementation was left up to each NICU's core team. RESULTS: The experience of each of the PBPs that is reported was selected from only 1 of the NICUs. These are summarized and described in a plan-do-study-act type of format. CONCLUSIONS: There was no ideal PBP with which to start. The intertwined nature of all of the PBPs provided additional opportunities to implement other PBPs. A change seemed to be a matter first of vocabulary, then of tentative acceptance, followed by gradual integration into the culture. Change was facilitated when there was acknowledgment of a need to do things differently by the NICU leadership. Although the validity of the PBPs and their importance in cultural change have yet to be confirmed, once there was a persisting intent to change, the makeup of the NICU culture moved to embrace change as part of its culture.

Benchmarking↗

PubMed2003

Implementing potentially better practices to improve neonatal outcomes after reducing postnatal dexamethasone use in infants born between 501 and 1250 grams.

OBJECTIVE: The purpose of this article is to describe how a neonatal intensive care unit (NICU) was able to reduce substantially the use of postnatal dexamethasone in infants born between 501 and 1250 g while at the same time implementing a group of potentially better practices (PBPs) in an attempt to decrease the incidence and severity of chronic lung disease (CLD). METHODS: This study was both a retrospective chart review and an ongoing multicenter evidence-based investigation associated with the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2000). The NICU specifically made the reduction of CLD and dexamethasone use a priority and thus formulated a list of PBPs that could improve clinical outcomes across 3 time periods: era 1, standard NICU care that antedated the quality improvement project; era 2, gradual implementation of the PBPs; and era 3, full implementation of the PBPs. All infants who had a birth weight between 501 and 1250 g and were admitted to the NICU during the 3 study eras were included (era 1, n = 134; era 2, n = 73; era 3, n = 83). As part of the NIC/Q 2000 process, the NICU implemented 3 primary PBPs to improve clinical outcomes related to pulmonary disease: 1) gentle, low tidal volume resuscitation and ventilation, permissive hypercarbia, increased use of nasal continuous positive airway pressure; 2) decreased use of postnatal dexamethasone; and 3) vitamin A administration. The total dexamethasone use, the incidence of CLD, and the mortality rate were the primary outcomes of interest. Secondary outcomes included the severity of CLD, total ventilator and nasal continuous positive airway pressure days, grades 3 and 4 intracranial hemorrhage, periventricular leukomalacia, stages 3 and 4 retinopathy of prematurity, necrotizing enterocolitis, pneumothorax, length of stay, late-onset sepsis, and pneumonia. RESULTS: The percentage of infants who received dexamethasone during their NICU admission decreased from 49% in era 1 to 22% in era 3. Of those who received dexamethasone, the median number of days of exposure dropped from 23.0 in era 1 to 6.5 in era 3. The median total NICU exposure to dexamethasone in infants who received at least 1 dose declined from 3.5 mg/kg in era 1 to 0.9 mg/kg in era 3. The overall amount of dexamethasone administered per total patient population decreased 85% from era 1 to era 3. CLD was seen in 22% of infants in era 1 and 28% in era 3, a nonsignificant increase. The severity of CLD did not significantly change across the 3 eras, neither did the mortality rate. We observed a significant reduction in the use of mechanical ventilation as well as a decline in the incidence of late-onset sepsis and pneumonia, with no other significant change in morbidities or length of stay. CONCLUSIONS: Postnatal dexamethasone use in premature infants born between 501 and 1250 g can be sharply curtailed without a significant worsening in a broad range of clinical outcomes. Although a modest, nonsignificant trend was observed toward a greater number of infants needing supplemental oxygen at 36 weeks' postmenstrual age, the severity of CLD did not increase, the mortality rate did not rise, length of stay did not increase, and other benefits such as decreased use of mechanical ventilation and fewer episodes of nosocomial infection were documented.

Anti-Inflammatory Agents↗

PubMed2003

Implementation of an open access scheduling system in a residency training program.

BACKGROUND AND OBJECTIVES: Open access is one method of improving the quality of clinical practice. Leaving the majority of appointments open to be scheduled the same day allows patients to have control of their access to care. These appointments can be used for all visit types, including physical exams. Our objective was to implement this system to improve efficiency, and patient/provider satisfaction, while maintaining financial profitability. METHODS: We implemented open access at our academic practice on January 2, 2002. Clinical teams are essential for continuity, and implementation required extensive patient, provider, and staff education. We prebook the first three patient appointments for patients requiring language interpretation, prearranged transportation, and procedures. A phone triage system is still necessary for clinical questions or hesitancy about the system. RESULTS: Charges and revenues have increased since implementing the new system, as have patient satisfaction, visits per full-time equivalent, and total monthly volumes. Patient satisfaction is improved, as measured by the percent of abandoned phone calls, average time to make appointments, and the number of no-shows. Nursing work, as measured by triage, nursing callbacks, and bumped appointments, has declined markedly. CONCLUSIONS: Open access has improved revenue, simplified office processes, decreased nursing work, and improved patient satisfaction without any increase in provider time or clinic expansion.

Appointments and Schedules↗

PubMed2004

Evidence-based and population-based medicine: national implementation under the UME-21 project.

BACKGROUND AND OBJECTIVES: The Undergraduate Medical Education for the 21st Century (UME-21) project developed and implemented innovations to medical school curricula at medical schools across the country. This report describes the development and implementation of innovative approaches to improving instruction in evidence-based medicine with a population-based perspective. METHODS: Each school participating in the UME-21 project designed, implemented, and evaluated its own unique curriculum initiatives. We examined these initiatives using data abstracted from written reports submitted to the project Executive Committee. Additional data were obtained by personal communication with project directors and evaluators at the various schools, student and preceptor comments, internal program evaluation at each school, and external evaluation by the UME-21 project leadership. The Association of American Medical Colleges Graduation Questionnaire was also used. RESULTS: Fourteen of 18 participating schools implemented a broad range of curricula to facilitate teaching and learning about evidence-based and population-based medicine. Common themes included the application of evidence to patient care, use of clinical practice guidelines and pathways, and the general incorporation of evidence-based techniques (literature searching, critical appraisal, etc) into the teaching of other content, such as clinical science and managed care. Teaching approaches included Web-based and other computer-based education, an emphasis on active and self-directed learning, use of small groups and workshops, and distribution of this content over multiple years. As an alternative to full-length evidence-based medicine courses, many schools incorporated an evidence-based approach into existing courses and clerkships. Data demonstrated an upward trend in student satisfaction with how topics were presented at UME-21 schools. CONCLUSIONS: These innovations successfully demonstrated that evidence-based and population-based medicine content can be introduced into medical school curricula. Introducing these constructs in ways that demonstrate their relevance to patient care facilitates student learning.

Community Health Planning↗

PubMed1994

Delivering services to the rural elderly: a study of policy implementation.

This article presents an analysis of two demonstration projects designed to improve delivery of services to elderly residents of rural Nebraska. One project employs a statewide system of care management focused on individual clients. In the other, local agencies in four communities coordinate services by using the local senior center as a focal point. This article uses established theory of policy implementation to illustrate problems encountered in starting new social programs that require state-local cooperation. Four guidelines are suggested for policymakers: (a) if local agencies are responsible for implementation, local managers must be involved in all the planning activities for new programs; (b) clear guidelines are needed to be sure that there is consensus concerning the details of implementation; (c) all health care providers should be involved in implementation when health care services are being coordinated; and (d) community coordinating councils can be effective.

Aged↗

PubMedDate not supplied

Heart health promotion: predisposition, capacity and implementation in Ontario Public Health Units, 1994-96.

The Canadian Heart Health Initiative-Ontario Project (CHHIOP) investigates predisposition and capacity in Ontario public health departments to implement community-based heart health promotion activities. The research draws upon diffusion of innovations theory and recent work on ecological approaches to health promotion within which public health agencies are seen to play a central role. Mail-back surveys were completed by heart health staff in all 42 health departments in 1994 and 1996. Predisposition and capacity were measured as the importance and effectiveness ascribed to 18 organizational practices supportive of community heart health activities. Level of implementation was reported for 74 activities spanning a range of risk factors and settings. Predisposition, capacity and implementation scores increased between 1994 and 1996. The findings confirm positive correlations between predisposition and capacity and between capacity and implementation.

Attitude of Health Personnel↗

PubMed2006

Development, implementation and prospective evaluation of guidelines for transfer of severely injured children to specialist centres.

BACKGROUND: Most injured children are appropriately treated at a district general hospital (DGH), but some require transfer to a specialist centre. The objectives of this study were to develop, implement and evaluate triage guidelines for the rapid recognition of injured children who require transfer. METHODS: This was a prospective, interventional cohort study of the 592 seriously injured children who presented to five regional DGHs during a 51-month period. A multispecialty steering group representing all participating DGHs developed and implemented the guidelines. Data were collected for 24 months before the guidelines were introduced, over the 3-month implementation period and for 24 months afterwards. Outcome measures were referral and management patterns before and after introduction of the guidelines. RESULTS: For level I (unstable) patients, after the implementation of guidelines there was a 29 per cent increase in the proportion of transfers to a specialist centre (from 40 (68 per cent) of 59 to 32 (97 per cent) of 33; P = 0.003), no admissions to a DGH intensive care unit and all 12 operations were performed at a specialist centre. Guideline users indicated that they were familiar with the guidelines. CONCLUSION: The introduction of triage guidelines within an effective communication network was associated with changes in the management of severely injured children.

Adolescent↗

PubMed2002

How rehabilitation therapists gather, evaluate, and implement new knowledge.

INTRODUCTION: Rehabilitation therapists are strongly encouraged to apply research to their practices, but relatively little is known about the processes therapists use for continuing their education. This study examines the strategies used by a sample of therapists to gather new knowledge, evaluate its appropriateness to their clinical problems, and implement new learning into their practices. METHODS: Twenty-four randomly selected occupational therapists and physical therapists from a large metropolitan area participated in in-depth interviews. Descriptive codes within interview transcripts described participants' individual approaches to continuing education (CE). Themes derived from comparative analysis across interviews were interpreted, building on prior understandings and suggesting strategies for CE research and programs. RESULTS: Participants valued formal CE highly and expressed frustration concerning its limited availability. Most participants relied on informal consultations with peers as their first educational resource. Peers also supported participants' evaluation and implementation of new knowledge. Although seven participants reported use of systematic methods to access, evaluate, and implement new knowledge, others described more haphazard approaches toward evaluation and application of their learning. Participants identified economic, administrative, and interprofessional barriers to integration of new knowledge into their practices. DISCUSSION: There is a need to develop and incorporate guidelines for evaluating and implementing learning within formal and informal CE programs. The appeal of formal CE suggests that more efficient strategies for continuing rehabilitation are required. Therapists' heavy reliance on peers suggests that educationally influential therapists may be effective media for informal CE interventions. CE targeted to policy makers should focus on promoting organizational change to enhance therapists' translation of research into practice.

Canada↗

PubMed2006

Impact of implementation of the MELD scoring system on the prevalence and incidence of chronic renal disease following liver transplantation.

The implementation of the model for end-stage liver disease (MELD) score decreased mortality of those awaiting liver transplantation (LT); however, the impact of the MELD allocation system on the risk of chronic renal disease after LT remains unknown. We conducted a non-concurrent single-center cohort study of 174 patients undergoing LT at our center. We compared patients who underwent LT one year prior to MELD implementation (pre-MELD cohort) to those patients who underwent LT 1 year following MELD implementation (MELD cohort). All patients were followed for at least 2 years after LT. Stage 3 chronic renal disease (CRD-3) was defined by an estimated creatinine clearance (CL(Cr)) below 60 ml/min/1.73 m2, and stage 4 chronic renal disease (CRD-4) was defined by an estimated CL(Cr) below 30 mL/min/1.73 m2 according to the validated Modification of Diet and Renal Disease (MDRD) formula. Requirement of kidney transplantation and need for hemodialysis were also evaluated following LT. The pre-MELD cohort (n=97) and the MELD cohort (n=77) were comparable in baseline characteristics, prevalence of diabetes and hypertension, and immunosuppression. Mean calculated MELD score in the pre-MELD cohort was significantly lower than in the MELD cohort (16 vs. 19, P < 0.05). The estimated CL(Cr) at time of LT was lower in the MELD cohort compared with the pre-MELD cohort (75 vs. 95, P < 0.01). However, the incidence and prevalence of CRD-3 and CRD-4 at 6, 12, and 24 months after LT were comparable between the two cohorts. Need for kidney transplantation or hemodialysis after LT was comparable between the groups. In multivariate analysis, serum creatinine at LT was the only variable associated with the development of CRD-3 in the first 2 years after LT. In conclusion, the implementation of the MELD allocation system is not associated with increased mortality or occurrence of CRD-3 or CRD-4 in the first 2 years after LT.

Adolescent↗

PubMed1995

Implementation of the Patient Self-Determination Act: a survey of Nebraska hospitals.

The purpose of this survey of Nebraska hospitals (N = 79) was to describe the planning, implementation, and evaluation of the Patient Self-Determination Act (PSDA) and to explore the role of the nurse in these processes. Results indicate nurses were very involved in the planning phase but rarely in the implementing phase. Few evaluation strategies were utilized and only some respondents identified problematic issues related to the implementation of the PSDA. Clinical implications for issues related to the PSDA are discussed and framed within the American Nurses' Association Position Statement on the PSDA (1991). Future studies are suggested, especially related to evaluation of PSDA implementation.

American Nurses' Association↗

PubMed1993

Effects of responding hand and concurrent verbal processing on time-keeping and motor-implementation processes.

Two experiments examined the effects of concurrent verbal processing on the ability to tap at a consistent rate with the left and right index fingers. Variability in the intertap intervals was divided into two components that reflect different processes involved in such paced tapping. One component reflects the consistency of an internal time-keeping mechanism and the other component reflects the consistency of motor implementation. The imposition of a concurrent verbal processing task increased variability attributable to the internal time-keeping mechanism, but had no effect on variability attributable to motor implementation. Furthermore, the interference caused by concurrent verbal processing was equivalent for the two hands. Variability attributable to motor implementation was consistently smaller for the right than for the left hand and was not increased by imposing a concurrent verbal processing task. This pattern of results indicates that there is an important dissociation between time-keeping and motor-implementation mechanisms. Furthermore, the results suggest that a single time-keeping mechanism serves both index fingers and that the left hemisphere of neurologically intact right-handers plays an important role in the time-keeping circuit regardless of which hand is tapping.

Adult↗

PubMed1992

A model for measuring the implementation of community support programs: results from three sites.

We present and test a model for measuring the implementation of Community Support Programs (CSPs) for persons with severe mental illnesses. The model is intended to facilitate the description and replication of these programs and the future study of their critical ingredients. The model defines important implementation variables in seven areas of program functioning; we then suggest instruments to measure each of these variables. Results of a study examining the application of the model and measures to three conceptually distinct CSPs illustrate the utility of the model and measures for implementation analysis of CSPs. Importantly, findings revealed that a priori hypotheses about how the programs were expected to differ on the implementation variables were largely supported.

Adolescent↗

PubMed1991

Ecological interventions and the process of change for prevention: wedding theory and research to implementation in real world settings.

Considers a preventive intervention effort designed to modify the characteristics and regularities of the school environment so as to enhance the expectations conveyed to high risk students. Employing this case effort (Weinstein et al., 1991) as a base, several issues are highlighted that deserve greater attention in the design, implementation, assessment, and reporting of other preventively-focused social interventions. These issues include: (1) the degree of program implementation fidelity, (2) the impact a lack of attainment of program fidelity may have on arriving at erroneous evaluation conclusions about social programs, (3) the ways in which the theory and basic research employed in the program rationale is appropriate to and reflected in the program as designed, (4) issues of program potency and dosage, (5) the ways in which quantitative and qualitative evaluation data can enhance each other, and (6) the import of evaluability assessments of programs prior to moving to outcome evaluations. In addressing these issues, the importance of developmentally- and ecologically-informed program formulations is underscored. Finally, the critical role that program reports such as the Weinstein paper, with its careful discussion of both the process of implementation and outcome assessments, can play in the development of more effective prevention program implementation efforts is highlighted.

Adolescent↗

PubMed1996

Joint Implementation: Biodiversity and Greenhouse Gas Offsets

/ One of the most pressing environmental issues today is the possibility that projected increases in global emissions of greenhouse gases from increased deforestation, development, and fossil-fuel combustion could significantly alter global climate patterns. Under the terms of the United Nations Framework Convention on Climate Change, signed in Rio de Janeiro during the June 1992 Earth Summit, the United States and other industrialized countries committed to balancing greenhouse gas emissions at 1990 levels in the year 2000. Included in the treaty is a provision titled "Joint Implementation," whereby industrialized countries assist developing countries in jointly modifying long-term emission trends, either through emission reductions or by protecting and enhancing greenhouse gas sinks (carbon sequestration). The US Climate Action Plan, signed by President Clinton in 1993, calls for voluntary climate change mitigation measures by various sectors, and the action plan included a new program, the US Initiative on Joint Implementation. Wisconsin Electric decided to invest in a JI project because its concept encourages creative, cost-effective solutions to environmental problems through partnering, international cooperation, and innovation. The project chosen, a forest preservation and management effort in Belize, will sequester more than five million tons of carbon dioxide over a 40-year period, will become economically self-sustaining after ten years, and will have substantial biodiversity benefits.KEY WORDS: Joint implementation; Activities implemented jointly; Carbon sequestration; Carbon dioxide; Global climate change; Greenhouse gas; Belize

Journal Article↗

PubMed1998

Large-scale PACS implementation.

The transition to filmless radiology is a much more formidable task than making the request for proposal to purchase a (Picture Archiving and Communications System) PACS. The Department of Defense and the Veterans Administration have been pioneers in the transformation of medical diagnostic imaging to the electronic environment. Many civilian sites are expected to implement large-scale PACS in the next five to ten years. This presentation will related the empirical insights gleaned at our institution from a large-scale PACS implementation. Our PACS integration was introduced into a fully operational department (not a new hospital) in which work flow had to continue with minimal impact. Impediments to user acceptance will be addressed. The critical components of this enormous task will be discussed. The topics covered during this session will include issues such as phased implementation, DICOM (digital imaging and communications in medicine) standard-based interaction of devices, hospital information system (HIS)/radiology information system (RIS) interface, user approval, networking, workstation deployment and backup procedures. The presentation will make specific suggestions regarding the implementation team, operating instructions, quality control (QC), training and education. The concept of identifying key functional areas is relevant to transitioning the facility to be entirely on line. Special attention must be paid to specific functional areas such as the operating rooms and trauma rooms where the clinical requirements may not match the PACS capabilities. The printing of films may be necessary for certain circumstances. The integration of teleradiology and remote clinics into a PACS is a salient topic with respect to the overall role of the radiologists providing rapid consultation. A Web-based server allows a clinician to review images and reports on a desk-top (personal) computer and thus reduce the number of dedicated PACS review workstations. This session will focus on effective strategies for a seamless transition. Critical issues involve maintaining a good working relationship with the vendor, cultivating personnel readiness and instituting well-defined support systems. Success depends on the ability to integrate the institutional directives, user expectations and available technologies. A team approach is mandatory for success.

Computer Communication Networks↗

PubMed1999

Electronic imaging and clinical implementation: work group approach at Mayo Clinic, Rochester.

Electronic imaging clinical implementation strategies and principles need to be developed as we move toward replacement of film-based radiology practices. During an 8-month period (1998 to 1999), an Electronic Imaging Clinical Implementation Work Group (EICIWG) was formed from sections of our department: Informatics Lab, Finance Committee, Management Section, Regional Practice Group, as well as several organ and image modality sections of the Department of Diagnostic Radiology. This group was formed to study and implement policies and strategies regarding implementation of electronic imaging into our practice. The following clinical practice issues were identified as key focus areas: (1) optimal electronic worklist organization; (2) how and when to link images with reports; (3) how to redistribute technical and professional relative value units (RVU); (4) how to facilitate future practice changes within our department regarding physical location and work redistribution; and (5) how to integrate off-campus imaging into on-campus workflow. The EICIWG divided their efforts into two phases. Phase I consisted of Fact finding and review of current practice patterns and current economic models, as well as radiology consulting needs. Phase II involved the development of recommendations, policies, and strategies for reengineering the radiology department to maintain current practice goals and use electronic imaging to improve practice patterns. The EICIWG concluded that electronic images should only be released with a formal report, except in emergent situations. Electronic worklists should support and maintain the physical presence of radiologists in critical areas and direct imaging to targeted subspecialists when possible. Case tools should be developed and used in radiology and hospital information systems (RIS/HIS) to monitor a number of parameters, including professional and technical RVU data. As communication standards improve, proper staffing models must be developed to facilitate electronic on-campus and off-campus consultation.

Diagnostic Imaging↗