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PubMed2006

[Kangaroo Mother Care in public hospitals in the State of São Paulo, Brazil: an analysis of the implementation process].

This study analyzed the implementation of the Kangaroo Mother method in 28 different São Paulo State public hospitals. Teaching hospitals, Baby-Friendly Hospitals, hospitals with human milk banks, and those with more than 12 trained health professionals showed higher implementation scores. Because of staff resistance to family participation in neonatal care, the Kangaroo Mother method is basically applied in-hospital. Changes in the initial training, including manager awareness-raising and proper financial resource allocation, are necessary for implementation, follow-up, assessment, and feedback.

Brazil↗

PubMed1996

Status of health promotion program implementation and future tasks in Japanese companies.

This study was performed to elucidate the status of the implementation of health promotion programs (HPPs) and future tasks in occupational settings in Japan. A survey was conducted using a multiple type questionnaire mailed to 395 companies throughout Japan in 1993. The questionnaire was mailed back, after having been answered anonymously, with a response rate of 59%. Companies with more than 300 employees accounted for 76% of the sample. Approximately 70% of the companies implemented HPPs of which health guidance and fitness programs were the two most frequently adopted programs. Nutrition education and mental health programs seemed to be emphasized as future possibilities. Smoking cessation programs were not as common as segregation policies, such as zoning of smoking areas. Currently, 45% of the companies used only in-house health personnel for HPPs, but the prospective percentage in the future was 24%. Most of the companies shared the cost of HPPs with a Health Insurance Society. Lack of health personnel and budgetary restrictions on HPPs constituted the major barriers to the implementation of HPPs. Small-scale enterprises were noted to be particularly influenced by these barriers.

Attitude to Health↗

PubMed1992

The use of selected interventions in monitoring primary health care implementation in rural Nigeria.

Nigeria's Primary Health Care (PHC)-based health system development aims to strengthen PHC in the local government areas (LGA) through technical planning and implementation that emphasize maternal and child health services. Convenient variables, including expanded programme on immunization (EPI), antenatal care (ANC) utilization and attended births, were selected as interventions to monitor the progress of implementation of PHC activities during 1985-90 in Odukpani LGA. Analysis of available data at the LGA showed that immunization coverage for most EPI antigens increased; ANC services showed increased utilization; health worker-attended births increased as traditional birth deliveries declined during the period. Some of the increases were modest but are considered important. The study offers a pilot approach to monitoring implementation of PHC activities in Odukpani LGA. The implications of the findings for similar studies are discussed.

Adolescent↗

PubMed2006

[Effects of the implementation of Universal Access with Explicit Guaranties (AUGE) Plan on the quality of care of patients with terminal renal failure].

BACKGROUND: The implementation of the AUGE plan for renal failure in Chile in August 2002, generated larger waiting list for outpatient care. AIM: To analyze the incidence of terminal renal failure, the proportion of patients that were admitted to hemodialysis using a definitive vascular access and the lapse of use of transitory catheters, before and after the implementation of AUGE in Calama. MATERIAL AND METHODS: Since 1999, in a dialysis center of Calama, all new patients that are admitted to hemodialysis and the type of vascular access they have are registered. Using this registry, the incidence of terminal renal failure and the lapse between the admission to the center and the installation of a definitive vascular access were calculated for the period 2000 to 2005. RESULTS: From January 2000 to December 2003, the incidence of terminal renal failure was stable in 190 +/- 21 patients per million inhabitants (ppmh). It decreased between January and September 2004 to 124 +/- 18.6. Afterwards, it progressively increased to 221 +/- 21 ppmh. In the study period, the proportion of patients admitted to hemodialysis with a definitive access decreased from 63 to 10% (p<0.01) and the mean lapse of transitory catheter use, increased from 32.9 +/- 42.6 to 73.1 +/- 80.4 days (p<0.01). CONCLUSIONS: The implementation of AUGE for chronic renal failure reduced the quality of care of patients admitted to hemodialysis.

Analysis of Variance↗

PubMed2004

Is evidence-based implementation of evidence-based care possible?

Traditional approaches to disseminating research findings have failed to achieve optimal healthcare. In a systematic review of 235 studies of guideline dissemination and implementation strategies, we observed the following: there was a median 10% improvement across studies, suggesting that it is possible to change healthcare provider behaviour and improve quality of care; most dissemination and implementation strategies resulted in small to moderate improvements in care; multifaceted interventions did not appear more effective than single interventions. The interpretation of our systematic review is hindered by the lack of a robust theoretical base for understanding healthcare provider and organisational behaviour. Future research is required to develop a better theoretical base and to evaluate further guideline dissemination and implementation strategies.

Australia↗

PubMed2004

[Implementation of a common clinical path for transurethral resection of prostate (TURP) in multiple hospitals].

PURPOSE: To investigate the length of hospitalization and medical charges when a common clinical path for TURP (transurethral resection of prostate) was implemented in multiple hospitals. PATIENTS AND METHODS: This study included 310 patients in 2001 and 298 in 2002, who were diagnosed with benign prostatic hyperplasia and who underwent TURP in seven hospitals in Japan. While the patients were treated according to the managing methods of each hospital in 2001, the patients were managed using a common clinical path in 2002, on which we conferred and established in 2001. We investigated the change of various outcome indicators before and after implementation of the common clinical path. RESULTS: The background of patients and surgical outcome in 2002 were equal to those in 2001, except in incidence of preoperative urinary tract infection, general anesthesia and blood transfusion, and number of surgeons. Implementation of a common clinical path shortened the pre- and postoperative hospital stay, duration of bed rest, administration of antibiotics and Foley catheter indwelling, and reduced the standard deviation of these indicators. The total medical charge decreased from 515,439 to 491,935 yen. However, outcomes were considerably different among the seven hospitals. Multivariate analyses identified the hospitals, cognitive impairment, preoperative indwelling catheter and preoperative variance as the factors affecting preoperative hospital stay, and the hospitals, co-existing disease, blood transfusion, postoperative urinary tract infection and postoperative variance as factors affecting postoperative stay. Based on these analyses, we determined four exclusion criteria against using a common clinical path: 1) patients requiring examination or surgery other than TURP simultaneously, 2) patients whose ADL disturbance, cognitive impairment, past history and/or coexisting disease are expected to affect postoperative convalescence, 3) patients with a preoperative indwelling catheter just before operation, and 4) patients with preoperative urinary tract infection. By excluding 122 (39.4%) and 129 (43.3%) patients fulfilling the above criteria in 2001 and 2002, respectively, there were reduction in the length of pre- and postoperative hospital stay, and the total admission fee. Furthermore, there were decrease in their standard deviations. CONCLUSIONS: A common clinical path was valid for reducing variance of the critical indicators affecting the clinical course of TURP and shortening the pre- and postoperative stay in the multiple hospitals. It is mandatory to establish the standard perioperative management for TURP from the viewpoint of urologists, under the circumstances of the impending introduction of the Diagnosis Procedure Combination (DPC).

Aged↗

PubMed1987

Identifying health care stakeholders: a key to strategic implementation.

As the number and complexity of stakeholders for health care organizations has increased, health care managers have become more aware of the ability of these groups to thwart or facilitate the implementation of strategic plans. Most stakeholder models have focused on identification of groups within the usual, global definition of affecting or being affected by an organization's actions. The authors argue that stakeholders management is critical to the implementation of strategic plans. They provide a narrower, more operationally useful stakeholder definition and present a framework for assessing the relative importance of each stakeholder for a given situation. The situational evaluation of stakeholders is critical to successful implementation of strategy.

Decision Making, Organizational↗

PubMed2000

Implementing the second generation social health maintenance organization.

BACKGROUND: In 1996 the Health Care Financing Administration implemented a second generation of the Social HMO demonstration. This model retained the chronic care benefits of the original Social HMOs while attempting to develop a geriatric service model integrated into primary care and a screening and assessment process focused directly on healthcare risk factors. Other refinements included risk-adjusted capitation payment, broadened eligibility for expanded care benefits, low co-payments for these benefits, and no caps on the expanded care benefits expenditures. OBJECTIVES: The geriatric approach is designed to facilitate integration among providers and levels of care. This includes timely application of primary care monitoring and treatment to reduce illness and disability as well as a geriatric education and consultation program to provide specialty support for complex cases. Care management is designed for those requiring home-based care, those discharged from hospitals or nursing homes, and those having difficulty with treatment regimens. DESIGN: A case study of the Social HMO implementation through the Fall of 1999. SETTING: Health Plan of Nevada (HPN), with locations in Las Vegas, Reno, and surrounding areas. PARTICIPANTS: More than 25,000 Medicare beneficiaries participated during the study period. MEASUREMENTS: Administrative reports, charts, and interviews with administrators and clinicians. RESULTS: Within 12 months of operation under this authority, HPN succeeded in putting in place most of the components of the planned geriatric approach: a screening program to identify patients "at risk" for high service costs and disability and timely application of primary care treatment to reduce illness and disability. Geriatric education and a consultation program for complex cases were available, but full implementation was delayed until the plan was able to hire a full time geriatrician. CONCLUSIONS: Health Plan of Nevada's Social HMO program reflects current perspectives on how to integrate chronic care into an HMO. The accomplishments affirm that the provision of risk-adjusted reimbursement, along with the 5 % supplement to the normal Medicare capitation payment, are sufficient incentives for a health plan to restructure itself so that it places a priority on retaining and serving populations at risk for high expenditures.

Aged↗

PubMed2001

HIPAA privacy standards raise complex implementation issues.

In November 1999, under the mandate of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, HHS issued proposed standards to protect the privacy of electronically transmitted personal health information. With publication of the final standards due soon, healthcare organizations must prepare to implement new processes and information systems to comply with the HIPAA requirements. The privacy standards are intended to accomplish three broad objectives: define the circumstances in which protected health information may be used and disclosed, establish certain individual rights regarding protected health information, and require that administrative safeguards be adopted to ensure the privacy of protected health information. Among the required administrative safeguards are designation of a privacy officer, implementation of compliance training programs for all applicable staff, establishment of a complaint system, and implementation of appropriate sanctions for violations of privacy requirements.

Computer Security↗

PubMed2001

Integration of mental health care into primary care. Preliminary observations of continuing implementation phase.

OBJECTIVE: The authors mainly focus on the initial observations of the implementation phase of a health project that aims to integrate mental health into primary care. METHODS: In the light of specific aims and objectives of both planning and curriculum development phases, 2- weeks of intensive psychiatric training consisting of basic theoretical and clinical concepts of psychiatry was imparted to a group of general practitioners and paramedical staff. In addition to assessing their pre-and post-training knowledge, attitude, and practice toward psychiatry, 2 internal Consultant Psychiatrists and participants evaluated the training course providing appropriate feedback to the organizers and trainers for modifying several adopted training methods, as well as a curriculum for subsequent courses. RESULTS: The 2-week psychiatric training of the medical personnel resulted in identifying several pros and cons of implementing this project at primary health care centers. Additionally, the immediate and the post-training evaluations of trainees by numerous methods were characterized by favourable changes in their attitude, knowledge and enhanced motivation to practice psychiatry at primary health care centers. CONCLUSION: The implementation of this project by training the first 3 groups of health personnel was successful, as evidenced both by the healthy encouraging comments of the evaluators and the post-training favourable positive responses of the trainees. The incorporation of mental health into primary care by offering condensed psychiatric courses to general practitioners should be the top training agenda as it is in line with the World Health Organization recommendations.

Delivery of Health Care, Integrated↗

PubMed2003

Evaluation, development, and implementation of potentially better practices in neonatal intensive care nutrition.

OBJECTIVE: The desire for evidence-based clinical guidelines for nutritional support of the preterm infant has been identified. Published evidence has not yielded clear guidelines about the best method of delivery, substrate use, or appropriate outcome measure to evaluate nutrition support. In addition, reports on research of nutrition support often fail to give the most rudimentary process necessary to improve quality in various unit settings. METHODS: The Vermont Oxford Network "Got Milk" focus group developed eight potentially better practices for nutrition support, implementation strategies for these practices, and a comprehensive appraisal process to measure nutrition outcome in preterm infants. RESULTS: After implementation of the potentially better practices, all participating institutions showed earlier initiation of nutrition support, earlier attainment of adequate energy intakes, reduced delay in reaching full enteral feeds, more consistent nutrition support practice, decreased length of stay, cost savings, and improved growth at time of discharge. CONCLUSIONS: Development and implementation of evidence-based better nutrition support practices in neonates led to improved nutrient intake and growth with reduced length of stay and related costs. Consistent, comprehensive, multidisciplinary appraisal of practice is an integral component of improving nutrition outcomes in the neonatal population.

Benchmarking↗

PubMed2004

A journey, not an event - implementation of shared governance in a NHS trust.

This article describes the implementation of a trust-wide shared governance structure in Barts and The London National Health Service Trust in the United Kingdom. Barts and The London is a large teaching trust, employing over 6,500 staff. The implementation process is described in detail and is followed by details of the current shared governance structure, an overview of the evaluation of the structure, and the objectives of each of the four nursing teams: the Quality, Management, Education, and Clinical Practice Teams. Also included are examples of the achievements of each of the teams and a personal account of one nurse who joined the Trust after shared governance had been implemented.

Attitude of Health Personnel↗

PubMed1992

[Comparison of anesthetic morbidity and mortality before and after the implementation of quality assurance in Tri-Service General Hospital].

The desire to improve anesthetic outcome is a cornerstone in modern anesthesia. There are many means to reach this goal, such as enforcement in personal training, elevation of monitoring standards, constant vigilance and stern quality assurance (QA). The department of Anesthesiology, Tri-Service General Hospital, has adopted the QA program and implemented it since March 1, 1990. Because there were no significant differences in terms of personnel training, monitoring standards and types of anesthesia and surgery before and after the application of QA program, we investigated the effects of QA on anesthetic major morbidity and coma/mortality. We analyzed the anesthetic results obtained in two separate periods respectively spanning from Jan. 1, 1989 to Dec. 31, 1989 and from Mar. 1, 1990 to Feb. 28, 1991. During the first two months of 1990, the department's personnel were trained to be familiar with the QA program. We compared the anesthetic major morbidity and coma/mortality of one year before the implementation of QA with those in a one-year period after its implementation. Before and after enforcement of QA, there were no significant differences (p greater than 0.05) regarding major morbidity and coma/mortality, but the rates of anesthetic complications were lower after the practice of QA program. Since the functions of QA was aimed at alerting the anesthetic personnel to keep constant vigilance over the act of anesthesia, QA in theory could reduce anesthetic accidents and mishaps related jointly to surgery and anesthesia. The reason why QA did not decrease anesthetic major morbidity and coma/mortality in this study may be due to limited number of anesthesia in relatively short period.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMedDate not supplied

Rationale and implementation of the SLICK project: Screening for Limb, I-Eye, Cardiovascular and Kidney (SLICK) complications in individuals with type 2 diabetes in Alberta's First Nations communities.

OBJECTIVE: Identifying diabetes complications through screening using portable laboratory equipment in Aboriginal communities, and providing education and client empowerment for improved follow-up care and self-care. PARTICIPANTS: First Nations people with known diabetes. SETTING: Screening was carried out in temporary clinics and laboratories set up at the local health centre in each of Alberta's 44 First Nations. INTERVENTION: Two mobile units ("SLICK vans"), equipped with professionally trained staff, portable lab instruments and a retinal camera, travelled to all 44 Alberta First Nations communities to facilitate implementation of the Canadian Diabetes Association Clinical Practice Guidelines (CPGs). The project provided relevant education and counselling in conjunction with screening activities. OUTCOMES: SLICK screened 1,151 clients between December 2001 and July 2003, and the project remains ongoing. A preliminary evaluation of the project's 19-month implementation period showed screening activities and satisfaction with diabetes services were low prior to SLICK. There were modest improvements in some program outcomes at 6-12 months follow-up. CONCLUSION: The SLICK project is designed to address the impact of diabetes by utilizing evidence-based CPGs with respect to screening for complications at the community level. It had a successful implementation period facilitated by community acceptance.

Alberta↗

PubMed1995

Implementing total quality management in an academic surgery setting: lessons learned.

Total Quality Management, a philosophy developed by W. Edwards Deming, has been used successfully in many countries and in many types of organizations to improve the quality of processes. The system is based upon the scientific method and provides the ability to solve long-standing, recalcitrant problems. The application of the TQM philosophy to health care, although recommended by many medical economists, is still in its infancy. At our medical center, three departments (Surgery, Anesthesiology, and Operating Room Services) joined forces to implement TQM. Critical activities early in implementation included establishing a Steering Committee, training key employees, providing systems for communicating TQM activities, and developing the leadership, facilitator, and other resources needed to support teams. Two of our first teams studied very different processes (one in the Operating Room, the other in outpatient Surgery clinics), providing many useful insights regarding keys to successful application of the TQM philosophy. We have learned strategies for increasing acceptance of and participation in TQM efforts on the part of staff members and, in particular, physicians, and for initiating the cultural change needed for TQM. Although the teams have met with resistance to behavioral changes and a lack of full support from some upper-level administrators in the Medical Center and the Hospital, most of them have been quite successful in improving the processes under study. We conclude that, with the proper leadership and facilitation, the TQM philosophy can be successfully implemented in the health care environment. Total Quality Management (TQM) as a system for improving the quality of processes has been successful in many countries throughout the world for organizations offering a wide variety of products and services. This article will describe specific TQM endeavors, both successful and unsuccessful, undertaken in an academic surgery department in the United States. This description will illustrate the lessons we have learned in our attempt to change a complex organization and will enable readers to determine whether an analogy exists between our organization's response to problem solving and theirs.

Academic Medical Centers↗

PubMed1996

Implementing therapist-driven protocols.

In January of 1993, as part of a hospital-wide cost-reduction strategy, the University of California San Diego (UCSD) Medical Center Respiratory Care Department implemented a patient-driven protocol program designed to utilize the assessment skills and judgments of respiratory care staff, within physician-approved guidelines. This program produced a 60% reduction in the use of hand-held nebulizer therapy and chest physical therapy in the institution, with a substantial decrease in operational expenses. This article describes key elements of the implementation of protocol-driven programs, provides examples from the UCSD experience, and offers insights gained from others who have been successful agents of change. It describes patient-driven protocols, how they can be implemented, the barriers to and promoters of such protocols, and what the results can be for a respiratory care department.

Clinical Protocols↗

PubMedDate not supplied

Implementing problem-based learning in a family medicine clerkship.

BACKGROUND AND OBJECTIVES: Problem-based learning (PBL) has been implemented in the curriculum of many medical schools, but limited information is available about the outcome of this learning technique. The educational intervention presented in this paper implemented a PBL learning component in our third-year family medicine clerkship and measured the outcomes of this curricular change. METHODS: One third of the curricular time devoted to didactic teaching in our family medicine clerkship was replaced with PBL activities. Simulated cases were developed and presented to students who, with the aid of faculty facilitators, studied the cases, gathered information about the cases, and developed diagnostic and management plans for the cases. The outcome of the intervention was measured by a) comparing students' scores on the National Board of Medical Examiners (NBME) family medicine clerkship examination to scores achieved by students in the year before PBL was introduced and b) students' evaluations of the relevance and success of PBL in the clerkship curriculum. RESULTS: Students' NBME clerkship examination scores increased from a mean of 66 the year before PBL began to 73 after PBL was implemented. More than 80% of students reported that PBL was a good way to learn family medicine, and 85% reported that the PBL technique provided sufficient information to formulate learning issues. CONCLUSIONS: PBL can be introduced into a third-year family medicine clerkship curriculum with general acceptance by students. Students rated the technique highly, and their examination scores improved.

Clinical Clerkship↗

PubMed1998

Are US hospitals making progress in implementing guidelines for prevention of Mycobacterium tuberculosis transmission?

BACKGROUND: Outbreaks of tuberculosis (TB) in hospitals have occurred when the Centers for Disease Control and Prevention (CDC) guideline recommendations for preventing the transmission of Mycobacterium tuberculosis were not fully implemented. OBJECTIVE: To determine whether US hospitals are making progress in implementing the CDC guidelines for preventing TB. METHODS: In 1992, we surveyed all public (city, county, Veterans Affairs, and primary medical school-affiliated) US hospitals (n = 632) and 444 (20%) random samples of all private hospitals with 100 beds or more. In 1996, we resurveyed 136 random samples (50%) of all 1992 respondent hospitals with 6 or more TB admissions in 1991. RESULTS: Of the 1076 hospitals surveyed in 1992, 763 (71%) respondents returned a completed questionnaire. Among these, 536 (71%) of 755 reported having rooms that met CDC criteria for acid-fast bacilli isolation, ie, negative air pressure, 6 or more air exchanges per hour, and air directly vented to the outside. The predominant respiratory protective device for health care workers was nonfitted surgical mask and attending physicians were infrequently (50%) included in tuberculin skin-testing programs. In the 1996 resurvey, 103 (76%) of 136 respondents returned a completed questionnaire. Of these, 99 (96%) reported having rooms that met CDC criteria for acid-fast bacilli isolation. The N95 respiratory protective devices were predominantly used by health care workers, and attending physicians were increasingly (69%) included in the hospitals' tuberculin skin-testing programs. CONCLUSIONS: Most US hospitals are making progress in the implementation of CDC guidelines for preventing the transmission of M tuberculosis.

Centers for Disease Control and Prevention, U.S.↗