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PubMed1999

[Requirements for the successful implementation of unity of care: study of a computer-assisted dispensation of pharmaceuticals].

PURPOSE: Even though computerized workstations bring undisputed benefits in nursing units, introducing them is still hard when most of the staff members have to share the workstation. We took advantage of the implementation of the drug prescription software SAUPHIX in a nephrology department to better define the encountered difficulties. The workstation described in this paper is shared by physicians who enter their prescriptions (proprietary names, doses, routes of administration), nurses who use dosage schedules for drug administration, and the chemist who has authority to control prescription orders. METHODS: Six months after the implementation of the workstation, physicians and nurses had to fill out an anonymous questionnaire aimed at assessing each function of the software. RESULTS: Prescriptions proved to be more accurate and legible, while management of drugs was more precise. However, interns complained that entering data was time consuming. Furthermore, they raised objections to control of prescription orders. Nurses criticized dosage schedules, the primary reason being that they had to change their practice. The convenience of notebooks was questioned by both physicians and nurses who would have preferred a greater number of desktop computers at their disposition. CONCLUSION: The implementation of a computerized workstation requires information, diplomacy and negotiations to obtain real implication of the staff. Tasks and schedules must be specified for everybody. The system has to be carefully customized, according to the requirement of the unit. Computers must be properly chosen and allocated in sufficient number. Finally, appropriate preparation, staff training and follow-up of the computerized system are essential.

Drug Prescriptions↗

PubMed2003

Implementing participatory intervention and research in communities: lessons from the Kahnawake Schools Diabetes Prevention Project in Canada.

Community public health interventions based on citizen and community participation are increasingly discussed as promising avenues for the reduction of health inequalities and the promotion of social justice. However, very few authors have provided explicit principles and guidelines for planning and implementing such interventions, especially when they are linked with research. Traditional approaches to public health programming emphasise expert knowledge, advanced detailed planning, and the separation of research from intervention. Despite the usefulness of these approaches for evaluating targeted narrow-focused interventions, they may not be appropriate in community health promotion, especially in Aboriginal communities. Using the experience of the Kahnawake Schools Diabetes Prevention Project, in Canada, this paper elaborates four principles as basic components for an implementation model of community programmes. The principles are: (1) the integration of community people and researchers as equal partners in every phase of the project, (2) the structural and functional integration of the intervention and evaluation research components, (3) having a flexible agenda responsive to demands from the broader environment, and (4) the creation of a project that represents learning opportunities for all those involved. The emerging implementation model for community interventions, as exemplified by this project, is one that conceives a programme as a dynamic social space, the contours and vision of which are defined through an ongoing negotiation process.

Child↗

PubMed2000

Perceived barriers to the implementation of diabetes guidelines in hospitals in The Netherlands.

OBJECTIVE: To determine the organisational and personal barriers to the implementation of diabetes guidelines in hospitals in The Netherlands and relate them to structural factors of diabetes care. METHOD: In a written survey internists specialised (or with a specific interest) in diabetes in all general hospitals in The Netherlands (n = 120) were asked to indicate the perceived organisational and personal barriers to adherence to the diabetes guidelines. In the same questionnaire their activities related to diabetes care and the working hours of the additional personnel involved were measured. RESULTS: There was at least one specialised diabetes nurse employed in all hospitals, although the extent of the appointment varied widely from 0.2 to 6.9 full-time equivalent (average 1.5). In most hospitals (90%) a diabetes care team had been established, while podiatrists were working in only 72% of the hospitals. Furthermore, 65-80% of the hospitals organised special consultation hours for diabetic patients, had a protocol for diabetes treatment, or patient held administration booklets. The most frequently mentioned barriers to the implementation of diabetes guidelines were high workload, no adequate financial compensation, and a shortage of necessary personnel. CONCLUSION: A number of preconditions for structured diabetes care, like the presence of a diabetes team and a specialised diabetes nurse, were in place. However, large differences between the hospitals in the organisation of diabetes care and the availability of staff, together with the related perceived barriers to the implementation of the guidelines showed that there are still many opportunities for improvements.

Attitude of Health Personnel↗

PubMed2001

Community innovation in hazardous materials management: progress in implementing SARA Title III in the United States. Superfund Amendments and Reauthorization Act.

Title III of the Superfund Amendments and Reauthorization Act (SARA Title III) established a new federal approach to managing toxic chemical hazards. This legislation required industry to disclose the type and quantity of such chemicals and also required the establishment of state and local government organizations to receive those data, evaluate community vulnerability, develop local emergency response plans, and communicate with the public. This paper reviews the law's historical context and empirical studies of its implementation. The available evidence suggests that significant progress has been made in reducing chemical hazards but there is considerable variation across jurisdictions in the effectiveness of the law's implementation. The research results reviewed here suggest a variety of ways in which SARA Title III implementation can be improved.

Communication↗

PubMedDate not supplied

Dialectical Behavior Therapy of borderline patients with and without substance use problems. Implementation and long-term effects.

OBJECTIVE: The aim of this article is to examine whether standard Dialectical Behavior Therapy (DBT) (1) can be successfully implemented in a mixed population of borderline patients with or without comorbid substance abuse (SA), (2) is equally efficacious in reducing borderline symptomatology among those with and those without comorbid SA, and (3) is efficacious in reducing the severity of the substance use problems. METHOD: The implementation of DBT is examined qualitatively. The impact of comorbid SA on its efficacy, as well as on its efficacy in terms of reducing SA, is investigated in a randomized clinical trial comparing DBT with treatment-as-usual (TAU) in 58 female borderline patients with (n = 31) and without (n = 27) SA. RESULTS: Standard DBT can be applied in a group of borderline patients with and without comorbid SA. Major implementation problems did not occur. DBT resulted in greater reductions of severe borderline symptoms than TAU, and this effect was not modified by the presence of comorbid SA. Standard DBT, as it was delivered in our study, however, had no effect on SA problems. CONCLUSIONS: Standard DBT can be effectively applied with borderline patients with comorbid SA problems, as well as those without. Standard DBT, however, is not more efficacious than TAU in reducing substance use problems. We propose that, rather than developing separate treatment programs for dual diagnosis patients, DBT should be "multitargeted." This means that therapists ought to be trained in addressing a range of severe manifestations of personality pathology in the impulse control spectrum, including suicidal and self-damaging behaviors, binge eating, and SA.

Adolescent↗

PubMed2000

American brachytherapy society recommendations for clinical implementation of NIST-1999 standards for (103)palladium brachytherapy. The clinical research committee of the American Brachytherapy Society.

PURPOSE: Recent important developments in palladium-103 ((103)Pd) dosimetry mandate a reevaluation of (103)Pd brachytherapy prescribing practices. METHODS AND MATERIALS: The clinical research committee of the American Brachytherapy Society (ABS) convened a consensus session of brachytherapists and physicists to develop recommendations regarding future dose prescribing guidelines for National Institute of Standards and Technology (NIST-1999) calibrated (103)Pd sources. RESULTS: The ABS recommends that clinicians attempt to reproduce the implant doses delivered and reported in the literature through the past decade. CONCLUSIONS: The following should be immediately implemented for (103)Pd dosimetry: 1) All practicing physicians, physicists, dosimetrists, and suppliers implement NIST-1999 air-kerma strength standard for (103)Pd brachytherapy. 2) All treatment planning systems and dose calculation algorithms must be updated to reflect new dose rate constants. The AAPM-recommended validated value for Theraseed model 200 is 0.665 cGy h(-1) U(-1). The dose rate constant for the Mentor MED3633 seed is currently reported as 0.68 cGy h(-1) U(-1). This latter value and the values for seeds from other manufacturers are awaiting independent confirmation. 3) Physicians who previously prescribed 115 Gy for (103)Pd monotherapy prostate implants should now prescribe 125 Gy. When using (103)Pd as a boost following 45 Gy of external beam irradiation, 100 Gy should be prescribed instead of the previous 90 Gy. It is critical that all three changes be implemented concurrently, because they are interdependent.

Brachytherapy↗

PubMed2003

Feasibility of implementation of a Dutch smoking cessation and relapse prevention protocol for pregnant women.

A cross-sectional design was used to asses whether Dutch midwives trained to use a smoking cessation counseling protocol appreciated it and could implement it in routine care. Midwives received a questionnaire after the implementation period of the effectiveness study was finished. In total, 118 midwives from 42 practices participated in the study, 69 midwives (58.5%) returned the questionnaire. To validate the results collected among midwives, clients who participated in the study were also questioned about the information they received about smoking cessation from their midwife. Experimental midwives more often reported giving the advice to quit (B=0.50, S.E.=0.24, P<0.05), setting a quit date with clients who indicated to be motivated to quit (B=1.69, S.E.=0.28, P<0.001) and discussing aftercare (B=1.10, S.E.=0.25, P<0.001). These results were confirmed by data collected among clients. This easy-to-implement program is recommended for broad dissemination. Further investigation is needed to improve the partner and postpartum component.

Adult↗

PubMed1997

Euthanatics: implementation of a protocol to standardise euthanatics among pharmacists and GPs.

The purpose of this study was to evaluate the implementation of a protocol to standardise euthanatics among pharmacists and general practitioners (GPs). Data over 1993 and 1994 were collected by means of an anonymous postal questionnaire sent to all pharmacists (n = 37) and all GPs (n = 283) working in the area in which the protocol was implemented. In total, 76% of the pharmacists and 63% of the GPs responded. All pharmacists and 65% of the GPs were aware of the existence of the protocol and all pharmacists and 42% of the GPs were also familiar with the content of the protocol. Both pharmacists and GPs had fairly positive attitudes towards the importance and possibility of the standardisation of euthanatics. Of the GPs who performed euthanasia or assisted with suicide during the research period, 59% made use of one or more standard packages. The majority of pharmacists and GPs were satisfied with the standard packages, and all GPs indicated that they intend to use the packages again in the future. This study shows that the implementation of standardised euthanatics was quite successful.

Adult↗

PubMed2002

Adoption and implementation of new technologies in substance abuse treatment.

In addition to clinical outcomes, understanding the adoption and implementation of new treatment interventions is essential. This analysis was designed to assess the predictive utility of organization-level features in understanding the adoption and implementation of new technologies in substance abuse treatment. Naltrexone, which was found to be in current use in 44.1% of a national sample of 400 private substance abuse treatment centers, was selected as an appropriate sample technology for study. Adoption of naltrexone is significantly related to both the treatment center's age and its administrative leadership. Naltrexone adoption is also significantly associated with the percentage of the center's caseload covered by managed care programs and by the percentage of relapsers represented in the caseload. The analysis was less successful in predicting naltrexone implementation for either primary alcohol dependence or primary opiate addiction.

Humans↗

PubMed2005

The cost of developing and implementing a pathway for Congestive Heart Failure: not an inexpensive journey.

This article describes the cost of developing and implementing an integrated care pathway (ICP) for Congestive Heart Failure. Costs were tracked prospectively and allocated to either development or implementation. The development took 1,980 hours of staff time at a salary cost of $67,800. The ICP implementation took 2,083 hours of personnel time at a salary cost of $66,900. Even though an available pathway was adapted for local use, a substantial amount of time and money was required. This article may be useful to others who are interested in monitoring costs of pathways.

Critical Pathways↗

PubMed1998

Best laid plans: effective implementation of re-engineering recommendations.

Continuing pressures on health care funding have led most hospitals to undertake re-engineering and restructuring projects to reduce operating expenses. Unfortunately, savings often turn out to be less than anticipated, as the projects falter in the implementation stage. As part of a two-year process improvement and expense reduction project, Toronto's St. Michael's Hospital developed an aggressive and comprehensive implementation process to ensure that it met its savings targets and maintained its financial viability. This article outlines the Hospital's implementation strategy and reviews the project's major challenges and key success factors.

Budgets↗

PubMed1999

Evaluating the implementation of a pain management flow sheet.

This study evaluated the outcome of implementing a pain flow sheet, using protocols derived from the Agency for Health Care Policy and Research (AHCPR) guidelines for pain management, for children recovering from surgery. Findings indicated the flow sheet was not used as designed; thus, implementing the flow sheet did not result in increased documentation of pain assessments, interventions, and outcomes, except in the increased documentation of nonpharmacological interventions for pain management. Rogers' Diffusion of Innovation Theory gives insight as to why this occurred and provides rationale for more intensive in-service education when new innovations are implemented.

Analgesics↗

PubMed2003

On the practice of the clinical implementation of enhanced dynamic wedges.

Practical aspects of the clinical implementation of enhanced dynamic wedges (EDW) replacing manual wedges are presented and discussed extensively. A comparison between measured and calculated data is also presented. Relative dose distributions and wedge factors were calculated with a commercially available treatment planning system and measured in a water-phantom and with an ionization chamber. Wedge factor calculations and measurements were also compared with an independent method of wedge factor calculations available from the literature. Aspects of the clinical implementation, such as safety and quality assurance, were evaluated. Measurements and calculations agreed very well and were slightly better than results of previous studies. Profiles and percentage depth doses (PDDs) agreed within 1% to 1.5% and within 0.5%, respectively. Measured and calculated wedge factors ratios agreed within 0.5% to 1%. Calculated and measured EDW dose distributions showed excellent agreement, both relative and absolute. However, for safe and practical use, specific aspects need to be taken into consideration. Once the treatment planning system is commissioned properly, the clinical implementation of EDW is rather straightforward.

Humans↗

PubMed2004

Policy implementation in practice: the case of national service frameworks in general practice.

National Service Frameworks are an integral part of the government's drive to 'modernise' the NHS, intended to standardise both clinical care and the design of the services used to deliver that clinical care. This article uses evidence from qualitative case studies in three general practices to illustrate the difficulties associated with the implementation of such top-down guidelines and models of service. In these studies it was found that, while there had been little explicit activity directed at implementation overall, the National Service Framework for coronary heart disease had in general fared better than that for older people. Gunn's notion of 'perfect implementation' is used to make sense of the findings.

Family Practice↗

PubMed2003

Changing schools, changing health? Design and implementation of the Gatehouse Project.

PURPOSE: To describe the Gatehouse Project which addresses the social context of high school with an aim of changing students' sense of school connection and in turn, health risk behavior and well-being. METHODS: Distinguishing features of the project were its conceptual framework, implementation process, and evaluation design. The conceptual framework derived from attachment theory and focused on three aspects of the school social context: security, communication, and participation. Implementation was standardized around a survey of the school social environment, creation of a school-based action team, and the implementation of strategies matched to a school's profile of need. In addition, an early high school curriculum addressed the skills relevant to social functioning and emotional adjustment. The evaluation design was based on a cluster randomized trial involving 26 schools. It used follow-up of an individual cohort and repeat cross-sectional surveys to capture outcomes at an individual student and whole-school level. RESULTS AND CONCLUSIONS: The Gatehouse Project drew on both health and education research to develop and coordinate a broad-based school health promotion intervention. It represents a promising new direction for school-based preventive work.

Adolescent↗

PubMedDate not supplied

Implementation of an innovation in the ophthalmic operating room: the Memory lens.

I have participated in the evolution of the cataract procedure for the last 23 years. This year, as nursing director for an eye surgery center, I was responsible for the implementation of a new prerolled intraocular lens: The Memory lens. I review 5 implementation strategies, which are: Be open to recently approved products Utilize all company resources Introduce, train, train, train Evaluate, review, review, review Enjoy the questions and attention from others considering the innovation The implementation of this innovation confirmed both my and the operating room staff's ability to change and reaffirmed their commitment to achieve the resultant patient benefits.

Cataract Extraction↗

PubMed1996

Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines.

BACKGROUND: A multisite, randomized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing (AD) and continuous quality improvement (CQI) teams-on the implementation of national guidelines for the primary care of hypertension and depression. STUDY: Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound (Seattle) and two at academic medical centers-were randomized in blocks along with their primary care patients to receive AD alone, AD plus CQI, or usual care. A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8-9 minutes. Each CQI team, which met, on average, 14 times in nine months, devised at least one intervention (for example, weight loss counseling for hypertensives by nurse practitioners). RESULTS: The detailing endeavors differed greatly across organizations. Although all teams generally worked well together, organizational factors such as staff layoffs and reorganizations competed for the teams' attention. Team leaders differed in their ability to inspire members to "run with" ideas and to motivate personnel outside the team to implement interventions. SUMMARY AND CONCLUSIONS: Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that resulted in varied implementation across the different organizations. Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques.

Academic Medical Centers↗

PubMed1997

Implementing programs for chronic illness management: the case of hypertension services.

BACKGROUND: This article describes the process by which HealthSystem Minnesota (a vertically integrated health care organization), functioning in a competitive managed care environment, has been implementing a hypertension services program. The program involves a team approach to care, with emphasis on patient participation in treatment; decentralized care delivery by nurse coordinators at primary care practice sites; ongoing training and education for patients and providers; and the continuous monitoring and evaluation of patient outcomes and satisfaction. JOB-LEVEL ISSUES: A variety of issues, such as the role and responsibilities of the nurse coordinator, became evident as the program moved towards operational status at four primary care practice sites, which prolonged the implementation period. PROCESS-LEVEL ISSUES: Issues relating to work process changes were more complicated to resolve and required, in some cases, changes in the proposed model. The most significant process-level issues related to educating physicians about the program to secure their participation and support. ORGANIZATION-LEVEL ISSUES: Such issues, which were the most difficult for program implementors to anticipate and resolve, included an organizational culture that emphasized decision making autonomy at primary practice sites. In part, the difficulty encountered in resolving organization-level issues reflected the implementors' lack of awareness of the strength or complexity of the environmental pressures facing the organization, as well as a lack of sensitivity to nuances relating to organizational culture. MOVING AHEAD: Two groups of hypertensive patients--at the implementation and comparison sites--will be compared with respect to satisfaction with care, clinical outcomes, and costs. Expansion of the model to patients with other chronic conditions is under consideration.

Case Management↗