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PubMed1997

Implementing a formal cytotoxic agent program at an overseas medical treatment facility.

United States Naval Hospital (USNH), Okinawa, Japan, is the Navy's largest outside continental U.S. hospital, with 104 inpatient beds. An historical vision for the hospital has been to become the military's medical referral center for the Western Pacific. In keeping with this version the hospital has sought to expand, upgrade, or initiate certain health care services. One service that has been pursued over the last decade has been implementation of a formal cytotoxic agent program. This was finally accomplished in August 1995 with the signing by the Commanding Officer of USNH Okinawa Instruction 6570.1. The purpose of this paper is to explain how the program was implemented; described the services of the program sought to provide; discuss the key players involved with the implementation process; describe hindrances to program implementation; and, finally, to describe USNH Okinawa's experience with the program.

Antibiotics, Antineoplastic↗

PubMedDate not supplied

Clinical pathway for pneumonia: development, implementation, and initial experience.

BACKGROUND: As part of a large multidisciplinary project to reduce cost, decrease hospital length of stay, and improve efficiency of patient care at Saint Mary's Hospital, a clinical pathway for pneumonia was developed and implemented. METHODS: After using analysis of severity-adjusted data to determine which conditions would be best targets for improvement, a utilization management steering committee created a multidisciplinary group to develop a clinical pathway for pneumonia. This group was led by physician champions and consisted of representatives from nursing, respiratory therapy, pharmacy, and home healthcare. With information gained from chart abstraction, which identified "best practice" patterns, guidance from the medical literature, and local expertise, this group developed a clinical pathway that included an auxiliary protocol for respiratory care and a detailed educational brochure for patients. Before implementing the clinical pathway, extensive educational activities were undertaken involving the medical staff, house staff, nurses, and other staff. Data collected on consecutive patients discharged after implementation of the pathway were compared with data collected on patients discharged before the pathway in 1994. RESULTS: For DRG 89, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.45 days (5.84 vs. 7.29 days) and a lower average total charge by $1,453 ($9,511 vs. $10,964). For DRG 90, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.83 days (3.45 vs. 5.28 days) and a lower average total charge by $1319 ($5450 vs. $6769). CONCLUSIONS: The pneumonia clinical pathway that was implemented was associated with reductions in the length of stay and total charges. These reductions were seen in relationship to historical controls and to patients cared for concurrently who were not placed on the pathway. Although not fully used on all pneumonia patients, the presence of the pathway probably had some positive effects even on patients not formally on the pathway, through systems changes and educational influences. The pathway also positively influenced other conditions by the use of ancillary algorithms for conditions other than pneumonia, and the more rapid administration of antibiotics for other infectious diseases. Also, lessons learned in the creation of this first pathway have been helpful in streamlining the process of future pathway development.

Connecticut↗

PubMed1997

Implementation of the Ottawa ankle rules in France. A multicenter randomized controlled trial.

OBJECTIVES: To assess the impact of the implementation of the Ottawa ankle rules on radiography requests in French hospitals during a 5-month intervention period and the impact of using posters alone to sustain the effect of the rules during a 5-month postintervention period. DESIGN: Multicenter randomized controlled trial preceded and followed by observational studies of radiological practices. SETTING: The emergency departments of 5 Paris university teaching hospitals of the Assistance Publique-Hôpitaux de Paris. PATIENTS: A total of 2218, 1911, and 851 patients-all aged 18 years and older-who were seen for acute ankle or midfoot injuries in emergency departments during preintervention, intervention, and postintervention periods, respectively. INTERVENTION: Implementation of the Ottawa ankle rules by emergency department physicians in the intervention hospitals (using meetings, posters, pocket cards, and data forms). During the postintervention period, posters alone were used to sustain the intervention effect. MAIN OUTCOME MEASURE: Percentage of patients for whom radiography was requested. RESULTS: During the preintervention period, 98% and 98.5% of patients were referred for radiography in the intervention and control groups, respectively. During the intervention period, the mean proportions of patients referred for radiography by physicians was 78.9% in the intervention group and 99% in the control group (P=.03). Between preintervention and intervention periods, a relative reduction of 22.4% (95% confidence interval [CI], 19.8%-24.9%) in radiography requests was observed in the intervention group, while requests increased by 0.5% (95% CI, 0%-1.4%) in the control group. During the postintervention period, the proportion of radiography requests in the intervention hospitals was lower than the proportion observed in the preintervention period (83.1% vs 98%). CONCLUSIONS: Implementation of the Ottawa ankle rules significantly reduced radiography requests in French hospitals. Using a minimal postintervention implementation strategy, the effect of this intervention decreased but persisted after it was discontinued.

Ankle Injuries↗

PubMed1997

Drinking and driving prevention in the community: program planning and implementation.

This paper describes the rationale, development and implementation of the Drinking and Driving Component, which is one of five components of the Community Trials Project conducted by the Prevention Research Center, Berkeley, California (USA). It traces the background of drunk driving enforcement technology and practice against which the programs at the three sites were implemented. A conceptual model for the enforcement component of a comprehensive community alcohol-related trauma project is presented and its implementation at the three sites is described. Limitations in the available police department resources delayed the implementation of local programs. Media advocacy tied to specific operations proved to be successful in publicizing sensors and sobriety checkpoints were only partially accepted. Overall, the community trials sites increased or held steady their arrest rates in contrast to the comparison sites where DUI arrests declined.

Accidents, Traffic↗

PubMedDate not supplied

Regional planning implementation and its impact on integration of a mental health care network.

This article questions the effectiveness of a managerial tool in changing a health-care system. The process of implementing regional planning and its impact on creating integrated service networks is examined, using a case study and a multi-dimensional analytic model. This model highlights the influence of contextual, structural, cultural and dynamic factors on forming networks. The regional planning developed in the province of Québec (Canada), aimed at a major transformation of the mental health-care system. In each district, organizations working with people who have serious mental disorders were mobilized to plan and implement a more coordinated, continuous and diversified supply of services, under the direction of a regional health body. This study outlines the limitations of regional planning as a tactic for transforming the system. It recommends instead developing more diversified integration strategies to further the process of forming integrated service networks within a complex system. In conclusion, a brief discussion deals with the difficulties related to the study of systemic change implementation.

Delivery of Health Care, Integrated↗

PubMedDate not supplied

Health policy and its implementation in small island developing states in the British West Indies.

Health policy and its implementation in small island developing states (SIDS) is a neglected area of study, and, seemingly, of little interest. The existing literature is generally characterized by descriptions of failure or incompetence, with little attempt to understand the nature and workings of the policy process in these small, yet complex, societies. The research undertaken in this article was carried out over 6 years in Anguilla (pop. 9000) and the British Virgin Islands (pop. 20 000), two British Overseas Territories in the North East Caribbean. The purpose of the research was to determine to what extent policy theory and the tools of policy analysis could be used to explain the nature and the outcomes of the health policy and implementation process. In trying to analyse and understand the policy process in these small islands it was necessary to understand their socio-politic character. In addition, the development of a model of the public policy and public administration system in the English-speaking Caribbean was an essential part of this process. It was found that the conduct and outcome of the policy and implementation process in these islands varied significantly. It is postulated that the variations are anchored in the nature of the local context, the working practices and ideologies of politicians, senior public servants and the local policy elite.

Attitude of Health Personnel↗

PubMed2007

Lessons learned in the implementation of an innovative consultation and liaison service for children of cancer patients in various hospital settings.

OBJECTIVE: To evaluate the process of implementing a family-oriented consultation and liaison service in various hospital-based settings, with special regard to problems and obstacles encountered. METHOD: Qualitative content analysis using categorization and sequential, phenomenological analysis of descriptive progress notes during the implementation period. The team members of the liaison service were defined as participant observers. Interpretations of the material were derived in previously defined, sequential steps in team discussions. RESULTS: Despite a consistent concept behind the new service, the degree to which it was able to be integrated into different medical settings varied to a remarkable degree. Obstacles encountered were often linked to a lack of consideration being given to divergent concepts of care. It was necessary to give special attention to providing physicians with practical evidence of the value of the intervention. The new service was most readily utilized by families when physicians personally communicated the referrals as a standard procedure to their patients and when the referrals were not made too quickly after the parent's initial diagnosis. CONCLUSIONS: Hospital-based services for cancer patients with children under the age of 18 should carefully address patients' fears of psychiatric stigmatization. Furthermore, they should include modules for acute crisis intervention. Implications for future implementation activities in this field are discussed.

Adaptation, Psychological↗

PubMed2003

Prevention of neural tube defects: effect of an intervention aimed at implementing the official recommendations.

OBJECTIVES: The periconceptional intake of 0.4 mg folic acid is recommended in many countries to prevent neural tube defects. This paper describes the poor implementation of corresponding guidelines in Germany, the effectiveness of an intervention-based on providing adequate information and the problems associated with the implementation. METHODS: Two cross sectional studies investigated knowledge, attitude, and behaviour of randomly sampled gynaecologists (n = 24/27), pharmacists (n = 21/21), and women in childbed (n = 131/118) before and after the information campaign. RESULTS: Before the intervention, 3.8% of the women implemented folic-acid-prophylaxis compared with 9.3% afterwards (p = n.s.). The awareness of the prophylaxis before pregnancy correlated with socio-economic status and rose from 28% (before) to 42% after intervention (p < 0.05). Before the intervention, 38% of the gynaecologists and 38% of the pharmacists recommended the prophylaxis compared with 74% (p < 0.05) and 43% (p = n.s.) afterwards. CONCLUSIONS: The effect of the intervention was small. To improve the situation, fortification of specially selected and labelled food should be considered. An accompanying nationwide information campaign should focus on women with lower socio-economic status.

Female↗

PubMed2006

Strategies for dissemination and implementation of guidelines.

Interventions designed to effectively implement and disseminate clinical practice guidelines (CPG) fall into different categories. A systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies was recently undertaken by the Health Technology Assessment (HTA) Programme in UK. Overall, the majority of comparisons reporting dichotomous process data observed improvement in care. However, there was considerable variation in the observed effects both within and across interventions. Evaluation studies provided evidence that adherence of physicians to CPG is a strong predictor of the stroke outcome. Cochrane Collaboration performed a systematic review including studies published up to 2004 that compared integrated clinical pathways (ICP) for stroke care with standard medical care. They found no significant difference between ICP and control groups in terms of death or discharge destination. Patients managed with a care pathway were more dependent at discharge, less likely to suffer a urinary tract infection, less likely to be readmitted and more likely to have neuroimaging. A positive effect was reported from a validation study of a multifaceted strategy for stroke care ICP implementation in Italy.

Health Plan Implementation↗

PubMed2006

Challenges in implementing a cervical screening program in South Africa.

BACKGROUND: The Cervical Health Implementation Project was initiated with the aim of developing and evaluating health system interventions for improving public sector cervical screening services. The project was conducted between January 2001 and May 2003 in three districts in South Africa. This paper describes the districts, interventions and their evaluation, and discusses the implications of these findings for the roll out of a national cervical screening program. METHODS: A pretest/post-test study design was employed. The following interventions were developed and implemented: health worker training workshops, health system tools and protocols and a community awareness program. Pre- and post-intervention facility audits, key informant interviews, staff knowledge, attitude and practice (KAP) surveys and client KAP surveys were conducted. Clinic records and cytology laboratory data were reviewed. RESULTS: Service organization, availability of screening equipment and education and communication materials improved. The proportion of staff who knew the screening policy increased from 43% to 82%; and 68% of staff agreed with the screening policy after, as opposed to 23% before the intervention. In two of the districts, cytology turnaround times continued to be long. Only 50% of women with a high-grade squamous intraepithelial lesion had a colposcopy and biopsy within 6 months of a Pap smear. Although the number of new smears performed in the three districts increased from 1544 in 2001 to 2801 in 2002, overall the coverage remained less than 4%. CONCLUSION: This project highlights the considerable challenges that need to be addressed to effectively implement the national screening policy.

Adult↗

PubMed1998

Theory and practice for the implementation of 'in-house', continuous improvement participatory ergonomic programs.

This paper presents a case study of an implementation of a participatory ergonomics program in a public service agency. The objective of the study was to develop a theoretical model and related design principles for the implementation of 'in-house', continuous improvement participatory programs. The proposed model is based on the behavioral cybernetic theory of learning (Smith and Smith, 1966, Cybernetic Principles of Learning and Educational Design held, Rhinehart and Winsten, New York) and emphasizes the concepts of action, feedback, feedback control, and individual learning as essential for a progression from external regulation (by outside experts) to internal regulation (by organizational members) of participatory programs. Results support the proposed model, but do suggest an expansion of the model to include macro-level organizational variables as additional factors necessary for developing internally regulated participatory programs. Results have led to the specification of several design principles for implementing 'in-house', continuous improvement participatory programs.

Ergonomics↗

PubMed2000

Maximum waiting time - a threat to clinical freedom? Implementation of a policy to reduce waiting times.

This article focuses on physicians as implementers of health policy reforms. In 1992, a maximum waiting-time guarantee was introduced in Sweden. Initially the policy was a successful way to come to terms with long waiting times. However, after 2 years the waiting lists started to increase. To understand this development it is important to look at the reactions to the policy among the implementers, i.e. the physicians. Three questions are addressed: Did the implementers understand the intentions and the goals of the reform? Were they able to fulfil the guarantee? And, did they approve of the initiative? The study subjects were chief physicians at the hospital departments involved with the guarantee. Their attitudes towards the policy were ascertained by two surveys. Other material, such as statistics on waiting times, was also used. The study shows that the physicians approved of the guarantee initially. The measures taken in the first years were effective and did not conflict with earlier practice. However, increased demand in combination with economic restraints necessitated new priorities among patient groups. These changes of clinical practice did not coincide with the physicians' professional values and hence they became more critical to the initiative and finally chose to abandon the intentions in the guarantee.

Attitude of Health Personnel↗

PubMed2003

Implementation of provincial/territorial health goals in Canada.

During the past two decades, policy makers in most of Canada's provinces and territories developed broad population-level goal statements about desired health or health and social outcomes. The health goals development process used in each province/territory has been described in government documents and studied by a small number of researchers. However, there is a lack of published research examining the implementation and use of the health goals since they were developed. To begin to fill this gap, we conducted a study between 1998 and 2000 that examined the implementation of provincial/territorial health goals in Canada. Our findings indicate that as the 1990s drew to a close, provincial/territorial health goals were not being used explicitly by policy makers at either provincial/territorial or regional levels in most provinces in Canada to guide health policy and program development, implementation, or evaluation. Instead, the majority of health ministry and regional policy makers were employing strategic/business plans that, at best, reflected or were similar to the original provincial/territorial health goals. Moreover, even though all provinces and the NWT/Nunavut had health goals associated with broad social, economic, and physical environment health determinants, regional-level policy makers were giving priority to health care system goals over all other types of goals. We discuss our findings in relation to studies about health goals in other countries, and we suggest implications that our findings have for both future research and health policy.

Canada↗

PubMed2001

Implementing AIDS policy in post-apartheid South Africa.

In common with the rest of the Southern African sub-continent. South Africa is currently experiencing a serious HIV epidemic. When it came into power in 1994, the new, Mandela-led government immediately mobilised funds and adopted a far-reaching AIDS Plan for the country. However, the implementation of AIDS policy in the first four years after 1994 has been characterised by a lack of progress and a breakdown of trust and co-operation, both within government and between government and NGOs. This paper outlines the political context which shaped the development of the AIDS Policy, then examines the difficulties of implementing a comprehensive response to AIDS in a country undergoing restructuring at every level. It questions the notion of "inadequate political will" as an explanation for lack of progress. Involvement by politicians has, in fact, been experienced as a double-edged sword in South Africa, with inappropriate, "quick-fix" actions creating conflict and hampering a more longer-term, effective response. The paper also highlights the importance of groupings outside of government in promoting effective policy actions, and the types of leadership required to mobilise a broad range of actors around a common vision. It concludes by emphasising the need to develop approaches to policy implementation rooted in the possibilities and constraints of the local situation, rather than relying on universal blue-prints developed out of context.

Communicable Disease Control↗

PubMed2006

Implementation of an asthma intervention in the inner city.

BACKGROUND: Despite availability of asthma self-management interventions for children, few have been implemented in community-based settings. OBJECTIVE: To describe implementation of the Inner-City Asthma Intervention and factors associated with higher rates of program completion by enrollees. METHODS: Descriptive analyses of data from multiple data sources. Two-tailed Pearson correlation coefficients and analyses of variance were used to calculate associations of descriptive variables with the retention rate (percentage of enrolled children who completed the core intervention and had more than 1 follow-up visit) and with the percentage who had allergy testing done. RESULTS: A total of 4,174 children were enrolled at 22 sites; 2,153 (52%) completed the core intervention and had more than 1 follow-up visit. A total of 2,014 enrolled children (48%) were tested for allergies. Retention was related to type and location of site, ease of obtaining written plans, language and ethnicity of asthma counselor, and on-site allergy testing. Higher rates of allergy testing were associated with the same factors, as well as flexibility in scheduling and selective enrollment of participants. CONCLUSIONS: Inner-city children with asthma can be enrolled in the Inner-City Asthma Intervention outside a controlled research setting. However, completion of all intervention components is difficult to achieve. We identify having an asthma counselor who is representative of the community, access to asthma action plans, and on-site allergy testing as factors that facilitate the implementation of this intervention in community-based settings.

Asthma↗

PubMed2006

The effect of national guidelines on the implementation of outpatient preoperative evaluation clinics in Dutch hospitals.

BACKGROUND AND OBJECTIVES: Preoperative evaluation performed by anaesthesiologists primarily aims to estimate the risk of perioperative complications and to create opportunities to optimize the patients' condition before surgery. In this study an inventory was made of the current practice of preoperative evaluation in Dutch hospitals. It was estimated how many hospitals had implemented an outpatient preoperative evaluation clinic in 2004. Subsequently, current practice was compared with the results of a previous inventory (2000). It was also evaluated to what extent the guidelines of the Dutch Health Council and the Netherlands Society of Anaesthesiology were followed. METHODS: The study consisted of two phases. First, a literature research was performed and pilot interviews were constructed. The interviews were conducted face-to-face with anaesthesiologists in a sample of Dutch hospitals. Based on the results, written questionnaires were constructed. In the second phase these questionnaires were sent to all general and academic hospitals in the Netherlands. RESULTS: In 2004, 74% of the hospitals had an outpatient preoperative evaluation clinic, compared with 50% in 2000. The percentage of hospitals with an outpatient preoperative evaluation clinic available for all elective patients increased from 20% to 52%. CONCLUSIONS: The Dutch guidelines on preoperative evaluation seem to have influenced current practice. An increase in the number of outpatient preoperative evaluation clinics was seen after the guidelines were published. The implementation of an outpatient preoperative clinic seems to warrant that anaesthesiologists are carrying out the activities prescribed by the guidelines. Most hospitals without a clinic aim to implement one in the future.

Anesthesia Department, Hospital↗

PubMed2006

[Successful strategies and methods of nursing standards implementation].

UNLABELLED: Standards and guidelines are useful elements in quality development and helpful to influence practice of health professionals. However, there are some unanswered questions regarding the circumstances and preconditions of effective change in practice. In German research there is a lack of ambitious evaluation studies concerning implementing standards. Getting evidence about supporting and restricting factors of implementing guidelines into nursing practice is the aim of this article. METHOD: With the help of a search of relevant literature in appropriate data bases the research findings are systematically analysed. FINDINGS: Effective implementation and distribution strategies are programs that realise an active involvement of practitioners and that are practically orientated. Passive attempts to distribute information and specification reveal only little success. A multiple intervention program addressing the introduction process and organisational conditions promise the very best influence on the practice of care.

Evaluation Studies as Topic↗

PubMed2002

Effects of an implemented care policy on patient and personnel experiences of care.

A care policy was implemented within health care in the county of Västerbotten, Sweden. A questionnaire was administered before and after the implementation of the care policy to assess its effects. Patients within hospital care and primary health care described their experiences in a base-line study (n=3950) in 1994 and a follow-up study (n=2941) in 1996. On the same occasions personnel (n=2362 and 2310, respectively) answered the same questionnaire assessing what they thought their patients experienced. No significant positive effects of the implementation were seen by the patients. Fewer patients felt that they were understood when they talked about their problems, dared to express criticism or denied they were treated nonchalantly in the follow-up study. The experiences of the personnel were in line with those of the patients concerning nonchalant treatment in the follow-up study. Furthermore, fewer staff members thought that their patients felt they had adequate help with hygiene whilst more thought that their patients felt they were responded to in a loving way. One interpretation of the negative outcome is that organizational changes, strained resources and cuts in staffing during the 90s may have reduced the possibility of integrating the care policy in spite of an ambitious and extensive intervention.

Adult↗