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PubMed1996

Implementation of discharge plans for chronically ill elders discharged home.

Although discharge plans are viewed as the primary means to ensure that patients' needs will be met in the posthospital environment, little is known about the implementation of arranged care. This study addressed the extent to which discharge plans for elderly patients with congestive heart failure were implemented as planned, tested the consequences of implementation problems, and identified factors associated with implementation problems. For 40 percent of patients, one or more components of the discharge plan were not implemented as planned, with discrepancies more likely among low-income patients. Implementation discrepancies had negative consequences in terms of unmet needs, deficient quantity of help, and less than adequate care. Implications for hospital discharge planners and home health care are discussed.

Activities of Daily Living↗

PubMed2000

What is the quality of the implemented meta-analytic procedures in chronic pain treatment meta-analyses?

OBJECTIVE: Meta-analysis (MA) is the application of quantitative techniques for the purposes of summarizing data from individual studies. This type of review has many advantages over traditional reviews. However, different investigators performing MAs on the same data set have reached different conclusions. These reliability problems have been attributed to differences in the quality of the implemented meta-analytic procedures. We, therefore, examined the chronic pain treatment meta-analytic literature for MA procedure quality and for the consistency of conclusions. DESIGN, SETTING, PARTICIPANTS, OUTCOME MEASURES: Chronic pain treatment MAs were isolated according to inclusion/exclusion criteria. Data from these MAs were abstracted into structured tables. Table format reflected eight meta-analytic procedures identified previously as being important to MA implementation quality. These were: adequacy of retrieval, publication bias, inclusion/exclusion criteria, abstraction of data, quality, homogeneity/heterogeneity, independence, and statistical versus clinical interpretation. Each meta-analytic procedure was then independently rated by two raters. Rating results were then analyzed by procedure for each individual MA for percentage scores out of 100%, and mean scores. For MAs addressing the same topic area (pain facility treatment, antidepressant treatment, manipulation treatment) direction of effect size was noted. Mean effect sizes were calculated for these subgroups. RESULTS: Sixteen chronic pain treatment MAs fulfilled inclusion/exclusion criteria. Mean procedure ratings indicated that four procedures may not be implemented adequately. These were publication bias, abstraction of data, quality, and homogeneity/heterogeneity. There was wide MA implementation score variability, with 37.5% scoring less than 50%. The effect sizes of the MA subgroups demonstrated replicate nonvariability. CONCLUSIONS: Some meta-analytic procedures could be interpreted to be implemented inadequately in some chronic pain treatment MAs. There is wide variability between individual chronic pain treatment MAs on adequacy of implementation of these procedures. However, the effect sizes of the different MA subgroups demonstrated consistency. This finding indicates that for these MA subgroups, MA results are consistent between authors. In addition, chronic pain MAs, as compared with other groups of MAs, appear to address some of the procedures in a more adequate fashion. Future chronic pain MAs should concentrate on improving the quality of their methods with particular emphasis on the above four procedures. Because of potential validity problems with these results, these data cannot and should not be used to make administrative decisions about previous MAs.

Chronic Disease↗

PubMed2000

Implementation and evaluation of a clinical pathway for TRAM breast reconstruction.

Among strategies recently proposed to reduce practice variation, promote quality, and control costs in health care delivery, the concept of the clinical pathway has received considerable attention. Because transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a common and often costly intervention, this institution sought to evaluate cost and quality outcomes of a clinical pathways program for this procedure. The TRAM reconstruction clinical pathway was implemented in April of 1996 to standardize postoperative care in this patient population. Outcomes of consecutive pathway cases for the first 14 months of the program were assessed in a retrospective cohort design, by using all nonpathway TRAM cases from the 18 months immediately before pathway implementation as controls. Outcomes assessed included length of hospital stay, postoperative complications, total postoperative charges, and total postoperative costs in relative value units. Data on these dependent variables were collected from hospital charts and billing records. The effects of pathway implementation on the outcomes of interest were analyzed by using analysis of covariance to control for potential confounding by other independent variables, including surgical site (unilateral versus bilateral reconstructions), technique (pedicle versus free TRAMs), timing (immediate versus delayed reconstructions), and patient age. Finally, a comparison of variances in the outcomes of interest between the two groups was analyzed by using an Ftest. For all statistical tests, p values of < or = 0.05 were considered significant. Twenty-nine patients were treated in the TRAM pathway group, whereas the control population included 40 nonpathway patients. After implementation of the TRAM pathway, length of stay decreased from 6.0 to 5.2 days; total postoperative charges were reduced from $8587 to $7744; and total postoperative relative value unit utilization declined from 1686 to 1104. Analysis of covariance showed that the decreases in length of hospital stay and relative value units in the TRAM pathway were statistically significant (p = 0.05 and p = 0.007, respectively). By contrast, no significant increase in complications was observed after pathway implementation. Variability in the TRAM pathway group, as measured by SD, decreased significantly for both length of hospital stay (p = 0.039) and relative value units (p = 0.023). Implementation of the TRAM reconstruction clinical pathway resulted in significant declines in length of hospital stay and total costs. These decreases in resource utilization had no significant effect on postoperative complication rates. Although additional research is needed to further assess the impact of clinical pathways, this approach offers considerable promise for improving the cost-effectiveness of health care.

Adult↗

PubMed1996

Implementation of an inpatient case management program in rural hospitals.

The objective of the study was to identify factors that affected the implementation of an inpatient case management program in rural hospitals. The hospitals studied were from the Western New York Rural Health Care Cooperative. Five of the hospitals implemented the program in 1992. A qualitative evaluation was conducted by analyzing tape-recorded interviews with nurses and chief executive officers to identify obstacles to and facilitators of program implementation. Many obstacles to implementation could be traced to workload and time constraints, physician autonomy concerns, and limited nursing staff and physician participation. Implementation was facilitated foremost by the effort and supportive attitudes of nursing leaders and hospital chief executive officers. This study concluded that it should be possible to successfully implement conceptually sound managed care and case management programs in rural hospitals, but it will require a relatively long period of support, especially from hospital administration and nursing leaders.

Case Management↗

PubMed1997

Measuring the implementation of injury prevention programs in state health agencies.

OBJECTIVE: Injury prevention programs have been implemented with varying degrees of success in the United States. The objective of this study was to identify the variables that influence the successful implementation of injury prevention programs. METHODS: The key indicators of implementation success and its correlates were identified through consultation with a panel of experts. This consultation informed the content of a mail questionnaire sent to all United States state health departments, followed by telephone interviews. Data were analyzed using factor analysis and regression to identify significant relationships between variables. RESULTS: Data were obtained from 64 programs, representing 44 states; these included 24 programs in injury control units, 12 in maternal and child health units, 10 in health promotion/education units; and eight in emergency medical services units. Analysis identified four factors that are associated with an index of successful injury prevention program implementation; (1) participation and advocacy by constituent groups; (2) organizational capacity; (3) administrative control; and (4) attributes of relevant policies. CONCLUSIONS: Findings indicated that constituent participation (the extent and efficacy of constituency support and advocacy) and organizational capacity (a function of program staff and their skill levels) had the greatest influence on successful program implementation. Support from advocacy groups and knowledgeable staff members, whose time is dedicated to the program, are critical for conducting the activities necessary for successful implementation of these programs.

Accident Prevention↗

PubMed1998

Incremental cost of department-wide implementation of a picture archiving and communication system and computed radiography.

PURPOSE: To determine the incremental cash flows associated with department-wide implementation of a picture archiving and communication system (PACS) and computed radiography (CR) at a large academic medical center. MATERIALS AND METHODS: The authors determined all capital and operational costs associated with PACS implementation during an 8-year time horizon. Economic effects were identified, adjusted for time value, and used to calculate net present values (NPVs) for each section of the department of radiology and for the department as a whole. RESULTS: The chest-bone section used the most resources. Changes in cost assumptions for the chest-bone section had a dominant effect on the department-wide NPV. The base-case NPV (i.e., that determined by using the initial assumptions) was negative, indicating that additional net costs are incurred by the radiology department from PACS implementation. PACS and CR provide cost savings only when a 12-year hardware life span is assumed, when CR equipment is removed from the analysis, or when digitized long-term archives are compressed at a rate of 10:1. CONCLUSION: Full PACS-CR implementation would not provide cost savings for a large, subspecialized department. However, institutions that are committed to CR implementation (for whom CR implementation would represent a sunk cost) or institutions that are able to archive images by using image compression will experience cost savings from PACS.

Academic Medical Centers↗

PubMed1998

Improvement of medical care quality after implementation of a clinical path monitoring program for transurethral prostatectomy patients.

OBJECTIVES: The purpose of this study was to determine the effect on quality of care through the implementation of a clinical path for patients receiving transurethral prostatectomy. METHODS: We selected ten quality indicators with important clinical relevance as representative elements of the clinical path. These quality indicators were monitored during the entire hospitalization period of 100 consecutive patients who received transurethral prostatectomy. Monitoring data obtained from these patients were compared to data from 100 patients who received transurethral prostatectomy prior to implementation of the clinical path. Data was assessed to determine the relationship between quality indicators and management processes. RESULTS: Implementation of the clinical path for transurethral prostatectomy significantly decreased the percent of patients with incomplete preoperative tests on admission day, the duration of intravenous antibiotics administration, the percent of patients who required acute pain management postoperatively, the percent of patients who received postoperative bladder irrigation with normal saline and the percent of patients who had their Foley catheter removed after postoperative day 2. Three of the quality indicators had a significant relationship with management processes and may have directly affected the total admission charges. CONCLUSIONS: To evaluate the effect of the transurethral prostatectomy clinical path implementation on the quality of medical care, we compared ten quality indicators before and after implementation of this path. We concluded that implementation of the clinical path resulted in a statistically significant improvement in the quality of medical care.

Aged↗

PubMed1981

Implementing comprehensive health education: educational innovations and social change.

The effectiveness of health education is ultimately determined by whether it is implemented, and how it is implemented. Although a given health education innovation may be designed and experimentally assessed to promote well-being with some measure of effectiveness and efficiency, the actual impact of the innovation will depend upon the manner in which it is disseminated, initiated, and maintained. The implementation of health education programs in schools or elsewhere is a function of the types of innovations available, certain characteristics of those innovations that influence their use, and the manner in which the innovations are brought into practice. This paper has been prepared to review, synthesize, and apply current and relevant information about educational innovations and social change to provide a conceptual base for the design, execution, and analysis of efforts to implement health education in schools. The American system of public and private schools could be an agent vitally important to the realization of a second public health revolution. Indeed, in a democratic society, the implementation of health education in schools seems a condition necessary for such a revolution. By analyzing and learning from our own health education efforts, as well as the efforts of those experienced with implementing other types of educational innovations in schools, we might ensure that future populations are informed sufficiently about factors that influence their health and well-being.

Adolescent↗

PubMed1984

Competitive bidding as a cost-containment strategy for indigent medical care: the implementation experience in Arizona.

The State of Arizona recently instituted a competitive bidding process, in order to establish a health services delivery system for indigents and to determine capitated reimbursement levels for providers in that system. This article describes the implementation of that bidding process, and identifies factors which had a significant impact on the implementation experience. Implementation of competitive bidding in Arizona encountered problems which appear to be common to the implementation of innovative public programs. It also uncovered political liabilities that suggest that effective implementation of competitive bidding for indigent medical care contracts in other environments will be difficult, even if technical implementation problems can be overcome.

Arizona↗

PubMed1998

Implementing nurse-based systems to provide American Indian women with breast and cervical cancer screening.

OBJECTIVE: To describe the factors critical to implementation of a nurse-based system to increase access for American Indian women to breast and cervical cancer screening. MATERIAL AND METHODS: We report the experience of 103 nurses at 40 clinics who were trained to use the nurse-based screening system. In addition, the critical elements are discussed in the context of one particularly successful site. RESULTS: Fifteen factors were identified as critical to the implementation of a nurse-based cancer screening process once a nurse had been trained to perform clinical breast examinations and collect Papanicolaou (Pap) test specimens: knowledge of benefit, skills, organization, adequate return, perceived patient demand, perceived effectiveness, legitimacy, confidence, commitment, adequate resources, a data-driven iterative approach to program implementation, an objective measure of quality, leadership, the passage of time, and a focus on delivering the service to the patient. For example, in one site that was particularly successful, the nurses, administrators, and other key health-care professionals contributed their respective resources to implement the screening program. The program was also supported by the lay community, the state board of nursing, and the state health department breast and cervical cancer control program. During the 3-year study period, the 103 nurses performed screening tests on 2,483 women, and only 18 of the Pap test specimens were unsatisfactory. CONCLUSION: Nurse-based systems designed to collect high-quality Pap test specimens and perform detailed clinical breast examinations can be implemented if the factors that are critical to implementation are identified and addressed.

Breast Neoplasms↗

PubMed1979

Implementing a human services program: how hard will it be?

A framework is presented for examining obstacles to the implementation of human services delivery programs. These obstacles appear to arise from three basic sources: (1) from the operational demands implied by a particular program concept, (2) from the nature and availability of the resources required to run the program, and (3) from the need to share authority with, or retain support of, other bureaucratic and political actors in the implementation process. Within these three broad categories, fifteen areas deserve special attention: the people to be served, the nature of the service, the likelihood of distortions or irregularities, the controllability of the program, money, personnel, space, supplies and technical equipment, and intersections with overhead agencies, other line agencies, elected politicians, higher levels of government, private-sector providers, special-interest groups, and the press. By searching each of these fifteen areas diligently and systematically--with the aid of some 44 "factors for consideration"--it appears possible to make relatively powerful predictions about the obstacles that the implementation of a given human services program will entail. In addition, the framework can be used as a comparative instrument in allocating scarce political, managerial, and financial resources among human services programs, and as an aid to decision-making within particular programs and to identifying obstacles that cut across programs. Finally, some general guidance is offered on how implementing agency managers might deal with one of the more important and difficult dimensions of program implementation--namely, getting the cooperation of players in the implementation game whom the managers do not control, and who have different interests and agendas.

Community Health Services↗

PubMed1999

Clinical pathway implementation improves outcomes for complex biliary surgery.

BACKGROUND: Complex biliary surgery is associated with significant morbidity, prolonged hospital stay, and high cost. Clinical pathway implementation has the potential to standardize treatment and improve outcomes. Therefore the aim of this analysis was to determine whether clinical pathway implementation and/or feedback of outcome data would alter hospital stay, charges, and mortality rates for complex biliary surgery at an academic medical center METHODS: Pre- and postoperative length of stay, hospital charges, and mortality rates were monitored for 36 months before (period 1) and for 2 18-month periods (periods 2 and 3) after implementation of a clinical pathway for hepaticojejunostomy. Outcome data were provided to the surgeons 18 months after pathway implementation to determine whether further clinical practice improvement was possible. RESULTS: From 1991 to 1997, 339 patients underwent hepaticojejunostomy at The Johns Hopkins Hospital for malignant and benign biliary obstruction. Total length of stay was 13.3 +/- 0.9 days for period 1 compared with 12.5 +/- 0.8 days for period 2 (not significant) and 10.1 +/- 0.3 days for period 3 (P < .01 vs period 1; P < .03 vs period 2). Hospital charges averaged $24,446 during period 1 compared with $23,338 during period 2 and $20,240 during period 3 (P < .01 vs periods 1 and 2). Hospital mortality rate was 4.5% during period 1 compared with 0.7% during periods 2 and 3 (P < .05). CONCLUSIONS: These data suggest that implementation of a clinical pathway for hepaticojejunostomy reduces hospital mortality rates and that feedback of outcome data to surgeons results in further clinical practice improvement. Thus clinical pathway implementation and feedback are effective methods to control costs at an academic medical center.

Academic Medical Centers↗

PubMed1999

Evaluation of an implementation of PRODIGY phase two.

PRODIGY is a prescribing decision-support tool that encourages evidence-based cost-effective prescribing and supports information for patients with patient information leaflets. Following two successful pilot phases, the Department of Health has announced plans for a nation-wide rollout to all general practitioners in the UK. This paper describes the implementation and evaluation of PRODIGY Phase Two by AAH Meditel, one of the five participating GP system vendors. Based on the results and feedback from Phase One, Meditel made a number of changes to the software and training for Phase Two. The results showed Meditel's implementation of Phase Two was significantly better than the implementation of the other vendors (27% use versus 13% use), and also significantly better than its own implementation of Phase One (27% use versus 9.3% use). Patient information leaflets were issued 5.7% of the times versus 2.3% for the other vendors and 1.0% for Phase One. Detailed log files enabled the evaluation of the implementation of both phases and the software and training improvements made in Phase Two, and are recommended for the successful implementation of any clinical decision-support system project.

Computer User Training↗

PubMed1999

A RCT of three training and support strategies to encourage implementation of screening and brief alcohol intervention by general practitioners.

BACKGROUND: Providing doctors with new research findings or clinical guidelines is rarely sufficient to promote changes in clinical practice. An implementation strategy is required to provide clinicians with the skills and encouragement needed to alter established routines. AIM: To evaluate the effectiveness and cost-effectiveness of different training and support strategies in promoting implementation of screening and brief alcohol intervention (SBI) by general practitioners (GPs). METHOD: Subjects were 128 GPs, one per practice, from the former Northern and Yorkshire Regional Health Authority, who agreed to use the 'Drink-Less' SBI programme in an earlier dissemination trial. GPs were stratified by previous marketing conditions and randomly allocated to three intensities of training and support: controls (n = 43) received the programme with written guidelines only, trained GPs (n = 43) received the programme plus practice-based training in programme usage, trained and supported GPs (n = 42) received the programme plus practice-based training and a support telephone call every two weeks. GPs were requested to use the programme for three months. Outcome measures included proportions of GPs implementing the programme and numbers of patients screened and intervened with. RESULTS: Seventy-three (57%) GPs implemented the programme and screened 11,007 patients for risk drinking. Trained and supported GPs were significantly more likely to implement the programme (71%) than controls (44%) or trained GPs (56%); they also screened, and intervened with, significantly more patients. Costs per patient screened were: trained and supported GPs, 1.05 Pounds; trained GPs, 1.08 Pounds; and controls, 1.47 Pounds. Costs per patient intervened with were: trained and supported GPs, 5.43 Pounds; trained GPs, 6.02 Pounds; and controls, 8.19 Pounds. CONCLUSION: Practice-based training plus support telephone calls was the most effective and cost-effective strategy to encourage implementation of SBI by GPs.

Alcohol Drinking↗

PubMedDate not supplied

Project planning, training, measurement and sustainment: the successful implementation of voice recognition.

Computerized voice recognition systems (VR) can reduce costs and enhance service. The capital outlay required for conversion to a VR system is significant; therefore, it is incumbent on radiology departments to provide cost and service justifications to administrators. Massachusetts General Hospital (MGH) in Boston implemented VR over a two-year period and achieved annual savings of $530,000 and a 50% decrease in report throughput. Those accomplishments required solid planning and implementation strategies, training and sustainment programs. This article walks through the process, step by step, in the hope of providing a tool set for future implementations. Because VR has dramatic implications for workflow, a solid operational plan is needed when assessing vendors and planning for implementation. The goals for implementation should be to minimize operational disruptions and capitalize on efficiencies of the technology. Senior leadership--the department chair or vice-chair--must select the goals to be accomplished and oversee, manage and direct the VR initiative. The importance of this point cannot be overstated, since implementation will require behavior changes from radiologists and others who may not perceive any personal benefits. Training is the pivotal factor affecting the success of voice recognition, and practice is the only way for radiologists to enhance their skills. Through practice, radiologists will discover shortcuts, and their speed and comfort will improve. Measurement and data analysis are critical to changing and improving the voice recognition application and are vital to decision-making. Some of the issues about which valuable date can be collected are technical and educational problems, VR penetration, report turnaround time and annual cost savings. Sustained effort is indispensable to the maintenance of voice recognition. Finally, all efforts made and gains achieved may prove to be futile without ongoing sustainment of the system through retraining, education and technical support.

Certification↗

PubMed2000

Case study of an inter-professional and inter-organisational programme to adapt, implement and evaluate clinical guidelines in secondary care.

This paper describes the implementation of a clinical guideline across three acute Trusts. A Clinical Effectiveness Steering Group identified prevention of venous thromboembolism as a health priority. A local guideline development group adapted the recommendations of an existing review and produced a local guideline. Then, a multidisciplinary implementation group developed the practical aspects of implementing guidelines into routine daily practice. They identified appropriate staff to carry out risk assessment and to administer appropriate prophylaxis, as necessary. They also produced a "guideline pack" containing a training resource manual and implementation aids. Following this a multiple strategy implementation programme was used to introduce the guidelines, and an evaluation was carried out eight to ten months after the introduction of the guidelines. The evaluation identified a number of areas for improving current practice. Guideline implementation is a complex, time-consuming process.

Antibiotic Prophylaxis↗

PubMed1986

Implementing a stand-alone packaged pharmacy computer system in a 580-bed hospital.

The problems experienced by a hospital pharmacy department in implementing a stand-alone packaged computer system are discussed, and recommendations for avoiding and managing these problems are presented. In 1984, a stand-alone packaged computer system was implemented in a 580-bed, tertiary-care institution that provides services from a central pharmacy and five satellite pharmacies. The department developed a request for proposal and contracted with a vender for a system that would support unit dose drug distribution and i.v. admixture services. During the implementation process, the following problems were experienced: The hardware was insufficient for the department's workload, the software design was limited, and personnel were frustrated with learning to use the system. These problems were intensified by the heavy workload and the large number of users. In the 18 months since implementation, the department has purchased more hardware, improved the software applications, and resolved many of the problems associated with employee frustration. Pharmacy departments at other large institutions might avoid some of these problems by training personnel adequately before implementation and by researching and estimating hardware and software needs in advance. In this large hospital, the efficiency of a stand-alone packaged pharmacy computer system has improved 18 months after implementation.

Computers↗

PubMed1984

Research on disseminating and implementing health education programs in schools.

Numerous school health education programs have been developed. No matter how effective a given program may be, however, its impact will be determined by the extent to which it actually is disseminated and maintained in classrooms. The dissemination of a program involves purposeful efforts by agencies usually outside the school to implement the program in many different schools, efforts by agencies usually outside the school to implement the program in many different schools, while program implementation involves efforts by those within a given school to effectively use the program in its classrooms. This paper has been prepared to review concepts, strategies, and methods used to study dissemination and implementation; to specify the functions of dissemination and implementation research; and to describe general approaches and specific procedures to evaluate the effectiveness of dissemination and implementation activities. As we develop more and better school health education interventions, the need for research that will allow us to efficiently transport these interventions to classrooms throughout the nation becomes increasingly important.

Adolescent↗