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PubMed1999

The ability of non-ergonomists in the health care setting to make manual handling risk assessments and implement changes.

The health care setting presents particular risks from manual handling and it is known that training in manual handling techniques is ineffective in reducing these risks when used as a stand-alone measure. The 'Manual Handling Operations Regulations 1992' requires employers to consider hazardous manual handling, advising the use of an ergonomics approach. However, it is not known how well-equipped non-ergonomists in the health care setting are to deal with this approach. Therefore, the ability of non-ergonomists to make manual handling risk assessments, with or without additional training, and to implement changes to the work environment was investigated. Twenty-five pairs of subjects from a broad cross section of departments in a busy teaching hospital were studied; training and a guide book were provided for one of each pair and the guide book only for the other. Subjects then independently prioritised three tasks in their department and undertook a full assessment of a specified task. All work was repeated by an ergonomist and the subjects' assessments were scored in comparison with the ergonomist. Each department was followed up after six months to assess progress with implementing recommendations. Trends in the data indicated that both groups appeared able to identify hazards though not necessarily to prioritise the tasks. The trained group tended to score better in assessments although wide variation existed within both groups and inter-group differences were not significant at the 5% level. Approximately half of staff assessments were considered 'adequate' to 'very good', in comparison with the ergonomist. Implementation of assessment recommendations ranged from nil to almost full compliance. Incomplete implementation seemed to be related to an apparent confusion in some departments over who was responsible for making changes, a lack of finances for changes and overstretched managers having other priorities.

Ergonomics↗

PubMed1998

Working conditions and effects of ISO 9000 in six furniture-making companies: implementation and processes.

What effects will the implementation of the quality standard ISO 9000 have regarding working conditions and competitive advantages? Which are the most important change process characteristics for assuring improved working conditions and other desired effects? These are the main questions behind this study of six furniture-making companies which implemented ISO 9000 during the period 1991-1994. The results show that customer requirement was the dominant goal to implement ISO 9000. Five of the six companies succeeded in gaining certification. The influence on working conditions was limited, but included better order and housekeeping, more positive attitudes towards discussing quality shortcomings, a few workplace improvements, work enrichment caused by additional tasks within the quality system and a better understanding of external customer demands. Among the negative effects were new, apparently meaningless, tasks for individual workers as well as more stress and more physically strenuous work. The effects on the companies included a decrease in external quality-related costs and improved delivery precision. The study confirms the importance for efficient change of the design of the change process, and identifies 'improvement methodology' as the most important process characteristic. Improved working conditions are enhanced by added relevant strategic goals and by a participative implementation process.

Humans↗

PubMed2004

[Clinical benefit following the implementation of a specialized urgent stroke care system].

BACKGROUND AND OBJECTIVE: Several strategies as stroke teams, stroke code teams, or stroke units development have demonstrated to improve stroke care quality. The potential benefit of implementing them as a whole has not been studied. We aimed to test the clinical efficacy of a specialized and urgent stroke assistance system in a University Hospital, as well as the specific impact of each part of the system on several clinical indicators. PATIENTS AND METHOD: The implementation of the system followed three consecutive steps: stroke team and stroke code development, stroke unit creation and finally on-call stroke neurologists incorporation. Several clinical indicators to evaluate results have been selected. We compared data available before system onset (1992-1997) with data obtained during the system implementation (1998-2002). Modification in the results indicators following each of the individual steps of the system was also evaluated. RESULTS: During the five years of the system implementation, 5843 stroke patients have been prospectively studied. Admission and readmission necessities were reduced up to 34.2% and 81.8% respectively. Length of stay progressively decreased from 18 (pre-1998) to 7 days (2002). In-hospital mortality and institutionalization necessities were reduced to 50.1% and 50.5% respectively. The third step, in which on-call stroke neurologist were incorporated to the system, has demonstrated to be the most efficient in decreasing the length of stay, hospital mortality and institutionalization necessities. CONCLUSIONS: The creation of a specialized urgent stroke care system, protocol based and developed in stroke units, improves the medical assistance quality for stroke patients. Stroke neurologists on-call have a relevant role in the system working.

Aged↗

PubMedDate not supplied

The International Space Station human life sciences experiment implementation process.

The selection, definition, and development phases of a Life Sciences flight research experiment has been consistent throughout the past decade. The implementation process, however, has changed significantly within the past two years. This change is driven primarily by the shift from highly integrated, dedicated research missions on platforms with well defined processes to self contained experiments with stand alone operations on platforms which are being concurrently designed. For experiments manifested on the International Space Station (ISS) and/or on short duration missions, the more modular, streamlined, and independent the individual experiment is, the more likely it is to be successfully implemented before the ISS assembly is completed. During the assembly phase of the ISS, science operations are lower in priority than the construction of the station. After the station has been completed, it is expected that more resources will be available to perform research. The complexity of implementing investigations increases with the logistics needed to perform the experiment. Examples of logistics issues include- hardware unique to the experiment; large up and down mass and volume needs; access to crew and hardware during the ascent or descent phases; maintenance of hardware and supplies with a limited shelf life,- baseline data collection schedules with lengthy sessions or sessions close to the launch or landing; onboard stowage availability, particularly cold stowage; and extensive training where highly proficient skills must be maintained. As the ISS processes become better defined, experiment implementation will meet new challenges due to distributed management, on-orbit resource sharing, and adjustments to crew availability pre- and post-increment.

Biological Science Disciplines↗

PubMed2003

Comparison of peptic-ulcer drug use and expenditures before and after the implementation of a government policy to separate prescribing and dispensing practices in South Korea.

BACKGROUND: The South Korean government instituted a new policy, the separation of prescribing and dispensing (SPD) of medications, on July 1, 2000, to provide greater differentiation between the roles of physicians and pharmacists than had historically existed in South Korea. It was hoped that this policy would promote the rational use of medications and reduce medication expenditures, which accounted for approximately 30% of the total health care expenditures before the implementation of SPD. OBJECTIVE: The purpose of this study was to assess the effects of SPD on drug market share and expenditures for branded and generic medications by comparing the use of and expenditures for peptic-ulcer medications before and after the implementation of SPD. METHODS: Data on expenditures and quantity of use in January and December 2000 (in terms of defined daily dose [DDD]) of peptic-ulcer medications were obtained from the Korean National Health Insurance claims database. These data were derived using a 3-stage probability sample of prescription data from medical clinics in South Korea. RESULTS: The number of prescription drug claims for peptic-ulcer drugs increased by 13.9% after the introduction of SPD. Medication expenditures increased by 98.4% for peptic-ulcer medications. The use of more expensive drugs and branded products, even when generic products were available, accounted for most of this increase. In particular, the use of branded ranitidine 150 mg (measured by DDD) increased from 6.3% of the market share before SPD to 27.6% of the market share after the implementation of SPD. CONCLUSIONS: The implementation of SPD increased both prescription drug claims and expenditures for peptic-ulcer medications. A principal factor contributing to the increase in expenditures was the use of branded medications.

Anti-Ulcer Agents↗

PubMed2000

AVS/express for the PC implementation of a 3D visualization module for radiotherapy.

Treatment planning systems (TPS) are nowadays of great help in cancer radiotherapy. Basically, they allow the pair physician/physicist to simulate the beams' irradiation effects on tumors as well as healthy tissues in terms of delivered radiation doses and finally to assess the validity of a beam setup. The state of the art in TPS leads to the following evidence concerning the future of such softwares: an access to a 3D visualization at each step of the design and verification of a plan has become necessary. Moreover, the fast increasing performances of personal computers (PC) will make possible in a near future the implementation at a lower cost of a complete 3D TPS. One of the keys of such an ambition is the compatibility between the implementation tools and the needs for power and flexibility. A first implementation on Open VMS of a simple 3D visualization for Institut Curie's TPS ISIS using Advanced Visual Systems' AVS 5 has been achieved. Their next generation tool, AVS/Express, seemed to meet the needs of a wide scale development. The use of AVS/Express working together with Microsoft Visual C++ in the implementation on Windows NT of a 3D visualization module is exposed.

Humans↗

PubMed2003

Consumers and families as partners in implementing evidence-based practice.

Evidence-based practices represent an extremely important advance in the mental health system, and NAMI continues its support of efforts to develop and implement these interventions. Moving forward, the authors envision consumers and family members playing a much greater role in developing and promulgating EBP. Individually and corporately, consumers can: facilitate research that will expedite equitable implementation of existing and new EBPs; play a significant role in providing services; play a lead role in promoting policies that support EBP implementation through the development and use of advocacy toolkits; influence provider adaptation of EBP through the broad development and testing of resources that urge EBP consumerism; and, advance through the monitoring of EBP. These consumer-led activities generally have been relegated to a lower level of importance in the current research, policy, and funding environment leading to poorly developed partnerships and "buy in" from the consumer community. It is important that the level of importance of these activities and the role of consumers and families be rethought. Further advancement of EBP will require implementing a three-track program of research, including a much greater focus on action research and the involvement of consumers as research and evaluation partners. This is the fastest and most effective way to achieve breakthrough results in practices for treating people with serious mental illnesses and to address the serious and growing problem of racial and cultural disparities and the disconnect that causes between those individuals and the means to their recovery. The hope of consumers and families rest on the ability to initiate action now.

Community Participation↗

PubMed1984

Trauma mortality in Orange County: the effect of implementation of a regional trauma system.

One hundred eighteen deaths from motor vehicle accidents were reviewed retrospectively to evaluate the effect of implementation of a regional trauma system. Fifty-eight deaths occurring prior to implementation and 60 occurring after were reviewed by teams of four physicians. Following implementation the proportion of potentially salvageable deaths dropped from 34% (20/58) to 15% (9/60) (P less than .02). Seven of the nine potentially salvageable deaths occurred in 13 patients treated in non-trauma facilities (54%), while only two potentially salvageable deaths occurred in 47 patients treated in trauma facilities (4%) (P less than .0002). The median age of patients dying of trauma rose from 22 to 27 years (P less than .04); the median Injury Severity Score rose from 42.5 to 52.0 (P less than .03). The 1981 death rate for vehicular trauma dropped to 13.93 per 100,000 population compared to a projected rate of 15.72 (P less than .03); the 1982 rate dropped to 12.37 compared to a projected rate of 15.80 (P less than .02). Implementation of a regional trauma system has resulted in significant improvements in trauma care and a reduction in the death rate from vehicular trauma.

Accidents, Traffic↗

PubMed1985

Utilization of medical care in Orange County: the effect of implementation of a regional trauma system.

To determine the effect of implementation of a regional trauma system on utilization of medical care we studied ambulance transports, emergency department (ED) visits, and hospital days for trauma and nontrauma patients before and after system implementation. Serious injury affects approximately one of every 1,000 persons each year and accounts for approximately one of every 250 ED visits, one of every 100 hospital days, and one of every 20 ambulance transports. Following system implementation the trauma hospitals experienced insignificant changes in annual percentage of market share of ED visits and hospital days and in annual rate of growth of ED visits and hospital days. We conclude that implementation of a medically directed regional trauma system has resulted in a predictable redistribution of a small number of seriously injured patients, and has not been associated with significant changes in utilization of EDs or hospitals.

California↗

PubMed2001

An implementation strategy for IMRT of ethmoid sinus cancer with bilateral sparing of the optic pathways.

PURPOSE: To develop a protocol for the irradiation of ethmoid sinus cancer, with the aim of sparing binocular vision; of developing a strategy of intensity-modulated radiation therapy (IMRT) planning that produces dose distributions that (1) are consistent with the protocol prescriptions and (2) are deliverable by static segmental IMRT techniques within a 15-minute time slot; of fine tuning the implementation strategy to a class solution approach that is sufficiently automated and efficient, allowing routine clinical application; of reporting on the early clinical implementation involving 11 patients between February 1999 and July 2000. patients and methods: Eleven consecutive T1-4N0M0 ethmoid sinus cancer patients were enrolled in the study. For Patients 1-8, a first protocol was implemented, defining a planning target volume prescription dose of 60 to 66 Gy in 30-33 fractions and a maximum dose (Dmax) of 50 Gy to optic pathway structures and spinal cord and limit of 60 Gy to brainstem. For Patients 9-11, an adapted (now considered mature) protocol was implemented, defining a (planning target volume) prescription dose of 70 Gy in 35 fractions and a Dmax to optic pathway structures and brainstem of 60 Gy and to spinal cord of 50 Gy. RESULTS: The class solution-directed strategy developed during this study reduced the protocol translation process from a few days to about 2 hours of planner time. The mature class solution involved the use of 7 beam incidences (20-37 segments), which could be delivered within a 15-minute time slot. Acute side effects were limited and mild. None of the patients developed dry eye syndrome or other visual disturbances. The follow-up period is too short for detection of retinopathy or optic nerve and chiasm toxicity. CONCLUSION: Conventional radiotherapy of ethmoid sinus tumors is associated with serious morbidity, including blindness. We hypothesize that IMRT has the potential to save binocular vision. The dose to the optic pathway structures can be reduced selectively by IMRT. Further enrollment of patients and longer follow-up will show whether the level of reduction tested by the clinical protocol is sufficient to save binocular vision. An adaptive strategy of IMRT planning was too inefficient for routine clinical practice. A class solution-directed strategy improved efficiency by eliminating human trial and error during the IMRT planning process.

Adenocarcinoma↗

PubMed1997

Planning, delivery, and quality assurance of intensity-modulated radiotherapy using dynamic multileaf collimator: a strategy for large-scale implementation for the treatment of carcinoma of the prostate.

PURPOSE: To improve the local control of patients with adenocarcinoma of the prostate we have implemented intensity modulated radiation therapy (IMRT) to deliver a prescribed dose of 81 Gy. This method is based on inverse planning and the use of dynamic multileaf collimators (DMLC). Because IMRT is a new modality, a major emphasis was on the quality assurance of each component of the process and on patient safety. In this article we describe in detail our procedures and quality assurance program. METHODS AND MATERIALS: Using an inverse algorithm, we have developed a treatment plan consisting five intensity-modulated (IM) photon fields that are delivered with DMLC. In the planning stage, the planner specifies the number of beams and their directions, and the desired doses for the target, the normal organs and the "overlap" regions. Then, the inverse algorithm designs intensity profiles that best meet the specified criteria. A second algorithm determines the leaf motion that would produce the designed intensity pattern and produces a DMLC file as input to the MLC control computer. Our quality assurance program for the planning and treatment delivery process includes the following components: 1) verification of the DMLC field boundary on localization port film, 2) verification that the leaf motion of the DMLC file produces the planned dose distribution (with an independent calculation), 3) comparison of dose distribution produced by DMLC in a flat phantom with that calculated by the treatment planning computer for the same experimental condition, 4) comparison of the planned leaf motions with that implemented for the treatment (as recorded on the MLC log files), 5) confirmation of the initial and final positions of the MLC for each field by a record-and-verify system, and 6) in vivo dose measurements. RESULTS: Using a five-field IMRT plan we have customized dose distribution to conform to and deliver 81 Gy to the PTV. In addition, in the overlap regions between the PTV and the rectum, and between the PTV and the bladder, the dose is kept within the tolerance of the respective organs. Our QA checks show acceptable agreement between the planned and the implemented leaf motions. Correspondingly, film and TLD dosimetry indicates that doses delivered agrees with the planned dose to within 2%. As of September 15, 1996, we have treated eight patients to 81 Gy with IMRT. CONCLUSION: For complex planning problems where the surrounding normal tissues place severe constraints on the prescription dose, IMRT provides a powerful and efficient solution. Given a comprehensive and rigorous quality-assurance program, the intensity-modulated fields can be efficaciously and accurately delivered using DMLC. IMRT treatment is now ready for routine implementation on a large scale in our clinic.

Adenocarcinoma↗

PubMed1998

Multiple machine implementation of enhanced dynamic wedge.

PURPOSE: After acquiring 4 years of experience with Dynamic Wedge, a software-driven one-dimensional (1D) compensation system, we implemented a new software version called Enhanced Dynamic Wedge (EDW). The EDW allows larger (30 cm) and asymmetric field sizes and additional angles for wedged fields. We implemented this software on four similar dual-energy accelerators that also possess upper and lower physical wedge sets. Our goal was to implement EDW with one common wedge factor (WF) table and one set of treatment-planning files. METHODS AND MATERIALS: We measured WFs with an ionization chamber and isodose profiles with both film and a diode array. We used a calculation scheme that requires only entry of the wedge angle and fixed jaw value. Filters for computerized treatment planning were configured for each wedge angle. We also examined to what degree the multileaf collimation (MLC) orientation, which is orthogonal to the EDW direction, was compromised for specific treatment sites. As a comparative test, we examined the dosimetric consistency for the 8 sets of physical wedges on the four machines. Finally, we updated our DW quality assurance program for EDW. RESULTS: The measured EDW WF was common for all four machines to within +/- 1.5% and the calculation scheme held to within 1.5%. The EDW isodoses were consistent among the machines as measured by film and diode array. The treatment-planning filters provided computed isodose profiles that were nearly identical to measured profiles. Regarding MLC orientation, we found that the collimator angle needed for EDW did not compromise isodose distributions, as apparent in measured isodoses and calculated dose-volume histograms. The consistency of the physical wedges did not fare as well. Two of the lower wedge sets had Wfs and profiles different (> 3%) from the other wedge sets. CONCLUSIONS: We have successfully implemented EDW on four machines using only one WF table and one set of treatment-planning filters. The EDW provides for improved treatment techniques for particular sites due to the large field sizes and additional angles available. Daily treatment efficiency has increased because of the remote capability provided by EDW.

Humans↗

PubMed2003

Primary health care professionals' activity in intervening in patients' alcohol drinking during a 3-year brief intervention implementation project.

AIM: The study examined the change of primary health care professionals' activity in asking patients about alcohol and giving advice to heavy drinkers during a 3-year brief intervention implementation project. METHOD: A patient questionnaire survey after consultation blind to the primary health care professionals before and after the implementation project. Brief intervention implementation was based on action research. Subjects were 1,000 consecutive 16-65-year-old patients consulting general practitioners at two primary health care centres at baseline and follow-up, of whom 655 and 768, respectively, participated. RESULTS: No statistically significant differences were found regarding asking or advising about alcohol between baseline and 3-year follow-up. Of all patients, 19.1% (125/655) at baseline versus 19.7% (151/768) at follow-up were last asked about alcohol during the consultation in question or during past year (P=0.784). Likewise, of heavy drinkers, 30.9% (30/97) versus 33.9 (38/112) were asked (P=0.644). Of heavy drinkers, 13.4 (13/97) versus 14.9% (17/114) were advised about alcohol during the consultation in question (P=0.754). CONCLUSION: The activity to do brief intervention remained stable. This may be due to the short follow-up time, the way brief intervention was implemented in the present study or the saturation in the activity reached already before the present study.

Adult↗

PubMedDate not supplied

A novel and efficient implementation of the marching cubes algorithm.

In this paper, a novel and efficient implementation of the marching cubes (MC) algorithm is presented for the reconstruction of anatomical structures from real three-dimensional medical data. The proposed approach is based on a generic rule, able to triangulate all 15 standard cube configurations used in the classical MC algorithm as well as additional cases presented in the literature. The proposed implementation of the MC algorithm can handle the Type A 'hole problem' which occurs when at least one cube face has an intersection point in each of its four edges. Theoretical and experimental results demonstrate the ability of the new implementation to reproduce standard MC results, resolving Type A 'hole problem'. Finally, the proposed implementation was applied to real medical date to reconstruct anatomical structures. The output of the proposed technique is in WWW compliant format.

Algorithms↗

PubMed2000

The value of advocacy in promoting social change: implementing the new Domestic Violence Act in South Africa.

South Africa's first democratic government passed the Domestic Violence Act (DVA) into law in 1998 as part of local and international commitments to protecting the human rights of women. Although the Act was welcomed as groundbreaking legislation, delays in implementing it led to increasing frustration. This paper describes an advocacy campaign conducted by the Soul City Institute for Health and Development Communication in partnership with the National Network on Violence against Women, to ensure the effective implementation of the DVA. Lessons from the campaign stress the importance of coalition building to draw on diverse strengths, and the use of a combination of advocacy tools, including lobbying, media advocacy and social mobilisation to achieve campaign goals. Given the critical role NGOs dealing with victims/survivors of domestic violence and the justice system played in lobbying for change and drafting the new law, their exclusion from the implementation process was ironic. While many advocacy efforts focus on the development of policy and legislation, ongoing efforts are needed to ensure effective implementation, the commitment of adequate resources and monitoring to identify gaps and propose new solutions. Our experience highlights the important role of policy advocates in connecting the multiple streams at play in the policy and legislative arena.

Communication↗

PubMed2001

Implementing guidelines for interdisciplinary care of low back pain: a critical role for pre-appointment management of specialty referrals.

BACKGROUND: Improving health care will require more effective guideline implementation and redesign of delivery processes and systems. Patient referral for specialty care is a key component of health system function that needs to be improved. Low back pain care is a widely documented example of the need for improvement. An interdisciplinary systemwide back pain program was developed using process improvement methods. Proactively managing referrals for specialty care-a departure from traditional referral processes-played a critical role in implementing the program. METHODS: Program components included guidelines for care, defined provider roles, uniform service coding, provider and patient education, pre-appointment specialty referral management, and monitoring of management processes. To evaluate program performance, system back pain visits were compared before, during, and after implementation of referral management. A case series study was performed on 581 consecutive patients with low back pain or lumbar radiculopathy referred for consultative spine care between April 1998 and March 1999. RESULTS: A shift of care was accomplished for acute back pain from spine orthopedists to primary physicians and for chronic back pain from spine orthopedists to medical specialists. More than 95% of initial assignments were accurate. Seventy-six percent of surveyed chronic back pain patients improved, and 90% were highly satisfied with the referral management process. This program has saved an estimated $400,000 per year in manpower cost and has reduced specialty service billings by 20%. DISCUSSION: Pre-appointment referral management offers an approach for improving guideline implementation, access to specialty services, and the effectiveness of care for complex health problems. It deserves broader study and adoption.

Acute Disease↗

PubMed2002

Implementing an evidence-based acute gastroenteritis guideline at a children's hospital.

BACKGROUND: Guidelines for preventing and treating acute gastroenteritis (AGE) have generally not been incorporated into medical practice. An evidence-based clinical practice guideline was adapted from national guidelines to meet the practice styles characterizing care in southwestern Ohio and implemented at the Children's Hospital Medical Center (Cincinnati). Its efficacy was assessed in terms of emergency department (ED) encounters and admissions, mean and total hospital costs, and mean length of hospitalization. METHODS: Comparisons were made between patients seen during peak gastroenteritis months (December-May) before (fiscal year [FYs] 1994-1997) and after (FYs 1998 and 1999) guideline implementation. Data were extracted from hospital charts, clinical databases, and billing records. RESULTS: Following implementation, mean yearly ED encounters for AGE decreased 22% and mean yearly admissions decreased 33%. The percentage of admitted children with minor illness decreased (p = 0.002). Mean length of stay decreased 21% for children with minor illness (p = 0.0001) and 5% for others. Hydration status was noted in only 15% of ED charts examined but increased to 63% in FY 1998 and 86% in FY 1999 (p < 0.001). The proportion of admitted patients who advanced to a regular diet by discharge increased from 4.9% (FY 1997) to 23% (FY 1998) and 76% (FY 1999; p < 0.0001). Total inpatient days/year decreased by 43%. Mean hospital costs did not change significantly. DISCUSSION: Following implementation, fewer patients with AGE were seen in the ED and fewer were admitted to the hospital for care. Hospital stays were shorter, and children were more likely to resume their diets before discharge.

Acute Disease↗

PubMed1995

Implementing CQI on a budget: a small hospital's story.

BACKGROUND: The need to move toward continuous quality improvement (CQI) is often perceived as a financial hardship on large and small hospitals alike. Avista Hospital, a small, 50-bed hospital, accepted the challenge to implement CQI in a thorough but cost-effective manner. METHOD: Without the use of consultants, the CQI process was developed internally using formal and informal methods of education for the change agents, and just-in-time education for improvement teams. All employees were involved in a brainstorming session to introduce them to the concept of CQI and to define quality and identify customers. The implementation plan was established on a five-year timeline to provide a methodical and systematic approach, and the entire process was under the direction of a quality council. ROUNDTABLES: To date 18 RoundTables have been chartered by the quality council. One RoundTable, "The Care of the MI [myocardial infarction] Patient," addressed the lack of continuity in the teaching of the MI patient. The team developed a teaching plan, with all printed materials provided in a binder to patients. CONCLUSIONS: The overall cost to implement the five-year plan, including education, staff time, and a budgeted amount to begin recognition celebrations in 1995, was estimated at $10,000. Commitment and determination are the necessary components for implementation of a CQI program. With proper planning and support from the administration, a small hospital can be successful at CQI.

Budgets↗