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PubMed1998

Constructing quantitative implementation scales from categorical services data. Examples from a multisite evaluation.

Like measures of outcome, measures of implementation are most useful and analytically powerful when measured at client-level and are quantitative. However, high-quality, individual-level, quantitative service utilization data can be expensive, intrusive, or otherwise impractical to obtain. Cruder data--for example, presence versus absence of a given service--are often more feasible to collect, as well as more likely to be available. Consequently, evaluators can benefit by finding ways to better exploit such data at the analysis phase to compensate for shortcomings at the collection phase. This article documents one such instance in which this was done. Specifically, it describes how quantitative, client-level implementation scales were derived from qualitative (categorical) data and used to support a cross-site synthesis of implementation and outcome analyses in a multisite evaluation. It also suggests additional scenarios in which quantitative implementation scales might be derived form qualitative services data.

Alcoholism↗

PubMedDate not supplied

Implementation and evaluation of a standardized herpes simplex virus prophylaxis protocol on a leukemia/bone marrow transplant unit.

OBJECTIVE: To assess the impact of a standardized acyclovir prophylaxis protocol for the prevention of herpes simplex virus (HSV) infection and disease in bone marrow transplant and leukemic patients. DESIGN: Two-phase, open sequential study involving prospective patient monitoring and retrospective health record review. SETTING: Tertiary care teaching hospital. PATIENTS: Fifty-seven patients (35 preprotocol, 22 postprotocol) who received acyclovir for HSV prophylaxis during an 18-month study period. INTERVENTIONS: An acyclovir HSV prophylaxis protocol was developed and implemented. Under this protocol, all HSV immunoglobulin G-seropositive hematology patients received an acyclovir regimen of 125 mg/m2 i.v. q6h or 600 mg p.o. q6h (if tolerated) from day -5 to day 30. Regimens not matching protocol were modified by pharmacists in conjunction with the prescriber. All treatment courses were followed daily by pharmacists to modify dosage according to renal function and assess appropriateness of the i.v. route. Tablets, capsules, or suspensions were promoted if the patient was considered tolerant of the oral route. MAIN OUTCOME PARAMETERS: Outcome parameters included (1) incidence of parenteral, oral, or combined therapy; (2) total prophylactic acyclovir dose per patient; (3) mean prophylactic acyclovir daily dose; (4) mean duration of acyclovir prophylaxis; and (5) HSV reactivation rate. RESULTS: Following implementation of the protocol, the mean total i.v. acyclovir dose per patient decreased from 20.1 g (range 3.6-109.5) to 11.7 g (range 1.0-43.0; p = 0.1162). The mean cumulative oral dose increased from 12.1 g (range 0.4-70.0) to 33.1 g (range 2.4-93.6; p = 0.0007). Mean duration of therapy increased from 27.6 to 33.5 days (p = 0.23). The mean duration of oral therapy increased from 10.5 days (+/- SD 10.9) to 17.2 days (+/- SD 12.1) (p = 0.034). The appropriateness of use of the i.v. dosage form increased from 53 to 88 percent of treatment days (p = 0.013). No difference in HSV reactivation rate was observed when comparing patients prior to and following protocol implementation. A drug acquisition savings of $1112.00 (CDN) per patient was realized. CONCLUSIONS: The implementation of a standardized HSV acyclovir prophylaxis protocol has resulted in significant drug acquisition cost savings without an apparent negative impact on patient outcome.

Acyclovir↗

PubMedDate not supplied

Classifying the effectiveness of Veterans Affairs guideline implementation approaches.

Hospitals use numerous guideline implementation approaches with varying success. Approaches have been classified as consistently, variably, or minimally effective, with multiple approaches being most effective. This project assesses the Department of Veterans Affairs (VA) use of effective guideline implementation approaches. A survey of 123 VA quality managers assessed the approaches used to implement the chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, and major depressive disorder guidelines. Approaches were categorized based on their effectiveness, and the total number of approaches used was calculated. Commonly used approaches were clinical meetings, summaries, and revised forms. Consistently and minimally effective approaches were used most frequently. Most hospitals used 4-7 approaches. Odds ratios demonstrated that consistently effective approaches were paired with minimally and variably effective approaches. The frequent use of consistently effective approaches and multiple approaches benefits VA adherence. However, VA hospitals should consider selective combinations of approaches to ensure the use of the most effective implementation methods.

Aged↗

PubMed2004

Community-based school feeding during Indonesia's economic crisis: implementation, benefits, and sustainability.

The Indonesian Government initiated a community-based national school-feeding program in 1996. Implementation was decentralized and involved multiple participants. In 1998 we evaluated the implementation of the program and the perceived benefits for community stakeholders using a survey of principals in 143 randomly selected schools and follow-up with in-depth interviews and observations in a subsample of 16 communities. The evaluation covered the period of the 1998 Asian economic crisis, affording the opportunity to assess its impact on the program. The program was implemented in all targeted schools, with excellent community participation. Feeding was sustained through the crisis, in spite of a dramatic escalation in food costs. The families of schoolchildren, farmers, and those who prepared food received economic benefits. The snacks replaced those sold at schools and were of better nutritional value. The children benefited because the snacks compensated for losses in the home diet resulting from the economic crisis. Characteristics of the program that may be important in explaining its success include the involvement of a range of community stakeholders, engagement with existing village administrative structures, scope for local community adaptation and innovation, and the use of local foods that dispersed benefits and ensured sustained implementation during the crisis.

Adolescent↗

PubMed2006

The impact of the implementation of work hour requirements on residents' career satisfaction, attitudes and emotions.

BACKGROUND: To assess the impact of work hours' limitations required by the Accreditation Council for Graduate Medical Education (ACGME) on residents' career satisfaction, emotions and attitudes. METHODS: A validated survey instrument was used to assess residents' levels of career satisfaction, emotions and attitudes before and after the ACGME duty hour requirements were implemented. The "pre" implementation survey was distributed in December 2002 and the "post" implementation one in December 2004. Only the latter included work-hour related questions. RESULTS: The response rates were 56% for the 2002 and 72% for the 2004 surveys respectively. Although career satisfaction remained unchanged, numerous changes occurred in both emotions and attitudes. Compared to those residents who did not violate work-hour requirements, those who did were significantly more negative in attitudes and emotions. CONCLUSION: With the implementation of the ACGME work hour limitations, the training experience became more negative for those residents who violated the work hour limits and had a small positive impact on those who did not violate them. Graduate medical education leaders must innovate to make the experiences for selected residents improved and still maintain compliance with the work hour requirements.

Accreditation↗

PubMed2006

Evaluation of PROforma as a language for implementing medical guidelines in a practical context.

BACKGROUND: PROforma is one of several languages that allow clinical guidelines to be expressed in a computer-interpretable manner. How these languages should be compared, and what requirements they should meet, are questions that are being actively addressed by a community of interested researchers. METHODS: We have developed a system to allow hypertensive patients to be monitored and assessed without visiting their GPs (except in the most urgent cases). Blood pressure measurements are performed at the patients' pharmacies and a web-based system, created using PROforma, makes recommendations for continued monitoring, and/or changes in medication. The recommendations and measurements are transmitted electronically to a practitioner with authority to issue and change prescriptions. We evaluated the use of PROforma during the knowledge acquisition, analysis, design and implementation of this system. The analysis focuses on the logical adequacy, heuristic power, notational convenience, and explanation support provided by the PROforma language. RESULTS: PROforma proved adequate as a language for the implementation of the clinical reasoning required by this project. However a lack of notational convenience led us to use UML activity diagrams, rather than PROforma process descriptions, to create the models that were used during the knowledge acquisition and analysis phases of the project. These UML diagrams were translated into PROforma during the implementation of the project. CONCLUSION: The experience accumulated during this study highlighted the importance of structure preserving design, that is to say that the models used in the design and implementation of a knowledge-based system should be structurally similar to those created during knowledge acquisition and analysis. Ideally the same language should be used for all of these models. This means that great importance has to be attached to the notational convenience of these languages, by which we mean the ease with which they can be read, written, and understood by human beings. The importance of notational convenience arises from the fact that a language used during knowledge acquisition and analysis must be intelligible to the potential users of a system, and to the domain experts who provide the knowledge that will be used in its construction.

Antihypertensive Agents↗

PubMed2006

Implementing and managing self-management skills training within primary care organisations: a national survey of the expert patients programme within its pilot phase.

A key element of the United Kingdom (UK) health policy reform in relation to chronic disease management is the introduction of a national programme seeking to promote self-care from within the National Health Service (NHS). The mainstay of the Expert Patients Programme (EPP) is a six-week training course that provides the opportunity for anyone with a long-term condition to develop new skills to manage their condition better on a day-to-day basis. The course forms part of the NHS self-care support programme, is administered by Primary Care Trusts (PCTs) and delivered by people who have personal experience of living with a long-term condition. The NHS' official Expert Patients Programme website presently states that, "Pilot EPP courses began at 26 NHS PCT sites across England in May 2002, and by May 2004 approximately 300 PCTs had either actively implemented pilot courses or had committed to joining. The majority of PCTs are now coming to the end of the pilot phase, with many implementing plans to make EPP sustainable for the long-term." The NHS website heralds the pilot "a success."A national, postal survey of PCT EPP Leads was undertaken in order to examine both the evolvement of EPP during its pilot stage and future plans for the programme. A questionnaire was sent out to the 299 PCTs known to have committed to the EPP pilot, and an excellent 100% response rate was obtained over a 3-month period (April-July 2005). One marker of success of the Expert Patients Programme implementation is the actual running of courses by the Primary Care Trusts. This paper explores the extent to which the implementation of the pilot can indeed be viewed as a "success," primarily in terms of the number of courses run, and considers the extent to which PCTs have carried out all that they were committed to do. Findings suggest that the more time an EPP Lead dedicates to the Programme, the more likely it is that EPP has run successfully in the past, and the more likely it is that it will continue to run successfully in the future. Other factors indicating future EPP success include collaborating across PCTs to share co-ordinators, tutors, and funding.

Journal Article↗

PubMed2006

Development and implementation of a risk assessment tool for chemotherapy-induced neutropenia.

PURPOSE/OBJECTIVES: To evaluate a tool developed and implemented to help practitioners assess the risk of chemotherapy-induced neutropenia (CIN) and its complications in patients with nonleukemia cancer types. DESIGN: Retrospective survey of chart records. SETTING: Community-based oncology practice. SAMPLE: The medical records of 85 adult patients treated with new courses of chemotherapy, regardless of the cancer type or stage; 50 charts belonged to patients treated before the implementation of the tool and 35 to patients evaluated with the tool. METHODS: A risk assessment tool for CIN that was developed using risk factors from published studies and national guidelines was implemented. Patients who were found to be at increased risk for CIN were given colony-stimulating factor (CSF) support starting with the first chemotherapy cycle. The effectiveness of the tool was evaluated by comparing clinical outcomes before and after the implementation of the risk assessment tool. MAIN RESEARCH VARIABLES: Febrile neutropenia, IV antibiotic use, hospitalization for neutropenia, and chemotherapy dose reductions and delays. FINDINGS: Chemotherapy dose delays, febrile neutropenia, treatment with IV antibiotics, and hospitalization for neutropenia occurred less frequently in patients assessed with the tool and managed with the algorithm for CSF use than in those who were not assessed. CONCLUSIONS: The Risk Assessment for Neutropenic Complications Tool is effective in helping practitioners determine which patients are at high risk for CIN and its complications IMPLICATIONS FOR NURSING: By using the tool to identify patients treated with chemotherapy who need growth factor support, nurses can help to reduce the incidence of neutropenia and its complications.

Anti-Bacterial Agents↗

PubMedDate not supplied

Immediate benefits realized following implementation of physician order entry at an academic medical center.

OBJECTIVE: To evaluate the benefits of computerized physician order entry (POE) and electronic medication administration record (eMAR) on the delivery of health care. DESIGN: Inpatient nursing units in an academic health system were the setting for the study. The study comprised before-and-after comparisons between phase 1, pre-implementation of POE (pre-POE) and phase 2, post-implementation of POE (post-POE) and, within phase 2, a comparison of POE and the combination of POE plus eMAR. Length of stay and cost were compared pre- and post-POE for a period of 10 to 12 months across all services in the respective hospitals. MEASUREMENTS: Comparisons were made pre- and post-POE for the time intervals between initiation and completion of pharmacy (pre-POE, n=46; post-POE, n=70), radiology (pre-POE, n=11; post-POE, n=54), and laboratory orders (without POE, n=683; with POE, n=1,142); timeliness of countersignature of verbal order (University Hospitals [OSUH]: pre-POE, n=605; post-POE, n=19,225; James Cancer Hospital (James): pre-POE, n=478; post-POE, n=10,771); volume of nursing transcription errors (POE with manual MAR, n=888; POE with eMAR, n=396); length of stay and total cost (OSUH: pre-POE, n=8,228; post-POE, n=8,154; James: (pre-POE, n=6,471; post-POE, n=6,045). RESULTS: Statistically significant reductions were seen following the implementation of POE for medication turn-around times (64 percent, from 5:28 hr to 1:51 hr; p<0.001), radiology procedure completion times (43 percent, from 7:37 hr to 4:21 hr; p<0.05), and laboratory result reporting times (25 percent, from 31:3 min to 23:4 min; p=0.001). In addition, POE combined with eMAR eliminated all physician and nursing transcription errors. There were 43 and 26 percent improvements in order countersignature by physicians in OSUH and James, respectively. Severity-adjusted length of stay decreased in OSUH (pre-POE, 3.91 days; post-POE, 3.71 days; p=0.002), but not significantly in James (pre-POE, 3.68 days; post-POE, 3.61 days; p=0.356). Although total cost per admission decreased significantly in selected services, it did not change significantly across either institution (OSUH: pre-POE, 5,697 dollars; post-POE, 5,661 dollars; p=0.687; James: pre-POE, 6,427 dollars; post-POE, 6,518 dollars; p=0.502). CONCLUSION: Physician order entry and eMAR provided the framework for improvements in patient safety and in the timeliness of care. The significant cultural and workflow changes that accompany the implementation of POE did not adversely affect acuity-adjusted length of stay or total cost. The reductions in transcription errors, medication turn-around times, and timely reporting of results supports the view that POE and eMAR provide a good return on investment.

Academic Medical Centers↗

PubMed2004

Implementation of hospital computerized physician order entry systems in a rural state: feasibility and financial impact.

OBJECTIVE: The aim of this study was to estimate the costs of implementing computerized physician order entry (CPOE) systems in hospitals in a rural state and to evaluate the financial implications of statewide CPOE implementation. METHODS: A simulation model was constructed using estimates of initial and ongoing CPOE costs mapped onto all general hospitals in Iowa by bed quantity and current clinical information system (CIS) status. CPOE cost estimates were obtained from a leading CPOE vendor. Current CIS status was determined through mail survey of Iowa hospitals. Patient care revenue and operating cost data published by the Iowa Hospital Association were used to simulate the financial impact of CPOE adoption on hospitals. RESULTS: CPOE implementation would dramatically increase operating costs for rural and critical access hospitals in the absence of substantial costs savings associated with improved efficiency or improved patient safety. For urban and rural referral hospitals, the cost impact is less dramatic but still substantial. However, relatively modest benefits in the form of patient care cost savings or revenue enhancement would be sufficient to offset CPOE costs for these larger hospitals. CONCLUSION: Implementation of CPOE in rural or critical access hospitals may depend on net increase in operating costs. Adoption of CPOE may be financially infeasible for these small hospitals in the absence of increases in hospital payments or ongoing subsidies from third parties.

Costs and Cost Analysis↗

PubMed1998

Metacognition in action: the importance of implementation intentions.

When people furnish their goal intentions ("I intend to attain the goal x!") with implementation intentions ("I will initiate the goal-directed response y when situation z arises!"), the initiation of goal-directed responses becomes automatized. As this type of automaticity stems from a single act of will, it is referred to as strategic automaticity. We report various studies demonstrating that strategic automaticity leads to immediate and efficient responding, which does not need a conscious intent. In addition, the situational cues specified in implementation intentions seem to be easily detected and readily attended to. Further research indicates that the strategic automaticity induced by implementation intentions also helps resist temptations and fight bad habits. Following Nelson's (1996; Nelson & Narens, 1994) model of metacognition, we suggest that goal intentions and, in particular, implementation intentions are important components of the metacognitive control of action geared toward its initiation, continuation, and termination.

Journal Article↗

PubMed2005

The efficacy and safety of pain management before and after implementation of hospital-wide pain management standards: is patient safety compromised by treatment based solely on numerical pain ratings?

UNLABELLED: Inadequate analgesia in hospitalized patients prompted the Joint Commission on Accreditation of Healthcare Organizations in 2001 to introduce standards that require pain assessment and treatment. In response, many institutions implemented treatment guided by patient reports of pain intensity indexed with a numerical scale. Patient safety associated with treatment of pain guided by a numerical pain treatment algorithm (NPTA) has not been examined. We reviewed patient satisfaction with pain control and opioid-related adverse drug reactions before and after implementation of our NPTA. Patient satisfaction with pain management, measured on a 1-5 scale, significantly improved from 4.13 to 4.38 (P < 0.001) after implementation of an NPTA. The incidence of opioid over sedation adverse drug reactions per 100,000 inpatient hospital days increased from 11.0 pre-NPTA to 24.5 post-NPTA (P < 0.001). Of these patients, 94% had a documented decrease in their level of consciousness preceding the event. Although there was an improvement in patient satisfaction, we experienced a more than two-fold increase in the incidence of opioid over sedation adverse drug reactions in our hospital after the implementation of NPTA. Most adverse drug reactions were preceded by a documented decrease in the patient's level of consciousness, which emphasizes the importance of clinical assessment in managing pain. IMPLICATIONS: Although patient satisfaction with pain management has significantly improved since the adoption of pain management standards, adverse drug reactions have more than doubled. For the treatment of pain to be safe and effective, we must consider more than just a one-dimensional numerical assessment of pain.

Adult↗

PubMed1987

Implementing change: lessons for Medicaid reformers.

Major Medicaid reforms initiated in Arizona, California, and New York in the 1980s form the foundation of this study, which explores issues to consider when implementing change in state Medicaid programs. We prepared case studies of these reforms, describing the innovations and assessing the implementation process in each state. These case studies are used to illustrate broad issues and processes of Medicaid reform. Six lessons emerge from our analysis: Expect reform models to change over time; strive for predictability and continuity in the reform; encourage behavior changes through the use of incentives; use special administrative or political channels to simplify the reform; expect reform models to converge over time; and implementation difficulties can be predicted. These lessons should educate decision makers about how to implement possible future solutions to problems like those seen in Medicaid programs at the start of this decade.

Arizona↗

PubMed2004

Enrolling children in public insurance: SCHIP, Medicaid, and state implementation.

The Balanced Budget Act of 1997 established federal grants to the states to create the State Children's Health Insurance Program (SCHIP). This presented the states with a number of implementation choices concerning administrative models for the new programs, as well as choices about eligibility standards, enrollment simplification, crowd-out, and cost sharing requirements. At the same time, the states were also implementing welfare reform. We describe the most important of these implementation choices, and using data from the Current Population Survey, we estimate the impacts of state policy on enrollment in this multiprogram environment. The results indicate that SCHIP programs that are administered as Medicaid expansions are more successful than either separate SCHIP plans or combination programs in enrolling children. States that remove asset tests and implement presumptive eligibility and self-declaration of income have higher enrollment levels. Continuous eligibility and adoption of mail-in applications have no effect on overall enrollment. Waiting periods and premiums reduce enrollment. Stringent welfare reform reduces children's enrollment, despite federal policy that was intended to protect children from the consequences of welfare reform. The negative impacts of a number of these policy reforms substantially reduce enrollment, potentially offsetting the more favorable impacts of other policy choices. We estimate that if all states adopted the policy options that facilitate program use, enrollment for children with family incomes less than 200 percent of the poverty line could be raised from the current rate of 42 percent to 58 percent.

Child↗

PubMed2003

Implementation of an innovative grant programme to build partnerships between researchers, decision-makers and practitioners: the experience of the Quebec Social Research Council.

OBJECTIVES: This paper examines a grant programme developed by the Quebec Social Research Council in the 1990s to encourage the building of research partnerships between researchers, decision-makers and practitioners. In particular, it studies the perceptions of key participants concerning the reasons behind the programme's successful implementation and growth. METHODS: In addition to secondary data about institutional involvement in the programme, 10 researchers and administrators were consulted as key informants. The method of concept mapping was used in order to draw out a consensus on the different factors associated with the successful implementation of the programme. RESULTS: The participants identified 10 main factors that help explain the programme's successful implementation. These factors were then grouped into a model containing four dimensions: the leadership and coherence shown in the programme's implementation; the presence of a favourable political and social conjuncture; the programme's responsiveness to the needs of health and social services institutions; and the programme's responsiveness to the needs of the university milieu. CONCLUSIONS: Although this model remains specific to the prevailing situation in Quebec at the time of its application, it may help stimulate reflection and contribute to an understanding of how research policies can encourage partnerships between researchers, practitioners and decision-makers.

Cooperative Behavior↗

PubMed2002

A national pilot to implement pressure ulcer guidelines: results of the baseline audit.

The Royal College of Nursing (RCN) national pilot audit project aims to facilitate the dissemination and implementation of the RCN clinical guideline on pressure ulcer risk assessment and prevention using an evidence-based, tailored strategy. Recent government White Papers reinforced the move towards evidence-based healthcare that includes performance measures, clinical effectiveness and ongoing professional development. Structured dissemination and implementation of the RCN guideline can aid this process by improving patient care, as well as in a culture where more patients are seeking recompense for "poor" care assist in reducing litigation and complaints. This article focuses on the findings of the baseline audit. Providing a summary of the project to date, looking at site recruitment, the provisional results and recommendations of the baseline audit and local initiatives for supporting the ongoing implementation and the implementation resources developed to assist the sites in the process. The project is due for completion at the end of 2002 following which the final results will be published.

Education, Nursing, Continuing↗

PubMed2004

Essence of Care: Implementing continence benchmarks in primary care.

'Essence of Care' is a national programme which was launched in 2001. The document provides a set of national benchmarks which are evidence based. The benchmarks focus on basic care as identified in a First Class Service (DH, 1998). The programme has been implemented widely by acute services, however with community and primary care services, the take up appeared to have been spasmodic. A conference in 2003 'Implementing Essence of Care in Primary Care' described the implementation of Essence of Care in Primary Care as a 'challenge'. This article identifies the implementation of the continence benchmark within a PCT. The article details the process and the difficulties encountered within primary care, but also details the benefits of utilising the model despite a labour intensive process. In particular the article suggests the importance of incorporating the benchmarks into current systems within the PCT in order to avoid duplication and extra layers of groups and meetings. Finally the article highlights some of the benefits which the PCT consider the process has achieved to the continence service.

Benchmarking↗

PubMedDate not supplied

Effects of the purchaser/provider split on research implementation.

The issues surrounding the use of research to inform practice and the potential problems involved in this process have been the subject of debate within nursing for many years. The purchaser/provider relationship has led to an increase in the number of challenges nursing encounters regarding the implementation of research. These challenges and relationships, which will either promote or prevent the implementation of research in nursing practice, are explored using Nolan and Grant's (1993) framework. The analysis concludes that implementation of nursing research needs to be part of the contracting process involving shared dialogue between purchasers and providers. Discussions on clinical effectiveness need to include nursing evidence as part of the health-care contracting process. Professionals involved in contracting require equal knowledge about research and joint professional values in order to support its implementation within contracting appropriately.

Contract Services↗