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PubMed1995

Collaborating outside the box: when employers and providers take on environmental barriers to guideline implementation.

BACKGROUND: In 1992 15 employers in Minneapolis/St Paul, operating as the Business Health Care Action Group (BHCAG), combined their self-insured plans. To successfully bid for the BHCAG contract, three competing group practices and a health plan cooperated, operating functionally like a fully integrated care system to measure outcomes, develop practice guidelines, and meet other BHCAG requirements. To accomplish this, a new organization, the Institute for Clinical Systems Integration (ICSI), was conceived. PROVIDERS AND EMPLOYERS COLLABORATE: To reduce costs ICSI has implemented 16 of 80 planned guidelines. Teams including members from clinics and BHCAG develop best-practice algorithms. Each guideline is then reviewed and piloted before being implemented in all ICSI clinics. MANAGING EXTERNAL ENVIRONMENT: The guideline on cystitis in healthy women eliminated two costly practices-obtaining a urine culture and visiting the doctor. Yet many physicians and the clinics were afraid of losing significant revenue because they were reimbursed by BHCAG on a fee-for-service basis. In turn, BHCAG's hands were tied. If they changed to a capitated payment system, they would face onerous state insurance requirements. The solution lay in collaborating at a higher level. ICSI and BHCAG leaders persuaded the state legislature to pass a new law that allowed BHCAG to capitate providers without state regulation. As a result, the cystitis guideline is now widely implemented in ICSI clinics. LESSONS LEARNED: The cystitis guideline experience highlights the need to manage the external environment so that it reinforces, rather than inhibits, quality improvement in medical practices. Guidelines will not be implemented unless the macro-environment into which they are introduced is supportive.

Contract Services↗

PubMed1996

Cancer pain management: pilot implementation of the AHCPR guideline in Utah.

BACKGROUND: Using the Agency for Health Care Policy and Research's (AHCPR's) 1994 Clinical Practice Guideline for Management of Cancer Pain, HealthInsight, the peer review organization for Utah and Nevada, organized a cooperative project with physicians and nurses from seven acute care hospitals in Utah. The project's purpose was to adapt the guideline into action plans for participating hospitals and provide the tools necessary to address six "core" guidelines-to assess and relieve pain, educate the patient/family and health care workers, measure patient satisfaction, and provide a continuum of care postdischarge. GUIDELINE DEVELOPMENT: The guidelines were further adapted to meet the needs of the individual hospitals and were implemented in January 1995. Baseline data was collected on 10 patient records per hospital. RESULTS: Survey results confirmed that although attitudes about cancer pain management were changing, more needed to be done to prevent patient suffering. Follow-up data after one year showed significantly more compliance on all six core guidelines. CASE STUDY: The oncology nurse manager and the hematology/oncology physician chief at one hospital joined the project team to support their own ongoing efforts to implement the guidelines. At that hospital, patient satisfaction with pain management has since increased from the 60%-80% level to at least 90%. STATEWIDE PROJECT EXPANSION: Statewide expansion was planned in fall 1995 to extend implementation to the remaining acute care hospitals and to other health care settings in Utah and to ease a patient's transition from one setting to another. CONCLUSION: The project team continues to monitor progress in guideline implementation. Surveys demonstrate that, at the time of diagnosis, up to 45% of cancer patients experience moderate to severe pain; 65%-90% experience severe pain when cancer reaches the advanced stages. Unrelieved cancer pain can cause intense suffering, diminished activity, loss of appetite, and loss of sleep.

Attitude↗

PubMed1997

The development and implementation of an integrated multidisciplinary clinical pathway.

Clinical pathways, linear time-related representations of patient care processes, are widely encouraged as a mechanism to outline efficient, cost-effective, multidisciplinary care. The translation of pathways from concept to reality is, however, predictably difficult. All caregivers are dedicated to a common goal, but organizational, personal, and professional perspectives are barriers to development of a common tool. Moreover, the building process requires the discovery, articulation, and communication of previously tacit patient care processes. Although no prescription can work for all pathway development, some strategies can help ensure the best possible chance of pathway success. Participants must recognize that between-patient variability can be expected to decrease with pathway implementation, and educational processes must support that aim. "Stakeholder groups" must be identified and their investment must be assessed, with careful attention paid to acquiring the unconditional support of institutional leadership. Planning of precise building, implementation, and piloting processes, with provision for facilitation of building and implementation processes, is critical. Those charged with pathway development must commit to the establishment and explication of clear goals (economic and quality outcomes) and to careful integration of the pathway with planned and existing continuous quality improvement processes. These strategies are illustrated with actual experiences in implementing cystectomy and pressure ulcer pathways in one academic medical center.

Communication↗

PubMed1999

Implementation of the Anemia Guidelines.

Implementation of the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) Guidelines for the treatment of the anemia of chronic renal failure is a great challenge to all concerned with the improvement in the quality of life and survival of patients with chronic renal failure. These include physicians, nurses, technicians, dietitians, social workers, administrators, and private and public (Health Care Financing Administration) payers of the care. The principles of the process of implementation are reviewed and the barriers that can prevent implementation are discussed, showing how most of these can be overcome. Several of the more controversial Guidelines are discussed in detail, showing that with protocols that address the means for implementation, the goals of these Guidelines can be achieved.

Anemia↗

PubMedDate not supplied

[Assessment of the efficacy of the implementation of an arterial cannulation protocol as quality assurance method].

AIM: Arterial cannulation is a usual technique in intensive care. With this study, we aim to assess the efficacy of the implementation of an arterial cannulation protocol. MATERIAL AND METHOD: The study was performed in several phases: a first cross-sectional cut-off to assess the technique performed and the incidence of complications, without knowledge of the study by the staff involved. There was a second phase of development and explanation to the unit staff of a protocol performed based on the results obtained and the available evidence. The third phase was of reevaluation of the results after the implementation of the protocol by a new cross-sectional cut-off without knowledge of the staff. RESULTS: In phase 1, a total of 100 arterial cannulations were studied, obtaining the existence of a large amount of catheters not fixed by suture (44%) and a significant percentage of cases of accidental withdrawal (15%) as fundamental results. The protocol was implemented to solve these problems. It stressed the suture of all the cannalized catheters. Data on 80 patients and 133 catheters have now been gathered. The percentage of catheters that were sutured according to the protocol indication was 98%, significantly greater than phase 1 (p< 0.0001). The number of catheters whose withdrawal reason was accident removal was also significantly inferior (4%; p = 0.002). CONCLUSIONS: The implementation of an arterial cannulation protocol with a high rate of follow-up by the nursing staff has achieved a reduction in the incidence of iatrogenies due to the technique.

Catheterization, Peripheral↗

PubMed2006

Reconciling medications at admission: safe practice recommendations and implementation strategies.

BACKGROUND: Fifty hospitals collaborated in a patient safety initiative developed and implemented by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Hospital Association. METHODS: A consensus group identified safe practices and suggested implementation strategies. Four collaborative learning sessions were offered, and teams monitored their progress and shared successful strategies and lessons learned. Reports from participating teams and an evaluation survey were then used to identify successful techniques for reconciling medications. RESULTS: For the 50 participating hospitals, implementation strategies most strongly correlated with success included active physician and nursing engagement, having an effective improvement team, using small tests of change, having an actively engaged senior administrator, and sending a team to multiple collaborative sessions. DISCUSSION: Adoption of the reconciling safe practices proved challenging. The process of writing medication orders at patient transfer points is complex. The hospitals' experiences demonstrated that implementing the proposed safe practices requires a team effort with leadership support and vigilant measurement.

Cooperative Behavior↗

PubMed2001

Toward public health nutrition strategies in the European Union to implement food based dietary guidelines and to enhance healthier lifestyles.

This paper suggests strategies for implementing the EU food based dietary guidelines. Dietary guidelines have been developed and disseminated in many countries across the world. However, the EU guidelines are the first to include a specific section on implementation. The aims of the guidelines are twofold, 1) to provide food based dietary guidelines which can be used as a consistent communication tool and 2) as a springboard to planning, implementing, and evaluating public health nutrition strategies. The report is not intended to be prescriptive. It aims to build upon a solid evidence base to provide practical and cost effective suggestions for developing public health strategies, which member countries can use and tailor to the social, cultural and health needs of their populations. Diet and physical activity related diseases impose vast costs on the European economy. However, despite the enormous costs to healthcare systems and in terms of lost productivity, there have been a very few resources allocated in Europe to attempting to prevent these, rather than treating them. The burden of disease exists in the majority of the population, and not in high-risk groups. The optimal public health strategy is thus to focus on the population as a whole, rather than targeting those with increased risk factors or pre-existing disease. Reviews have been carried out on the health impact effectiveness of various types of intervention to promote healthy eating and physical activity in the population. These conclude that the most effective interventions a) adopt an integrated, multidisciplinary, and comprehensive approach b) involve a complementary range of actions, and c) work at an individual, community, environmental and policy level. Information provision in isolation is not effective, and may exacerbate inequalities in health. In some countries inequities in diet and physical activity are not only significant contributors to inequalities in health, but are increasing. Effective interventions to address inequities need to tackle the broader determinants of health, including social exclusion, social cohesion, environmental, and structural factors. One of the most easily transferable frameworks for the development of public health strategies attempts to capture the individual, community, environmental and policy levels, by working through 'target groups', 'settings', and 'approaches'. The Working Party has suggested outline strategies for each of the key target groups, setting and approaches which it has identified as having the potential for maximum reach and influence. The key characteristics of effective interventions for each of these is given. Finally, the evidence base points to the importance of a co-ordinated, multisectoral and population wide strategy. In order to develop and implement such strategies, identifiable structures and mechanisms will be needed at a national level within member states.

Cardiovascular Diseases↗

PubMed2000

Rational pharmacotherapy and clinical practice guidelines. Theories and perspectives on implementing pharmacotherapeutic treatment guidelines.

Several theories behind implementing clinical guidelines have been described within the literature. At first sight, these may seem different. However, there are similarities and eventually they are rather complementary than mutually exclusive. This article integrates several theoretical views on implementation of pharmacotherapeutic treatment guidelines and subsequently addresses some empirical considerations. Furthermore, specific limitations and potential harms of implementing guidelines are addressed. Several checklists are provided in order to make pharmacists, pharmacologists and clinicians aware of perspectives on dissemination, implementation, and subsequent application of pharmacotherapeutic treatment guidelines.

Drug Therapy↗

PubMed2001

Implementation of a Quality Plan (ISO 9002) In a Regional Tissue Bank.

Quality control and standardized preservation methods are essential in the field of transplantation. The International Organization for Standardization (ISO) has established a common set of manufacturing, trade and communications standards that are applicable worldwide and that provide the basis of a quality plan for Tissuebreak Banks.The Sectorial Tissue Banking (STB) of the Regional Blood Transfusion Center (RBTC) of Córdoba (Spain) is a non-profit-making tissue bank, established in 1992 to provide tissues for surgical procedures to the hospitals in a regional area. In 1998, the STB as a part of the RBTC embarked upon the path of becoming ISO-certified: after two years of the implementation of the project, STB attained ISO 9002 certification, thus becoming one of the first tissue banks in Europe to achieve this qualification. In this paper we describe the process of becoming ISO-certified, to demonstrate the positive impact that it has had on our entire organization.The assistance of an outside consultant who provided the necessary information for implementing an ISO quality management system was required. The initial improvement was: a well-defined quality manual to address all elements of the ISO 9002 standard, an improved document control system, detailed standard operating procedures (SOPs) and improved employees training processes. A quality committee team and developed quality indicators were created. The internal quality auditing program was established by the selection of employees from a cross-section of the organization, who were trained in internal auditing processes. A formal corrective action system was developed and implemented to facilitate process improvement. The consultant conducted a pre-certification audit, and one month later the certification audit was performed.In conclusion, the implementation of an ISO quality program in the STB has helped our center to establish a control process in the manufacturing of products and services to meet the expectations of our customers, by providing components and services that comply with the national regulatory standards and requirements.

Journal Article↗

PubMed1997

The Pharmacists' Implementation of Pharmaceutical Care (PIPC) model.

PURPOSE: Study purpose was to develop a theoretical framework that will explain pharmacists' behavior relative to the provision of pharmaceutical care. The model was developed from four attitude models by testing their predictive validity relative to pharmaceutical care implementation. Four hypotheses and one research question were investigated to identify determinants of behavioral intention and behavior. METHODS: 617 community pharmacists in the state of Florida, U.S.A., were surveyed twice using mail survey methodology to collect data. The first survey assessed community pharmacists' attitude, subjective norm, perceived behavioral control, past behavior recency, self-efficacies, instrumental beliefs and affect. The second survey assessed pharmacists' behavior relative to the implementation of pharmaceutical care. After establishing reliability and validity of measures, regression analysis was used to test hypotheses and research question investigated. RESULTS: The Pharmacists' Implementation of Pharmaceutical Care (PIPC) model developed postulates that (i) behavior is directly determined by past behavior recency, behavioral intention and perceived behavioral control; (ii) psychological appraisal processes-instrumental beliefs, self-efficacies, and affect toward means-influence behavior through past behavior recency; and (iii) behavioral intention is determined by attitude, social norm and perceived behavioral control. CONCLUSIONS: The PIPC model provides a formal scientifically validated theoretical framework which can be used to design successful intervention for pharmaceutical care implementation.

Community Pharmacy Services↗

PubMed2002

The challenge of implementing and sustaining integrated dual disorders treatment programs.

Integrated dual disorders treatment programs for people with severe mental illness and co-occurring substance use disorder have been implemented in a variety of community mental health center sites across the U.S. and in several other countries over the past 15 years. Consumers who receive services from programs that offer integrated dual diagnosis treatments that are faithful to evidence-based principles achieve significant improvements in their outcomes. Unfortunately, not all programs that attempt implementation are successful, and the quality of high-fidelity programs sometimes erodes over time. This article outlines implementation strategies that have been used by successful programs. As a general rule, success is achieved by involving all major participants (consumers, family members, clinicians, program leaders, and state or county mental health authorities) in the process and attending to the three phases of change: motivating, enacting, and sustaining implementation.

Community Mental Health Services↗

PubMed1997

Implementing a comprehensive program for the prevention of conduct problems in rural communities: the Fast Track experience. The Conduct Problems Prevention Research Group.

Childhood conduct problems are predictive of a number of serious long-term difficulties (e.g., school failure, delinquent behavior, and mental health problems), making the design of effective prevention programs a priority. The Fast Track Program is a demonstration project currently underway in four demographically diverse areas of the United States, testing the feasibility and effectiveness of a comprehensive, multicomponent prevention program targeting children at risk for conduct disorders. This paper describes some lessons learned about the implementation of this program in a rural area. Although there are many areas of commonality in terms of program needs, program design, and implementation issues in rural and urban sites, rural areas differ from urban areas along the dimensions of geographical dispersion and regionalism, and community stability and insularity. Rural programs must cover a broad geographical area and must be sensitive to the multiple, small and regional communities that constitute their service area. Small schools, homogeneous populations, traditional values, limited recreational, educational and mental health services, and politically conservative climates are all more likely to emerge as characteristics of rural rather than urban sites (Sherman, 1992). These characteristics may both pose particular challenges to the implementation of prevention programs in rural areas, as well as offer particular benefits. Three aspects of program implementation are described in detail: (a) community entry and program initiation in rural areas, (b) the adaptation of program components and service delivery to meet the needs of rural families and schools, and (c) issues in administrative organization of a broadly dispersed tricounty rural prevention program.

Child↗

PubMed2004

The nationwide evaluation of fetal and infant mortality review (FIMR) programs: development and implementation of recommendations and conduct of essential maternal and child health services by FIMR programs.

OBJECTIVE: An evaluation of fetal and infant mortality review (FIMR) programs nationwide was conducted to characterize their unique role in improving the system of perinatal health care. The aim of this paper is to examine intermediate outcomes of the FIMR, in particular the development and implementation of recommendations produced by the FIMRs and the conduct of essential MCH services by the FIMRs. METHODS: We report on 74 FIMRs whose communities were selected for the nationwide evaluation and for whom we had data from the FIMR director or comparable respondent. We focus on the recommendations of the FIMRs and the essential maternal and child health (MCH) services conducted by the FIMRs as intermediate outcomes (or outputs) and then examine how selected characteristics of the FIMR may influence these. RESULTS: FIMRs developed recommendations on a broad range of topics but there were some areas for which nearly all programs had developed recommendations. The FIMRs relied primarily on strategies related to programs and practices, with few FIMRs reporting attention to policy-oriented approaches. Implementation of recommendations was high. Factors that influenced likelihood of implementing recommendations and conduct of essential MCH services included structure of the FIMR and training received by FIMR directors and staff. CONCLUSIONS: The focus of FIMR recommendations and the likelihood of implementation vary across FIMRs as does the conduct of essential MCH services. FIMR team structure and training of the director and staff are important areas to consider in efforts to maximize the impact of FIMR.

Child Health Services↗

PubMed2000

Using implementation intentions to increase attendance for cervical cancer screening.

This article evaluates an intervention based on P. M. Gollwitzer's (1993) concept of implementation intentions. Women registered at a medical practice in rural England (N = 114) completed measures of the theory of planned behavior variables before a manipulation that induced one half of the sample to form implementation intentions specifying when, where, and how they would make the appointment. Subsequent attendance was determined from medical records. Findings show that the theory of planned behavior variables and previous delay behavior provided good prediction of attendance. However, despite equivalent motivation to attend, participants who formed implementation intentions were much more likely to attend for screening compared with controls (92% vs. 69%). Evidence also suggests that implementation intentions attenuated the relationship between previous delay behavior and subsequent attendance.

Adult↗

PubMed2006

Effects of implementation intentions on the self-reported frequency of drivers' compliance with speed limits.

This study tested the efficacy of implementation intentions in the context of drivers' speeding behavior. Participants (N = 300) completed self-report measures of goal intention and behavior, and they were randomly assigned to an experimental condition, which required them to specify an implementation intention, or a control condition. One month post-baseline, self-reported compliance with speed limits significantly increased for experimental participants but not for control participants. The effects of specifying an implementation intention on behavior increased with the strength of drivers' goal intentions. Finally, analysis of participants' implementation intentions revealed that specifying more behavioral strategies increased the frequency with which participants reported complying with the speed limit. Implications of the findings are discussed in relation to enhancing road safety interventions.

Adult↗

PubMed2003

Reducing acquired infections in the NICU: observing and implementing meaningful differences in process between high and low acquired infection rate centers.

BACKGROUND: Acquired infection is one of the most prevalent sources of concern in neonatal intensive care units (NICUs). Center-to-center variation has been noted by both the National Nosocomial Infection Surveillance System and the Vermont Oxford Network suggesting that site of care influences outcomes including acquired infection. OBJECTIVE: To reduce the acquired infection rate by isolating and then implementing meaningful process differences between high and low infection rate centers. DESIGN/METHOD: A multistaged observation and intervention study. The primary outcome measure was defined as a positive blood culture, collected more than 3 days after birth. Hospital patient days along with infection episodes were collected for all NICU admissions in the network during the baseline and post-implementation periods. A detailed observation guide was used during site visits to high and low infection rate centers. The observations recorded in the guide allowed the team to isolate meaningful differences, which were shared with the network. Individual NICUs decided which of the meaningful differences, if any, to implement. To estimate the impact on costs, additional data were gathered in a case-matched series of infants in one demonstration site. RESULTS: In all, 15 meaningful differences were isolated and shared with the network. The network rate for acquired infection dropped from 3.8 to 2.9 episodes per 1000 patient days. In the demonstration site, the infection rate dropped from 7.4 to 4.0 per 1000 patient days. CONCLUSION: Isolation of process level differences between high and low performing centers followed by implementation of these meaningful differences may reduce acquired infections. Other targeted areas of care may benefit from this quality improvement methodology.

Cross Infection↗

PubMed2006

Distributed memory parallel implementation of energies and gradients for second-order Møller-Plesset perturbation theory with the resolution-of-the-identity approximation.

We present a parallel implementation of second-order Møller-Plesset perturbation theory with the resolution-of-the-identity approximation (RI-MP2). The implementation is based on a recent improved sequential implementation of RI-MP2 within the Turbomole program package and employs the message passing interface (MPI) standard for communication between distributed memory nodes. The parallel implementation extends the applicability of canonical MP2 to considerably larger systems. Examples are presented for full geometry optimizations with up to 60 atoms and 3300 basis functions and MP2 energy calculations with more than 200 atoms and 7000 basis functions.

Journal Article↗

PubMed2002

Decrease in nickel sensitization in a Danish schoolgirl population with ears pierced after implementation of a nickel-exposure regulation.

BACKGROUND: To reduce the skin nickel exposure of the population, the Danish Ministry of Environment issued a regulation that was implemented in 1992, and the European Union countries have recently adopted an expanded regulation. OBJECTIVES: The aim of our combined patch testing and questionnaire investigation of girls in public schools and high schools/production schools was to evaluate whether the regulation has had an impact on the prevalence of nickel sensitization. METHODS: To find a group of girls with ears pierced mainly after implementation of the nickel-exposure regulation in Denmark, girls were recruited from the fifth and sixth grade in 12 public schools (the public school group). After the public school level almost all girls from a public school population continue their education in high schools or other schools such as production schools or technical schools. Therefore, to find girls demographically similar to the public school girls but older, and with ears pierced before implementation of the regulation, girls from seven high schools and two production schools were recruited (the high school group). Four hundred and twenty-seven girls in the public school group (mean age 12.4 years, range 10-14) and 534 in the high school group (mean age 18.8 years, range 17-22) participated. All participants filled out a questionnaire concerning ear piercing, use of oral braces and former patch testing for nickel sensitivity. Three hundred and five girls (71.4%) in the public school group and 275 (51.5%) in the high school group were patch tested or had been tested previously and the results of these tests were included in the study. The relation between the frequency of nickel sensitization and the various factors that might influence the prevalence of nickel sensitization was evaluated by multivariate logistic regression analysis. The investigation was conducted from March 1999 to March 2000. RESULTS: The study showed that both increasing age and having ears pierced before 1992 enhanced the prevalence of nickel sensitization. We found that 17.1% of the girls in the high school group demonstrated a positive patch test reaction to nickel. In contrast, the prevalence of nickel sensitization in the public school group was only 3.9%. Comparing girls with and without pierced ears, the prevalence of nickel sensitization was significantly higher in girls with ears pierced before, but not after, 1992 (odds ratio 3.34 and 1.20, respectively). Only in the high school group was there a tendency that wearing oral braces before ear piercing had a protective effect on nickel sensitization, but this did not reach statistical significance. CONCLUSIONS: As we found an effect of ear piercing before but not after 1992, this study strongly suggests that implementation of the nickel-exposure regulation in 1992 in Denmark has had the intended effect of protecting the female population from becoming allergic to nickel.

Adolescent↗