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PubMed1995

Implementation of community care policy in the United Kingdom: will it be achieved?

In the United Kingdom, the provision of health and social care within the community is the subject of major reform. This reform is aimed at reducing the dominance of the state as provider of welfare services whilst encouraging the independent sector to provide the bulk of services through competition and market forces. The purpose of this paper is to discuss the implementation of government policy with respect to health and social care in the community. The policy recommended in the 1989 White Paper Caring for People, which is sanctioned in the National Health Service (NHS) and Community Care Act (1990), is the focus for discussion. Implementation theory is used as a framework to explore the modification and reshaping which inevitably accompanies the translation of government policy into reality. The nature of any actual or potential deficit between stated policy and community care reform in practice is examined against this theoretical background. An historical stance is taken in order to place current policy into the wider context and consider what determinants may have led to the radical proposals for community care, and indeed other sectors of public service. A consideration of predominating philosophies is prudent to an analysis of government policy-making and therefore the values and beliefs of 'new public management' are employed as a conceptual framework underpinning current reform. The feasibility of a quasi-market in the delivery of health and social care is considered and some of the main issues which may result in implementation deficit with respect to the implementation of Caring for People are examined.

Communication↗

PubMed2001

Improvements in the quality of co-ordination of nursing care following implementation of the Resident Assessment Instrument in Dutch nursing homes.

AIM: To study the effect of implementation of the Resident Assessment Instrument (RAI) on the quality of co-ordination of nursing care in Dutch nursing homes. BACKGROUND: The Resident Assessment Instrument (RAI) was designed to improve the quality of care and quality of life in nursing homes. Until now, only noncontrolled studies on the effects of implementation of the RAI have been carried out. DESIGN/METHODS: Quasi-experimental; intervention wards with RAI compared with wards with no intervention. We used the co-ordination of nursing care instrument, which includes measures for case history, care plan, end of shift report, communication, patient allocation and patient report. The scores on these scales represent the quality of nursing procedures on a ward. The measurements were done 1 month before and 8 months after RAI-implementation in 18 wards in 10 nursing homes in the Netherlands. RESULTS: Out of 348 somatic patients on the participating wards who met the inclusion criteria and signed an informed consent, 278 could be measured at the first and 218 at the second data collection. 175 residents could participate twice. We used a meta-analysis technique to study the mean differences between eight couples of RAI/control wards before and after the intervention. The mean difference scores showed significant positive improvement in the RAI group for case history, there were minor (not statistically significant) improvements for all other scores and the total score. These results are encouraging especially in light of the fact that RAI-implementation in all the experimental wards did not proceed according to plan, owing to staffing and software problems. CONCLUSIONS: We conclude that the RAI has the potential to improve the quality of co-ordination of care in nursing homes.

Aged↗

PubMed2001

The impact of assessing the prevalence of pressure ulcers on the willingness of health care institutions to plan and implement activities to reduce the prevalence.

BACKGROUND: In 1998, 89 health care institutions (hospitals, nursing homes, residential homes, and community care institutions) participated in the first Dutch National Pressure Ulcer Prevalence Study. AIM: Based on the innovation-decision process for individuals (Rogers 1995), the effect of their participation was investigated at different levels in the institutions [prevalence assessment coordinator, director, ward management (enrolled) nurses, and the pressure ulcer committee]. METHOD: A mail questionnaire was developed and filled out by 54 coordinators of the participating health care institutions. RESULTS: Results showed that according to the coordinators most levels of the institutions were familiar with the results of the prevalence assessment, understood them, and were persuaded that their prevalence rate had to be changed. As a result, almost all of the coordinators of the institutions were planning activities to change pressure ulcer management, while half of the coordinators had already implemented some actions. The main activities planned or implemented were developing or updating the prevention and treatment protocol and educating the (enrolled) nurses. Some institutions were planning or had already implemented the appointment of a nurse specialist or a nurse paying special attention to pressure ulcers. Results showed that the different levels of the institutions took initiatives on different categories of activities. CONCLUSION: It is concluded that participating in the first national prevalence study was a positive experience for the institutions, because agenda-setting took place and most started to plan or implement activities to improve the prevention and treatment of pressure ulcers.

Cross-Sectional Studies↗

PubMed2002

Implementation research for 'evidence-based' guideline development by dietitians: a pilot study to test an instrument.

AIM: To improve the quality of dietetic care, dietitians in the University Medical Center Utrecht (UMCU) are encouraged to develop and implement 'evidence-based' guidelines. The aim of this pilot study was to develop and test a questionnaire for implementation research to monitor the process of developing and implementing these guidelines. METHODS: A questionnaire was developed and distributed to 15 dietitians, who have started developing an 'evidence-based' guideline. The questionnaire measures determinants of dietitians' behaviour and the presence of conditions facilitating the development of a guideline. Cronbach's alpha with a cut-off point of 0.7 was used to analyse the internal consistence between the items related to behavioural determinants. A panel of professionals such as a member of staff from the UMCU, a communication expert and project-managers ensured the completeness of the questionnaire. RESULTS: The internal consistency was high (alpha > 0.7) between the items related to the determinants of behaviour. The questionnaire gives a structured overview of factors affecting positively or negatively the process of guideline development. Although dietitians have a positive behaviour towards guideline development, they perceived barriers related to the presence of conditions to develop a guideline. CONCLUSION: We concluded that the applied questionnaire is appropriate for implementation research and has given a structured overview of factors that influence the development of dietetic guidelines by dietitians in the UMCU.

Attitude of Health Personnel↗

PubMed2000

Implementation of hospital care pathways for patients with schizophrenia.

AIM: This paper aims to discuss some of the issues for the implementation of care pathways for inpatients suffering from schizophrenia. This paper builds upon a previously published paper describing the development of the care pathway. BACKGROUND: The use of a care pathway may enable care to be delivered in a more efficient and effective way. Very little is known about the development or implementation of care pathways for mental health conditions. METHODS: Action research guided the process of implementation and led to 29 in-depth interviews. Participant observation and records of 15 working group meetings rounded the data analysis. FINDINGS: The nature of the study site changed dramatically over the course of the research programme with many staff leaving the ward. This led to many problems in implementing the care pathway including poor levels of morale and engagement; how the patients were admitted and managed on the care pathway; poor levels of documentation. CONCLUSIONS: The findings are particular to this research environment, although some wider issues could be applicable to other sites such as the nature of representing psychiatric work on the care pathway; the evidence-based practice movement and the role of the user and individualized care.

Adult↗

PubMed2002

The implementation of Tomorrow's Doctors.

BACKGROUND: In 1993 the General Medical Council published its recommendations on undergraduate medical education. AIM: To study the implementation of these recommendations in UK medical schools by means of informal visitations. METHODS: Teams consisting of 3-5 members visited the 25 UK medical schools in a 3-year period commencing in early 1995. RESULTS: Substantial changes have occurred in undergraduate medical education since the publication of Tomorrow's Doctors. Of the 13 principal recommendations, 3 had been implemented in most medical schools and a further 8 substantially implemented by the majority. However, progress in health promotion and the development of appropriate assessment schemes has been slower. CONCLUSIONS: Informal visits have served a useful purpose in monitoring the implementation of the General Medical Council's recommendations on undergraduate medical education. In addition, they have encouraged dialogue with the medical schools and allowed the identification of examples of good practice including the establishment by most schools of medical education units.

Attitude of Health Personnel↗

PubMed2003

Implementation of a formal in-training assessment programme in anaesthesiology and preliminary results of acceptability.

BACKGROUND: A new reform on postgraduate education in Denmark requires a formal in-training assessment in all specialties. The aim of this study was to survey the implementation and acceptability of the first example of a nation-wide in-training assessment programme for first-year trainees in anaesthesiology developed by a working group under the Danish Society of Anaesthesiology and Intensive Care Medicine. METHODS: A questionnaire about the implementation of the programme in practice and the characteristics of the trainees was sent to the educational responsible consultant (ERC) in each of the 26 anaesthetic departments in the country with first-year trainees in anaesthesiology. Standard evaluations of the assessment programme were regularly collected from trainees. RESULTS: Twenty-five (96%) departments returned the questionnaire. In total the departments reported on 100 trainees and 83 of these had been enrolled in the programme. Thirteen departments reported in total on 27 trainees who had completed their first year of training and these departments had applied a median 21 (range 17-21) of the 21 tests included in the entire programme. Time constraints and resistance among senior clinicians were the most frequently cited barriers to implementation. Evaluations from trainees showed a generally positive attitude towards most of the programme. They especially praised the programme's effect on structuring training and having a positive effect on learning. CONCLUSION: The in-training assessment programme has been widely implemented across the country. The majority of the programme was acceptable to trainees and had a positive effect on structuring training and on fostering learning.

Anesthesiology↗

PubMed2001

Implementing guidelines about colorectal cancer: a national survey of target groups.

BACKGROUND: An Australia-wide postal survey was undertaken to determine surgeons' attitudes towards guidelines and their preferred strategies for dissemination and implementation of guidelines for the management of colorectal cancer, developed by the Australian Cancer Network (ACN) and the Clinical Oncological Society of Australia (COSA). This survey was conducted as a baseline before the release of the definitive guidelines. METHODS: All members of the Royal Australasian College of Surgeons (RACS) with a self-nominated special interest in colorectal surgery and members of the Colorectal Surgical Society of Australia (CSSA) were surveyed. RESULTS: A total of 195 of the 219 surgeons eligible for the study returned questionnaires (89% response rate). Most (86%) were aware that these guidelines were being developed. More than one-half had read at least one draft version. Almost half (44.6%; 95%CI: 37.6-51.9%) agreed that guidelines represented 'cookbook medicine' and one-third (33.3%; 95%CI: 26.9-40.5%) agreed that guidelines might increase the number of malpractice suits. Local adaptation of guidelines and 'academic detailing' were most favourably ranked to assure implementation. Further, 54.9% (95%CI: 47.6-61.9%) of respondents believed that a successful legal defence of a surgeon whose practice had been within the guidelines would encourage uptake. Surgeons operating outside teaching hospitals were more likely to endorse this view than others. CONCLUSIONS: These results demonstrate that an important target group for colorectal cancer guidelines, namely surgeons, appears receptive to clinical practice guidelines. These results could also permit interventions that target attitudinal barriers to implementing guidelines and subgroups of surgeons who have particular concerns. Expensive strategies for implementation ought to be subject to rigorous evaluation for their impact in modifying clinical practice.

Attitude of Health Personnel↗

PubMed2001

A care policy and its implementation.

Chief physicians, nurse managers and head nurses (n = 50) in hospital care and primary health care in Västerbotten, Sweden, were interviewed to explore their views on adopting and implementing a new care policy. The results indicated agreement among the respondents concerning the values of the care policy and its adaptability to the health-care system. More respondents in hospital care than in primary health care expressed a positive view (63%, respectively 55%), reported involvement in the implementation process (64%, respectively 35%) and planned or ongoing activities (63%, respectively 45%). Obstacles in the implementation process due to a frustrated situation and barriers between professional groups were, however, expressed by 67% of the respondents, more among the respondents in primary health care than among those in hospital care (75%, respectively 62%). Divergent views among respondents working in the same department were seen in both hospital care and primary health care. The findings indicated demands for further efforts if the implementation is to move on from its early stages, especially in primary health care.

Attitude of Health Personnel↗

PubMed2002

Technical developments and a team approach leads to an improved outcome: lessons learnt implementing laparoscopic splenectomy.

BACKGROUND: To document the technical aspects, outcome and lessons learnt during the learning curve phase of implementing laparoscopic splenectomy, by comparing the results before and after the introduction of a standardized technique. METHODS: We present a retrospective and prospective review of laparoscopic splenectomies over a 4-year period. Two chronological periods were studied, before and after the implementation of a standardized technique of a laparoscopic splenectomy involving: (i) hilar dissection with ultrasonic shears; (ii) two experienced laparoscopic surgeons; and (iii) trained dedicated equipment and staff using a checklist approach in the preparation and conduct of the operation. Two groups of patients were studied relating to the periods before and after the implementation of a standardized technique. Statistical methods used were the Wilcoxon's rank sum test and the two-sample test. RESULTS: Thirty-one laparoscopic splenectomies were attempted. The most common indication was for idiopathic thrombocytopenic purpura. When comparing the early phase (n = 15) with the standardized technique phase (n = 16), there was a significant reduction in conversion rates (40% vs 6%), operating times (218 min vs 171 min), complication rates (6 cases including 1 death vs none) and length of stay (11 days vs 4 days). The results were significant for reduction in hospital stay, conversion rates and complications rates. CONCLUSIONS: A reduction in conversion rates, operating time, morbidity and length of stay was realized during the learning curve of implementing laparoscopic splenectomy by adopting a standardized technique. This technique involved hilar dissection using the ultrasonic shears, two experienced laparoscopic surgeons performing the surgery, dedicated equipment and trained staff using the checklist approach. We recommend such a standardized technique in performing laparoscopic splenectomy.

Adult↗

PubMed2002

Implementation of consultative geriatric recommendations: the role of patient-primary care physician concordance.

OBJECTIVES: To examine the effect on primary care physicians' implementation and their patients' adherence behaviors of patient-physician concordance about recommended geriatric health care. DESIGN: Case-series, independent interviews of patients and their physicians about their perceptions of the patients' health and the comprehensive geriatric assessment (CGA). SETTING: Community. PARTICIPANTS: Community-dwelling older patients (n = 111) who received consultative outpatient CGA and their primary care physicians. MEASUREMENTS: Concordance variables were generated using physician and patient responses to 10 questions on health- and CGA-related perceptions. An overall concordance score was generated by summing the total number of items on which patients and physicians agreed. Measures of the two dependent variables (physician implementation of and patient adherence to CGA recommendations) were by self-report. RESULTS: In multiple logistic regression analyses, overall concordance between patient and physician proved to be a significant and powerful predictor of physician implementation of (adjusted odds ratio (OR) = 2.7, 95% confidence interval (CI) = 1.6-4.6, P <.001) and patient adherence to (OR = 2.7, 95% CI = 1.7-4.2, P <.001) CGA recommendations, controlling for patient and physician gender and age, patients' functional status, duration of the patient-physician relationship, and frequency of visits in the previous year. Further analysis revealed that mutual patient-physician concordance on health-related perceptions was a significant predictor of these outcomes, whereas individual patient or physician perceptions were not. CONCLUSION: Concordance between older patients and their primary care physicians is a powerful predictor of physician implementation of and patient adherence to outpatient consultative CGA recommendations. Future research should focus on ways physicians can assess and negotiate patient-physician agreement on geriatric healthcare recommendations.

Aged↗

PubMed2002

[Effects of a regional intervention to promote asthma guidelines implementation].

AIM: Despite of asthma guidelines existing for years, secondary data analysis shows insufficient medical care of asthmatics in Germany. The aim of the present study was to improve asthma guideline adherence by promoting guidelines implementation. METHOD: We analyzed prospectively pre- and post-interventional medical care of a sample of 127 asthmatics who were recruited by physicians working in ambulatory care and in hospitals of the Region Neckar-Alb, Germany. Data came primarily from patient interviews by phone. Our intervention to promote guidelines implementation consisted of following methods: 1. analyzing regional asthma care followed by a feedback performance report to physicians; 2. delivering asthma patient diaries and peak flow meters to study patients; 3. developing and adapting regionally asthma guidelines for adult asthmatics in the Region of Neckar-Alb; 4. promoting guidelines utilization by publishing the adapted guidelines in a scientific journal, direct mailing of a short version to the practitioners, and boosting the guidelines at regional CE meetings; 5. reanalyzing asthma care of the study cohort and the implementation of the guidelines 13 months after the beginning of the intervention. We studied the effect of the intervention using a qualitative model comprising 18 quality indicators measuring the proportion of patients who were treated in accordance to the guidelines. To compare pre- and post-interventional proportions we used the McNemar test for statistical analysis. RESULTS: The proportion of asthmatics treated in accordance to the guidelines improved significantly from 48 % to 57 %. The increase was mainly due to an improvement of guidelines adherence within the field of promoting asthma self-management and continuous monitoring of patients (42 % pre- and 57 % post-intervention), whereas guidelines adherence in pharmacotherapy improved only from 53 % to 56 %. CONCLUSION: The proportion of asthmatics treated in accordance to guidelines can be improved by using a multifaceted regional approach to promote guidelines implementation.

Adult↗

PubMed2006

Implementation and synchronization of 3x3 grid scroll chaotic circuits with analog programmable devices.

The implementation of circuits with complex dynamics is a very challenging problem. In this paper we present a new chaotic circuit based on the dynamical equations introduced in IEEE Trans. Circuits Syst., I: Fundam. Theory Appl. 51, 2476-2490 (2004). This circuit has been realized by using programmable analog devices, and, in particular, field programmable analog arrays have been used to implement a two-dimensional 3x3 grid scroll chaotic attractor. The implementation of complex dynamics with low cost circuits is very appealing; moreover, the implementation of the chaotic attractor discussed in this paper is not present in the literature. The experimental results including the synchronization between two chaotic circuits show complete agreement with the simulation results reported in IEEE Trans. Circuits Syst., I: Fundam. Theory Appl. 51, 2476-2490 (2004).

Journal Article↗

PubMed2006

Identifying hazardous alcohol consumption during pregnancy: implementing a research-based model in real life.

AIMS: It has been repeatedly demonstrated that hazardous alcohol use during pregnancy is rarely detected in regular antenatal care, and that detection can be markedly improved using systematic screening. A major challenge is to translate research-based strategies into regular antenatal care. Here, we examined whether a screening strategy using the Alcohol Use Disorder Test (AUDIT) and time-line follow-back (TLFB) could be implemented under naturalistic conditions and within available resources; and whether it would improve detection to the extent previously shown in a research context. METHODS: Regular midwives at a large antenatal care clinic were randomized to receive brief training and then implement AUDIT and TLFB ("intervention"); or to a waiting-list control group continuing to deliver regular care ("control"). In the intervention-condition, AUDIT was used to collect data about alcohol use during the year preceding pregnancy, and TLFB to assess actual consumption during the first trimester. Data were collected from new admissions over 6 months. RESULTS: Drop out was higher among patients of the intervention group than control midwives, 14% (23/162) versus 0% (0/153), and p<0.0001. A one-day training session combined with continuous expert support was sufficient to implement systematic screening with AUDIT and TLFB largely within resources of regular antenatal care. The use of these instruments identified patients with hazardous consumption during the year preceding pregnancy i.e. AUDIT score 6 or higher (17%, 23/139), and patients with ongoing consumption exceeding 70 g/week and/or binge consumption according to TLFB (17%, 24/139), to a significantly higher degree than regular antenatal screening (0/162). The AUDIT- and TLFB-positive populations overlapped partially, with 36/139 subjects screening positive with either of the instrument and 11/139 were positive for both. CONCLUSIONS: We confirm previous findings that alcohol use during pregnancy is more extensive in Sweden than has generally been realized. Systematic screening using AUDIT and TLFB detects hazardous use in a manner which regular antenatal care does not. This remains true under naturalistic conditions, following minimal training of regular antenatal care staff, and can be achieved with minimal resources. The proposed strategy appears attractive for broad implementation.

Adult↗

PubMed2025

Implementation of a Face-To-Face Vs Virtual Peer-Integrated Collaborative Care Intervention for Mental Health Treatment of Physical Trauma Survivors: A Qualitative Study of Lessons from the COVID-19 Pandemic.

OBJECTIVE: We assessed the impact of the COVID-19 pandemic on the implementation of a peer-integrated enhancement of integrated clinical care intervention to address the mental health needs of 450 patients undergoing treatment for a physical injury. METHODS: Qualitative data were collected by 7 clinician investigators of a randomized controlled trial acting as participant observers in a trauma care setting of a major U.S. metropolitan hospital and analyzed in collaboration with an external mixed methods specialist. RESULTS: The pandemic created or exacerbated several implementation barriers, including increased risk of infection, homelessness, hospitalizations and comorbid conditions such as fentanyl overdoses that increased demand on emergency department and Trauma Center services, imposition of safety measures to reduce risk of infection in clinical settings, transition from face-to-face to virtual interactions with study patients, shortages of specialty mental health providers, suspension of recruitment of patients into the study, scheduling calls with patients, and an increased workload for the study clinical interventionists. Peer specialists perceived the transition to virtual interactions with patients reduced their effectiveness; however, this was not reflected in assessments of patient satisfaction with services received and may have inadvertently increased adoption by Trauma Center staff. Reduction in reach of the intervention to target population was temporary. CONCLUSIONS: The COVID-19 pandemic exacerbated existing barriers and created new barriers to successfully implementing evidence-based practices in trauma care settings, resulting in an attenuation of their effectiveness. However, the shift from face-to-face to virtual services delivery may have actually led to improved implementation outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03569878. Registered June 15, 2018.

Humans↗

PubMedDate not supplied

Effects of modified-implement training on fast bowling in cricket.

The effects of training with overweight and underweight cricket balls on fast-bowling speed and accuracy were investigated in senior club cricket bowlers randomly assigned to either a traditional (n = 9) or modified-implement training (n = 7) group. Both groups performed bowling training three times a week for 10 weeks. The traditional training group bowled only regulation cricket balls (156 g), whereas the modified-implement training group bowled a combination of overweight (161-181 g), underweight (151-131 g) and regulation cricket balls. A radar gun measured the speed of 18 consecutive deliveries for each bowler before, during and after the training period. Video recordings of the deliveries were also analysed to determine bowling accuracy in terms of first-bounce distance from the stumps. Bowling speed, which was initially 108 +/- 5 km h(-1) (mean +/- standard deviation), increased in the modified-implement training group by 4.0 km x h(-1) and in the traditional training group by 1.3 km x h(-1) (difference, 2.7 km x h(-1); 90% confidence limits, 1.2 to 4.2 km x h(-1)). For a minimum worthwhile change of 5 km x h(-1), the chances that the true effect on bowling speed was practically beneficial/trivial/harmful were 1.0/99/< 0.1%. For bowling accuracy, the chances were 1/48/51%. This modified-implement training programme is not a useful training strategy for club cricketers.

Adult↗

PubMed2004

When you assume...the reality of implementing a legally mandated substance abuse treatment program.

In 2000, the voters of California approved the Substance Abuse and Crime Prevention Act (SACPA), mandating that substance-abusing offenders who met the eligibility criteria receive treatment and not jail time. In preparation for implementation, the Santa Clara County Department of Alcohol and Drug Services Research Institute worked to identify the number and type of clients who would be eligible to receive treatment. The purpose of this article is to analyze the differences between a profile of SACPA-eligible clients that was based on pre-SACPA implementation clients and assumptions that were made concerning eligibility for the program and the reality of post-SACPA implementation clients. This article examines causes and consequences of the discrepancies between policy and implementation in the area of substance abuse treatment.

Adult↗

PubMed1998

Implementing clinical guidelines in the treatment of hypertension in general practice.

Discrepancies between clinical guidelines and clinical practice call for practical implementation strategies. This study evaluates the implementation of clinical guidelines for hypertension in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention. We carried out a randomized study of general practice health centres in Sør- and Nord-Trøndelag counties in Norway (population 380000). A total of 17 health centres were included, with 24 doctors and 984 patients in the intervention group. Data from 887 patients was used in the analyses. There were 12 health centres with 29 doctors and 1255 patients in the control group. Data from 1127 control patients was used in the analyses. The main outcome measures were doctor's behaviour, measured by adherence to registration of recommended variables in the Norwegian clinical guidelines for hypertension. The aim of the intervention was to lower the fractions of patients without registrations. However, there were no clinically significant differences between the intervention group and the control group for fractions of patients without registration of blood pressure (intervention group 14.3%, control group 14.2%) or serum cholesterol (62.3% vs. 56.8%) during 12 months, nor, during 18 months, for fractions of patients without a registration of cigarette smoking (82.9% vs. 87.1%), cardiovascular inheritance (79.5% vs. 73.4%) and body mass index (81.5% vs. 89.2%). One or several variables necessary for calculation of risk score for myocardial infarction were missing in 91.7% of patients in the intervention group and 91.9% of patients in the control group. Large centre variations were shown for all variables. Implementation of clinical guidelines in the treatment of hypertensive patients in general practice, by means of a CDSS and several procedures for implementation did not result in clinically significant changes in the doctors' behaviour. Of importance are both the lack of user-friendliness of the specific CDSS and problems in performing time-consuming multidimensional procedures.

Adult↗