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PubMed2006

Implementing iron management clinical practice guidelines in patients with chronic kidney disease having dialysis.

OBJECTIVE: To evaluate the outcomes of and barriers to implementing standard guidelines (Caring for Australasians with renal impairment [CARI]), using iron management in patients having dialysis as an example. DESIGN AND SETTING: On-site review of iron management processes at six Australian dialysis units varying in size and locality. Patients' iron indices and haemoglobin levels were obtained from the Australian and New Zealand Dialysis and Transplant Registry. PARTICIPANTS: Patients with chronic kidney disease who were dependent on dialysis. MAIN OUTCOME MEASURES: Processes for assessing indices of iron stores and iron supplementation; comparison with target indices in the CARI guidelines. RESULTS: There was considerable variability among the units in achievement of haemoglobin and iron targets, with 25%-32% of patients achieving haemoglobin targets of 110-120 g/L, 30%-68% achieving ferritin targets of 300-800 microg/L, and 65%-73% achieving transferrin saturation targets of 20%-50%. Implementation barriers included lack of knowledge, lack of awareness of or trust in the CARI guideline, inability to implement the guideline, and inability to agree on a uniform unit protocol. Factors associated with achieving the CARI guideline targets included nurse-driven iron management protocols, use of an iron management decision aid, fewer nephrologists per dialysis unit, and a "proactive" (actively keeping iron levels within target range) rather than "reactive" (only reacting if iron levels are out of the range) protocol. CONCLUSIONS: Variability in achievement of iron targets, despite the availability of a clinical practice guideline, may be explained by variability in processes of care for achieving and maintaining adequate iron parameters.

Adult↗

PubMed2003

Training in pathology informatics: implementation at the University of Pittsburgh.

CONTEXT: Pathology informatics is generally recognized as an important component of pathology training, but the scope, form, and goals of informatics training vary substantially between pathology residency programs. The Training and Education Committee of the Association for Pathology Informatics (API TEC) has developed a standard set of knowledge and skills objectives that are recommended for inclusion in pathology informatics training and may serve to standardize and formalize training programs in this area. OBJECTIVE: The University of Pittsburgh (Pittsburgh, Pa) core rotation in pathology informatics includes most of these goals and is offered as an implementation model for pathology informatics training. DESIGN: The core rotation in pathology informatics is a 3-week, full-time rotation including didactic sessions and hands-on laboratories. Topics include general desktop computing and the Internet, but the primary focus of the rotation is vocabulary and concepts related to enterprise and pathology information systems, pathology practice, and research. The total contact time is 63 hours, and a total of 19 faculty and staff contribute. Pretests and posttests are given at the start and end of the rotation. Performance and course evaluation data were collected for 3 years (a total of 21 residents). RESULTS: The rotation implements 84% of the knowledge objectives and 94% of the skills objectives recommended by the API TEC. Residents scored an average of about 20% on the pretest and about 70% on the posttest for an average increase during the course of 50%. Posttest scores did not correlate with pretest scores or self-assessed computer skill level. The size of the pretest/posttest difference correlated negatively with the pretest scores and self-assessed computing skill level. CONCLUSIONS: Pretest scores were generally low regardless of whether residents were familiar with desktop computing and productivity applications, indicating that even residents who are computer "savvy" have limited knowledge of pathology informatics topics. Posttest scores showed that all residents' knowledge increased substantially during the course and that residents who were computing novices were not disadvantaged. In fact, novices tended to have higher pretest/posttest differences, indicating that the rotation effectively supported initially less knowledgeable residents in "catching up" to their peers and achieving an appropriate competency level. This rotation provides a formal training model that implements the API TEC recommendations with demonstrated success.

Clinical Competence↗

PubMedDate not supplied

Amenability and implementation in secondary school antitobacco programs.

OBJECTIVES: To describe relationships between teachers' amenability to implement antitobacco programs and features of implementation settings. METHODS: A telephone random survey was administered to middle school and high school teachers in Florida. Data were analyzed via cluster analysis and other multivariate techniques. RESULTS: Teachers were classified by their amenability to implement tobacco-use-prevention education (TUPE). Cluster membership was associated with key contextual variables. Hierarchical multiple regression identified significant predictors of teachers' perceptions of program success. CONCLUSION: After controlling for other school and community factors, classroom activities remained significant predictors of program effectiveness. Findings may have implications for the design of secondary interventions to promote teacher efficacy related to delivery of antitobacco programs.

Adolescent↗

PubMed1999

Implementation of a hospitalist system in a large health maintenance organization: the Kaiser Permanente experience.

This paper presents preliminary quality and utilization data from a hospitalist system that is being implemented at Kaiser Permanente, a large health maintenance organization with 16 hospitals in northern California. Hospitalist programs, which are staffed by clinicians highly skilled in caring for inpatients, are being launched with the aim of delivering high-quality, efficient medical care in an increasingly competitive health care delivery environment. This paper also describes, in some detail, the process of implementation at one hospital. Challenges to implementation included 1) overcoming the reluctance of clinic physicians to relinquish inpatient care responsibilities, 2) developing sustainable work schedules, 3) creating effective channels of communication between staff in inpatient and outpatient settings, and 4) designing appropriate compensation scales for hospitalists. Mean length of stay, patient-day rates, admission rates, consultation request rates, costs, and readmission rates were examined for patients discharged from adult medicine services at all 16 hospitals between 1 January 1994 and 30 June 1997. These preliminary resource utilization data seem promising, but further analysis is needed to assess how hospitalist programs may affect clinical quality of care, costs, and patient and provider satisfaction.

Adult↗

PubMed1999

Cognition and utilization of Papanicolaou testing after the implementation of National Health Insurance in rural Taiwan.

Previous reports have indicated that knowledge and utilization of Papanicolaou (Pap) testing in Taiwan are low, especially among residents of rural areas. However, those studies were conducted before the implementation of National Health Insurance (NHI), which now covers Pap testing. To assess the cognition and utilization of Pap testing after the implementation of NHI in 1995, 708 women aged 40 years or more were interviewed by the Yang-Ming Crusade in July 1997. Of these women, 276 (39%) had heard of the Pap test, 226 (32%) had had the test, and 156 (22%) had had the test in the last 3 years (1995-1997). Of those who had never had the Pap test before 1995, 17% underwent it for the first time after the implementation of NHI. In contrast to an earlier comparable study, the present study shows a significant increase in both the cognition and utilization rates of Pap testing (from 27% to 39%, and 18% to 32%, respectively) among women in rural areas after the test was covered by NHI. However, both knowledge and use of the test among older and lower-educated women are still low.

Adult↗

PubMed1999

Decline in cigarette consumption following implementation of a comprehensive tobacco prevention and education program--Oregon, 1996-1998.

In November 1996, residents of Oregon approved a ballot measure increasing the cigarette tax by 30 cents (to 68 cents per pack). The measure stipulated that 10% of the additional tax revenue be allocated to the Oregon Health Division (OHD) to develop and implement a tobacco-use prevention program. In 1997, OHD created Oregon's Tobacco Prevention and Education Program (TPEP), a comprehensive, community-based program modeled on the successful tobacco-use prevention programs in California and Massachusetts. To assess the effects of the tax increase and TPEP in Oregon, OHD evaluated data on the number of packs of cigarettes taxed before (1993-1996) and after (1997-1998) the ballot initiative and implementation of the program. Oregon's results also were compared with national data. This report summarizes the results of the analysis, which indicate that consumption of cigarettes in Oregon declined substantially after implementation of the excise tax and TPEP and exceeded the national rate of decline.

Health Education↗

PubMed1990

Managing change. A step-by-step process helps sponsors implement change smoothly.

During the past six years the Catholic Health Association (CHA) has developed and modified a process to help leaders evaluate and implement merger, cosponsorship, and sponsorship transfer decisions. CHA's highest priority in these efforts has been to keep Catholic healthcare facilities under Catholic sponsorship, control, and management. Proposals to change sponsorship arrangements usually originate with sponsoring institutes, whereas local boards generally initiate merger proposals. In either case, it is critical that all interested parties--such as sponsors, boards, administrators, medical staff, employees, and the local Church--be involved in the decision-making process at some point. Once leaders have decided on a course of action, they should appoint a task force to implement the proposal. The board, administration, and medical staff will all have important roles to play in the implementation process. Another important step is to establish criteria for evaluating candidates for a proposed merger or sponsorship transfer. Leaders should ensure that people affected by the transaction have an opportunity to give input and to grieve their loss. After leaders have selected a candidate, they must negotiate the details of the agreement and take the necessary legal steps to complete the transaction. It is imperative that a facility secure outside legal counsel to help it through this stage.

Catholicism↗

PubMed1992

Implementing a mainframe coding/abstracting system.

In conclusion, the successful implementation of a medical record abstracting system was realized due to the following factors: extensive planning, thorough organization of tasks, controlled implementation, and ongoing controls. While thorough planning and organization will result in an efficient implementation, ongoing controls will ensure continued success and produce high quality results for any medical record system.

Abstracting and Indexing↗

PubMed1993

Implementation of a computerized medication administration record.

Implementation of a computerized medication record reduces both medication errors and the time pharmacy and nursing services have to spend keeping records. A collaborative team approach to the development of the computerized medication record is integral to its success. The team at Day Kimball Hospital included representatives from departments who participated in goal-setting and problem-solving. The collaborative team also addressed the basic problem areas common to the implementation of the project as well as follow up for the purpose of continuous quality improvement. This article provides insight to professionals who wish to implement a computerized medication record through the collaboration of a team. The outcome of the project is a safe medication administration document, which decreases the potential for medication errors and improves patient outcomes.

Clinical Pharmacy Information Systems↗

PubMed1993

The leader's role in implementing total quality management.

Quality experts state that ineffective leadership can hinder and even destroy efforts to implement total quality management (TQM). However, they rarely discuss the specific actions leaders should take in implementing TQM and when leaders should take them. This article discusses a four-phase TQM implementation model that includes specifications for leadership actions at each step.

Decision Making, Organizational↗

PubMed1994

Implementing total quality management in the health care industry.

Health care organizations across the nation have begun instituting quality improvement programs in order to meet the demands of improving service and clinical quality in health care. The implementation process requires time, effort, and money in order for the health care organizations to learn who their customers are and what they want. The results, which sometimes are not recognized until after a two- to three-year period, include reduced costs by cutting waste and complexity and by doing things right the first time. Still, there are many challenges in adapting total quality management (TQM) to public organizations such as the health care industry. This article discusses the founding principles of TQM and how they are applied in implementing TQM to enhance quality in health care organizations. This article also forecasts the future of TQM implementation in public health care.

Hospital Administration↗

PubMed1994

MRP (materiel requirements planning) II: successful implementation the hard way.

Many manufacturing companies embark on MRP II implementation projects as a method for improvement. In spite of an increasing body of knowledge regarding successful implementations, companies continue to attempt new approaches. This article reviews an actual implementation, featuring some of the mistakes made and the efforts required to still achieve "Class A" performance levels.

Aircraft↗

PubMed1994

MRP (materiel requirements planning) II implementation: a case study.

Manufacturing resource planning (MRP II) is a powerful and effective business planning template on which to build a continuous improvement culture. MRP II, when successfully implemented, encourages a disciplined yet nonthreatening environment centered on measurement and accountability. From the education that accompanies an MRP II implementation, the employees can better understand the vision and mission of the organization. This common goal keeps everyone's energy directed toward the same final objective. The Raymond Corporation is a major materiels handling equipment manufacturer headquartered in Greene, New York, with class "A" MRP II manufacturing facilities in Greene and Brantford, Ontario and an aftermark distribution facility in East Syracuse, New York. Prior to the implementation of MRP II in its Greene plant (from 1988 through 1990) good intentions and hard work were proving to be less than necessary to compete in the global market. Certified class "A" in February 1990. The Raymond Corporation has built a world-class organization from these foundations.

Goals↗

PubMed1994

Development and implementation of practice guidelines (Part 1).

Development and implementation of practice guidelines should be a team effort that includes pharmacists, the medical staff, and hospital administration. Described in this article are the steps involved in developing and successfully implementing practice guidelines. Also briefly presented are some practice guidelines developed by the staff at Cedars-Sinai Medical Center for the use of ondansetron in the post-op setting, colony stimulating factors, and sumatriptan for the treatment of migraine. Finally, discussion of a few practice guidelines that are in the implementation phase and future directions with regard to evolution of practice guidelines are presented.

Acquired Immunodeficiency Syndrome↗

PubMed1995

Washington State Health Services Act: implementing comprehensive health care reform.

In 1993, Washington State enacted the Health Services Act of 1993 (HSA) to guarantee universal access to health care through an employer mandate, with caps on premiums as the primary cost-control mechanism. The HSA represents the Nation's first formal experiment with managed competition. This article reports the results of a case study of the HSA's implementation. The study concludes that the Washington State initiative can be replicated in other States, but that implementation is complex, requires sustained public education, and requires cooperation from the Federal Government through program waivers. A major implementation challenge is to facilitate competition and minimize regulation.

Competitive Medical Plans↗

PubMedDate not supplied

Teleradiology: opportunities, problems, implementation.

With the introduction of computerized tomography and magnetic resonance imaging in the early 1970s, computers became integral to the imaging process. Shortly thereafter, scanners that create digitized images from film were introduced and teleradiology--images transmitted in real time--became possible. In the early 1980s, the idea of a picture archiving and communications system (PACS) began to develop. It promised to retrieve, connect and store every kind of image, from x-ray to CT, and render film obsolete. However, inflated expectations and inadequate technology hindered PACS implementation. Digital imaging offers the following benefits over film-based systems: - Less space is needed to store imaging studies. - Digital imaging files can be faster and easier for referring physicians to retrieve than film and are not susceptible to loss and damage. - Digital images can be enhanced, contrasted, colored and otherwise manipulated to maximize available information. - There are no chemicals to dispose of. While telemedicine promises to increase the efficiency and effectiveness of medical professionals, wide-scale implementation faces the following obstacles: - It has been difficult to establish a uniform standard that allows file transfer among systems made by different vendors. - There are unresolved legal questions about "interstate" medical practice as it occurs in teleradiology and about standards of care and image quality. - Any system available on a network is vulnerable to unauthorized users who may invade the database or operation of the system, and it is very difficult to detect fraud--data that has been tampered with--in digital records. - Connections to remote locations depend on local telephone lines, which may be slow. Other options are available, but they may be too expensive for facilities in the rural areas that need them the most. - Digital imaging equipment is still very costly to acquire and install. The future of telemedicine rests now with those who implement it. Once instituted, it will surpass traditional medicine by reducing the expense of storage and misplaced information and allowing faster and more accurate diagnoses.

Computer Security↗

PubMed1996

Implementation of total quality management: conventional wisdom versus reality.

Hospitals nationwide are beginning to implement continuous quality improvement (CQI) (Barsness et al. 1993; Kosta 1992). In large part this is due to the belief that the implementation of CQI will lead to higher quality patient care, improved patient satisfaction, better employee morale, and lower cost service delivery. However, to date there have been few empirical studies of CQI implementation efforts in healthcare (Shortell et al. 1994).

Chief Executive Officers, Hospital↗

PubMed1995

When push comes to shove: implementing VBAC practice guidelines.

The dramatic increase in U.S. cesarean sections over the past two decades has been significantly driven by repeat C-sections. In response to this trend, clinical guidelines recommending vaginal birth after cesarean-section (VBAC) have been promulgated by national organizations. Adherence to these guidelines would reduce the number of repeat C-sections, lower the overall C-section rate, and improve both the quality and the cost of health care. While these guidelines have received professional endorsement, their implementation has been clouded by issues of patient acceptance and provider payment. To examine implementation of these guidelines by health care organizations, the authors surveyed 156 members of the American College of Physician Executives to determine their policies, practices, and attitudes toward VBAC guidelines. Those surveyed generally were medical directors in HMOs, hospitals, and other practice settings. The findings indicate that the health care organizations represented by these physician executives have not consistently implemented VBAC guideline and that they are reluctant to hold physicians, their patients, or hospitals accountable for the financial, utilization, and quality impact of the elective decision ot to pursue appropriate VBACs. We conclude that, even when widely accepted, clinical practice guidelines may be ineffective in reducing the costs or improving the quality of medical care.

Attitude of Health Personnel↗