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PubMed2005

On the design of computer-based models for integrated environmental science.

The current research agenda in environmental science is dominated by calls to integrate science and policy to better understand and manage links between social (human) and natural (nonhuman) processes. Freshwater resource management is one area where such calls can be heard. Designing computer-based models for integrated environmental science poses special challenges to the research community. At present it is not clear whether such tools, or their outputs, receive much practical policy or planning application. It is argued that this is a result of (1) a lack of appreciation within the research modeling community of the characteristics of different decision-making processes including policy, planning, and (2) participation, (3) a lack of appreciation of the characteristics of different decision-making contexts, (4) the technical difficulties in implementing the necessary support tool functionality, and (5) the socio-technical demands of designing tools to be of practical use. This article presents a critical synthesis of ideas from each of these areas and interprets them in terms of design requirements for computer-based models being developed to provide scientific information support for policy and planning. Illustrative examples are given from the field of freshwater resources management. Although computer-based diagramming and modeling tools can facilitate processes of dialogue, they lack adequate simulation capabilities. Component-based models and modeling frameworks provide such functionality and may be suited to supporting problematic or messy decision contexts. However, significant technical (implementation) and socio-technical (use) challenges need to be addressed before such ambition can be realized.

Computer Simulation↗
PubMed1999

Implementation of the ANA report card.

A major challenge in healthcare today is measuring the quality of care. To explore nursing's contribution to patients in acute care settings, the American Nurses Association commissioned the development of the "Nursing Report Card." This study explored whether these report card indicators capture quality care. The convenience sample comprised 1,500 patients and 300 nurses from 16 units at an academic medical center. Using regression analysis, the most consistent predictor of outcome indicators was the percentage of RNs of the total staff.

Adult↗
PubMed1995

Beliefs and emotional reactions of care staff working with people with challenging behaviour.

Information collected in the context of a survey of all people with learning disabilities and challenging behaviour in a single metropolitan borough indicated: (1) care staff report that a significant proportion of their colleagues usually display such emotional reactions as sadness, despair, anger, annoyance, fear and disgust to episodes of challenging behaviour; (2) respondents reported that the most significant sources of stress associated with caring for someone with challenging behaviour centred upon the 'daily grind' of caring, their difficulty in understanding the person's behaviour, the unpredictability of the behaviour and the apparent absence of an effective way forward; (3) care staff attribute the causes of the person's challenging behaviour to a diversity of internal psychological, broad environmental, behavioural and medical factors. These results are discussed in relation to their implications for staff-seeking and implementing external advice regarding the management of challenging behaviour.

Activities of Daily Living↗
PubMed2006

Good governance for nutrition in the Philippines: elements, experiences, and lessons learned.

Malnutrition is a multifactorial problem that needs a multisectoral solution. This article reviews the role of good governance in nutrition programs, citing the Philippines as an example. In the Philippines, these efforts are reflected in the partnership between the public and private sectors in the establishment of the country's capability in research, policy-making, and program implementation. The establishment of the different public institutions engaged in research and policy-making is discussed, highlighting the role of political will through legislation. The evolving tasks of the nutrition program are discussed by citing the tasks in two eras. In the 1970s, the challenges were limited national nutrition data, man-power, tools, and health infrastructure. The public and private institutions were able to respond by legislating national nutrition surveys and dedicated nutrition workers in each village. The challenges in the current era are improved implementation of health programs, given the devolution of health services, and the gathering of an evidence base to further strengthen and refine the strategies of supplementation, fortification, breastfeeding, and food security. In responding to these challenges, multisectoral solutions and collaboration are critical in providing an evidence base to formulate policy. The role of the private sector, with the Nutrition Center of the Philippines used as an example, is that of a supportive and collaborative partner in good governance. Finally, the lessons learned from the past decades of implementing a national nutrition program, given changes in political and economic circumstances, are summarized.

Developing Countries↗
PubMed2006

Administration and leadership of the Health Professions Partnership Initiative: a medical school administrator's perspective.

The importance of requiring the principal investigator for a Health Professions Partnership Initiative (HPPI) to be from the top of the administrative chain and thereby have the responsibility of implementing, operating, and finding ways to sustain the HPPI is described. Further, it follows that initiatives such as HPPI require committed partners that also are from the top leadership from the affiliated health schools, school districts and community organizations. While the dean or vice president must be actively involved if the HPPI is to be successful, it is not realistic to expect that he or she has time to manage the day-to-day activities. Those should be delegated to a highly qualified and well-respected member of the administration. That person must have ready access to the principal investigator and be provided appropriate office space and staffing. The author describes strategies used to meet challenges that arose that impeded successful implementation of the HPPI and how those problems were met and solved.

Health Occupations↗
PubMed2026

Identifying stakeholder behaviors for competency-based pharmacy education: A stage 1 behavior change wheel analysis.

INTRODUCTION/OBJECTIVES: Competency-Based Pharmacy Education (CBPE) is a strategic priority for preparing graduates to meet evolving healthcare needs. However, efforts to implement CBPE can stall due to behavioral challenges among faculty, administrators, preceptors, and learners. This study aimed to apply Stage 1 of the Behavior Change Wheel (BCW) to identify stakeholder-specific behaviors and associated determinants needed to implement the five core components of CBPE. METHODS: A multi-method approach grounded in the BCW, the Capability, Opportunity, Motivation - Behavior (COM-B) model, and the Theoretical Domains Framework (TDF) was used. Data were gathered through (1) targeted literature review; (2) structured focus groups with competency-based education experts and pharmacy education stakeholders; and (3) an iterative consensus process. Behaviors were mapped to the five CBPE components: (1) defined competencies, (2) developmental progression, (3) tailored instruction, (4) authentic experiential learning, and (5) programmatic assessment, and then mapped to COM-B and TDF constructs. RESULTS: Over fifty stakeholder-specific behaviors were identified and specified across the CBPE framework. This revealed shared barriers such as limited instructional design knowledge (psychological capability), insufficient assessment of infrastructure (physical opportunity), and misaligned professional identity (reflective motivation). Key TDF domains included knowledge, environmental context, beliefs about capabilities, and professional roles. The behavioral problem statements, specifications, and determinants were identified to support future intervention planning. CONCLUSION: This Stage 1 analysis provides a behaviorally grounded foundation for CBPE implementation by identifying stakeholder behaviors and conditions that enable change. These findings will inform the development of readiness-to-change assessments and targeted interventions (BCW Stages 2 and 3), supporting scalable and sustainable CBPE transformation in pharmacy education.

Education, Pharmacy↗
PubMed1998

Course-based assessment: implementing outcome assessment in medical education.

Rapid, intensive change in the health care system requires a change in how the outcomes of medical education are measured. The post-Flexner model of evaluating the institution focuses on teaching (rather than learning) and is not relevant to ambulatory training. Medical education needs to use assessment that focuses on student learning, can respond quickly to changes, and is continuously refined by use of information about students' abilities. Course-based assessment is a systematic way to gather, analyze, disseminate, and use course data to improve student learning, and it is well suited to current trends in health professions education. The authors present and discuss six principles of effective outcome assessment in medical education and illustrate these principles from their experience of using this type of assessment in a pre-clinical course integrating basic science, social science, and clinical skills. Courses and programs for medical students and residents should use course-based assessment to ensure that medical trainees acquire the skills and attitudes needed to practice medicine well. The next challenge for medical educators is to implement course-based assessment that is intimately tied to a broader institutional plan.

Attitude of Health Personnel↗
PubMedDate not supplied

Evaluation of a treatment-appropriate cognitive intervention for challenging alcohol outcome expectancies.

The current study evaluated an alcohol expectancy challenge (EC) that did not require alcohol administration and could therefore be implemented in a treatment setting. Participants in the treatment group directly challenged alcohol expectancies endorsed on an expectancy questionnaire. A total of 62 male and female undergraduates completed the study (32 control participants, 30 EC participants). Self-report questionnaires were collected pre- and post-intervention, and alcohol logs were kept during the study. The EC resulted in significant reductions in alcohol expectancies across multiple expectancy dimensions. Although the analysis for alcohol consumption was not significant, there was a trend toward better outcomes for male participants in the EC condition. In contrast to study hypotheses, women in the EC condition increased their alcohol consumption from pre to post-test to a greater degree than did control participants.

Alcohol Drinking↗
PubMed2006

The role of formative evaluation in implementation research and the QUERI experience.

This article describes the importance and role of 4 stages of formative evaluation in our growing understanding of how to implement research findings into practice in order to improve the quality of clinical care. It reviews limitations of traditional approaches to implementation research and presents a rationale for new thinking and use of new methods. Developmental, implementation-focused, progress-focused, and interpretive evaluations are then defined and illustrated with examples from Veterans Health Administration Quality Enhancement Research Initiative projects. This article also provides methodologic details and highlights challenges encountered in actualizing formative evaluation within implementation research.

Benchmarking↗
PubMed2006

Ethical issues in haemophilia.

Ethical issues surrounding both the lack of global access to care as well as the implementation of advancing technologies, continue to challenge the international haemophilia community. Haemophilia is not given the priority it deserves in most developing countries. Given the heavy burdens of sickness and disease and severe resource constraints, it may not be possible to provide effective treatment to all who suffer from the various 'orphan' diseases. Nevertheless, through joint efforts, some package of effective interventions can be deployed for a significant number of those who are afflicted with 'orphan' diseases. With cost-effective utilization of limited resources, a national standard of care is possible and affordable. Gene-based diagnosis carries attendant ethical concerns whether for clinical testing or for research purposes, even as the list of its potential benefits to the haemophilia community grows rapidly. As large-scale genetic sequencing becomes quicker and cheaper, moving from the research to the clinic, we will face decisions about the implementation of prenatal, neonatal and other screening programs. Such debates will require input from not just the health care professionals but from all stakeholders in the haemophilia community. Finally, long-term therapeutic success gene transfer in small and large animal models raises the question of when and in which patient population the novel therapeutic approach should first be studied in humans with haemophilia. Although gene therapy represents a worthy goal, the central question for the haemophilia community should be whether it wishes to volunteer itself as a model for a much broader set of innovations.

Adult↗
PubMed2003

Magnetic resonance coronary angiography.

Magnetic resonance coronary angiography (MRCA) has witnessed tremendous technical advances over the past decade. Although high-quality images of the coronary arteries have been demonstrated, this imaging modality is not performed routinely today. The fundamental properties of the coronary arteries deterring noninvasive imaging are well known. This article provides an overview of the developmental efforts to overcome these challenges, and highlights key technical and clinical advances. The future prospect of MRCA depends on clinical implementation of the technique. In order to meet this challenge, the following issues must be addressed: contrast- and signal-to-noise ratio, temporal and spatial resolution, and scan protocol.

Coronary Angiography↗
PubMed1998

The philosophy of clinical practice guidelines: purposes, problems, practicality and implementation.

There are a number of technical and professional challenges to the use of clinical practice guidelines in the United Kingdom. Until recently, many guidelines have been consensus-based rather than being explicitly linked to evidence of effectiveness and have also been of variable quality. Moreover, clarity of purpose has been lacking with some guidelines being developed as a means of limiting access to secondary care rather than as a means of assisting clinical decision-making. Implementation of new research into practice and of clinical practice guideline recommendations shares many of the same barriers to changing clinician behaviour. Without local support systems to assist with implementation, including clinical audit programmes and methods of feeding back information on current practice, it is unlikely that guidelines will change practice in the majority of clinicians. Progress on the implementation of guidelines in the British National Health Service is discussed.

Employee Performance Appraisal↗
PubMed2002

Assessing clinical pathways use in a community hospital: it depends on what "use" means.

BACKGROUND: Many benefits have been associated with the use of clinical pathways, yet developing them can be costly, and implementing them is not always successful. A 300-bed Midwestern community hospital began a clinical pathways program in 1995, and by fall 1998, 15 pathways were in various stages of implementation, with 3 under development. Many challenges had been encountered, but hospital leaders were eager to find ways to increase pathway use. METHODS: A qualitative case study design was used to investigate four clinical pathways, two perceived as being "used" and two that were perceived as "not used". Each pathway was analyzed as a separate case, followed by cross-case analysis. Qualitative data were collected in 65 semistructured interviews with administrators, physicians, physicians' office staff, nurses, and allied health professionals at the hospital. Data were also collected through observation and document analysis. RESULTS: The two used pathways had been introduced as part of a larger change in care, whereas the two pathways not used had been introduced as stand-alone innovations. Confusing and inadequately developed aspects of the hospital's clinical pathways program included its purposes, the definition of pathway use, pathway procedures, accountability, education, and incentives. A new case management department, ongoing administrative support, and a sophisticated medical information system were viewed as supports for continued growth in the program. CONCLUSIONS: Implementation of clinical pathways was delayed and complicated by the varied perceptions of the program among stakeholders. Lack of clarity and consistency in how information about the program was communicated made it difficult for clinicians to develop a shared understanding of clinical pathways.

Attitude of Health Personnel↗
PubMed2007

Can we ensure the safe use of known human teratogens?: The iPLEDGE test case.

Minimising the public health burden of isotretinoin-induced teratogenicity has been a challenge for 24 years, the duration of availability of isotretinoin in the US for the treatment of severe, recalcitrant nodular acne. Although the teratogenicity of this drug is well known and risk-management programmes had been implemented, preventable fetal exposures continued to occur, largely as a result of the lack of sufficient controls within the programmes themselves. The manufacturers of isotretinoin implemented a new risk-management programme, iPLEDGE, in March 2006. iPLEDGE is a comprehensive distribution system that includes mandatory registration of patients, healthcare providers, pharmacies, and wholesalers. It allows real-time linkage of pregnancy-test results for verification prior to the dispensing of isotretinoin. Although the challenges of implementing a closed distribution system for a very widely used medication have been extensive, the potential public health benefits from preventing fetal exposure to isotretinoin are substantial.

Acne Vulgaris↗
PubMedDate not supplied

Information technology in complex health services: organizational impediments to successful technology transfer and diffusion.

OBJECTIVE: To identify impediments to the successful transfer and implementation of packaged information systems through large, divisionalized health services. DESIGN: A case analysis of the failure of an implementation of a critical application in the Public Health System of the State of New South Wales, Australia, was carried out. This application had been proven in the United States environment. MEASUREMENTS: Interviews involving over 60 staff at all levels of the service were undertaken by a team of three. The interviews were recorded and analyzed for key themes, and the results were shared and compared to enable a continuing critical assessment. RESULTS: Two components of the transfer of the system were considered: the transfer from a different environment, and the diffusion throughout a large, divisionalized organization. The analyses were based on the Scott-Morton organizational fit framework. In relation to the first, it was found that there was a lack of fit in the business environments and strategies, organizational structures and strategy-structure pairing as well as the management process-roles pairing. The diffusion process experienced problems because of the lack of fit in the strategy-structure, strategy-structure-management processes, and strategy-structure-role relationships. CONCLUSION: The large-scale developments of integrated health services present great challenges to the efficient and reliable implementation of information technology, especially in large, divisionalized organizations. There is a need to take a more sophisticated approach to understanding the complexities of organizational factors than has traditionally been the case.

Computer User Training↗
PubMed2002

The challenges of community-directed treatment with ivermectin (CDTI) within the African Programme for Onchocerciasis Control (APOC).

The principal strategy adopted by the African Programme for Onchocerciasis Control (APOC), for the control of onchocerciasis in the 19 countries of Africa that now fall within the programme's remit, is that of community-directed treatment with ivermectin (CDTI). Halfway through its 12-year mandate, APOC has gathered enough information on the main challenges to guide its activities in Phase 2. An analysis of reports and other documents, emanating from consultants, scientists, monitors and national and project-level implementers, indicates that there are three broad categories of challenge: managerial; technical; and socio-political. Under these three categories, this review identifies the most pertinent concerns that APOC must address, during Phase 2, to enhance the prospects of establishing sustainable systems for ivermectin distribution. The major challenges include: (1) maintaining timely drug-collection mechanisms; (2) integrating CDTI with existing primary-healthcare services; (3) strengthening local health infrastructure; (4) achieving and maintaining an optimal treatment coverage; (5) establishing and up-scaling community self-monitoring; (6) designing and implementing operations research locally; (7) ensuring the adequacy of community-directed distributors; (8) increasing the involvement of local non-govemmental develop organizations in the programme; (9) achieving financial sustainability; (10) implementing equitable cost-recovery systems; and (11) engaging in effective advocacy. The implications of the challenges and suggestions about how they are being (or could be) addressed are also highlighted in this brief review, which should be of value to other programmes and agencies that may be contemplating the adoption of this unique strategy.

Africa↗
PubMed2025

Polygenic risk scores in the clinic: Health-system leaders and primary care providers weigh in.

PURPOSE: The fourth phase of the Electronic Medical Records and Genome Network is testing the return of 10 polygenic risk scores (PRS) across multiple clinics. Understanding the perspectives of health-system leaders and frontline clinicians can inform plans for implementation of PRS. METHODS: A total of 15 health-system leaders and 20 primary care providers took part in semistructured interviews. A descriptive thematic analysis was performed. RESULTS: Interviewees generally perceived PRS to have limited clinical utility, although they saw value in the potential to identify and act upon risks that are not otherwise detectable. Perceived potential drawbacks included negative psycho-emotional effects on patients, unnecessary follow-up, distracting from population health priorities, opportunity costs, and medicolegal liability. Implementation considerations included increased encounter time and the need for clinical practice guidelines, provider training, care coordination, and point-of-care resources. CONCLUSION: Participants generally expressed favorable views of precision medicine and also identified potential challenges to introducing PRS in clinical care. Implementation will require careful assessment of clinical utility vs usual care; ensuring that the benefit to be realized merits the time and resources required to interpret, return, and act on results and developing guidelines and other decision-making supports for providers and patients.

Humans↗