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PubMed1998

Local implementation of national guidelines on lower urinary tract symptoms: what do general practitioners in Sydney, Australia suggest will work?

OBJECTIVES: Systematic reviews demonstrate that local initiatives are vital to implement nationally developed clinical practice guidelines. Evidence-based guidelines on the management of lower urinary tract symptoms in men were launched by the National Health and Medical Research Council in Sydney in April 1997. A study was conducted through interviews to establish patterns of care in the catchment area before the guidelines were implemented and general practitioners were surveyed in order to ascertain the most useful strategies for local implementation. DESIGN: A four-page questionnaire asked respondents to rate nine items about guideline dissemination; six items relating to the marketing of the guidelines and 15 implementation strategics: conventional educational activities (six); innovative educational strategies (four); quality improvement approaches (two) and patient-based approaches (three). SETTING: Sydney, Australia. STUDY PARTICIPANTS: Eighty-three randomly selected general practitioners (50 males; 33 females). RESULTS: Eighty-three out of 108 surveys were returned (77%). Respondents placed high value upon endorsement by eminent individuals and organizations other than the organization developing the guidelines; this was likely to gain their initial attention. One hundred per cent of respondents would be encouraged to use the guidelines if they were promoted as improving quality of care. Implementation strategies preferred by respondents included small group continuing education with a urologist and a general practitioner as a facilitator, lectures and patient education materials. Internet access, interactive computer systems, academic detailing' and distance education modules were of least interest. CONCLUSIONS: Our method is feasible as a first step in planning local dissemination and implementation for national guidelines. While useful in identifying preferred strategies, its longer-term predictive validity for improving patient outcomes through better guideline implementation needs to be established.

Adult↗

PubMed1999

A longitudinal, national study of the effect of implementing a required third-year family practice clerkship or a department of family medicine on the selection of family medicine by medical students.

PURPOSE: To conduct a longitudinal study of the effect of implementing a required third-year family practice clerkship or a department of family medicine on the proportion of graduating medical students choosing family practice as a specialty. METHOD: Using national data sets, the authors studied the proportion of students who chose family practice as a specialty at each medical school that implemented a required third-year family practice clerkship or a department of family medicine between 1984 and 1993. They compared the mean proportions of students choosing family practice for the three years before and three years after implementation of the required clerkship or the department. They controlled for national trends by comparing study schools with schools that did not have required family practice clerkships. RESULTS: The mean proportions of students who chose family practice increased 2.36% above control schools (95% CI = 1.06, 3.65) in public schools and 2.07% (95% CI = -2.58, 6.73) in private schools after a required third-year clerkship was implemented. The proportion of students choosing family practice declined by 0.84% (95% CI = -4.05, 2.47) after a department of family medicine was established. CONCLUSION: Implementing a required third-year family practice clerkship led to an immediate, significant increase in the proportion of students choosing family practice. Implementing a department of family medicine had no noticeable effect on the proportion of students choosing family practice in the first three years after implementation.

Career Choice↗

PubMed2001

Successes and failures in the implementation of evidence-based guidelines for clinical practice.

BACKGROUND: The development and implementation of (evidence-based) clinical practice guidelines is one of the promising and effective tools for improving the quality of care. However, many guidelines are not used after dissemination. Implementation activities frequently produce only moderate improvement. It is important to study specific guideline programs in detail to learn from their successes and failures. OBJECTIVES: Experiences with more than 10 years of development and dissemination of clinical guidelines for family medicine in the Netherlands are presented in this paper. RESULTS: More than 70 evidence-based guidelines have been set in a rigorous procedure and have been spread via a variety of strategies. Knowledge and acceptance of the guidelines in the target group is high. In particular, a multifaceted approach with written (scientific journal, support materials) and personal approaches (local consensus discussions, contact with colleagues, outreach visits by peers) seems to be effective in the dissemination. The guideline recommendations are followed in on average 67% of the decisions, but there is a large variation between different physicians and between different guidelines. Specific strategies designed to handle possible obstacles to implementation are needed to improve adherence. Specific implementation projects showed the importance of a "diagnostic analysis" of the target group and target setting before the start of the implementation. CONCLUSIONS: A program to implement a guideline should be well designed, well prepared, and preferably pilot tested before use. Such a program should be built into the normal channels and structures for improving care. More research into the details of implementation is needed to better understand the critical determinants of change in practice.

Evidence-Based Medicine↗

PubMedDate not supplied

Control mechanisms for guideline implementation.

OBJECTIVES: One approach to reducing health care costs while ensuring high-quality patient care is the use of medical practice guidelines. This study focuses on mechanisms that facilitate the implementation of guidelines primarily intended to reduce cost without increasing patient risk, using a multiinstitutional case study of a single guideline. SUBJECTS AND METHODS: We conducted semistructured interviews with physicians and administrators involved with guideline implementation in 61 academic medical centers. The interviews included questions on both implementation methods and the final success of implementation at each center. RESULTS: We identified 5 factors likely to be of importance to the guideline implementation process: (1) the use of a written form to routinize the process; (2) the acquisition of informed consent; (3) the presence of an active department chair (or section chief) to serve as an opinion leader; (4) the use of individual-level monitoring; and (5) the granting of financial incentives. CONCLUSIONS: This study allowed the identification of four processes for guideline implementation. For hospitals contemplating implementation of guidelines aimed toward cost reduction or selective use of various agents for other purposes, a decision process to identify the control mechanism best suited to an individual institution is a crucial step toward success.

Cost Control↗

PubMed1979

Implementation of a personalized clothing policy for long stay psychiatric patients: a study of communication.

This study raises the following question. Should the policy maker be responsible for ensuring adequate monitoring of policy implementation? A policy lays down a course of action for achieving a particular end. Implementation of a policy implies adherence to the course of action stated in the policy. This study was concerned with the relationship between a policy of personalized clothing and the implementation of a particular scheme. Divergence from the original policy occurred because of inadequate communication between those who formulated the policy, those who implemented the policy and the staff who were responsible for day-to-day management associated with the policy. The finding of this study was that the way policy was implemented did not relate to the original objective of the policy. Policy relating to a particular area of health cannot progress scientifically unless evaluation of the implementation of formulated policy occurs. This research therefore advocates that the policy maker should be responsible for ensuring adequate monitoring of the policy when it is implemented.

Activities of Daily Living↗

PubMed2005

Nursing best practice statements: an exploration of their implementation in clinical practice.

AIMS AND OBJECTIVES: To explore implementation of the first five Best Practice Statements from the perspective of nurses involved in their development. BACKGROUND: Best Practice Statements were introduced in Scotland to encourage consistent evidence-based nursing practice. As a new initiative, research was required to investigate their clinical implementation. DESIGN AND METHODS: In this descriptive study, semi-structured interviews of a purposive sample of nurses (n = 15) were undertaken. Content analysis was used to identify themes emerging from the interview data. FINDINGS: Four main themes emerged from analysis of transcripts: variations in use of the Best Practice Statements; benefits to patients; benefits to practitioners; and, barriers and drivers to use. Amongst participants, personal users adopted the statements in their own practice but enablers also actively encouraged others to use the statements. Whether participants acted as enablers depended on individual, team and organizational factors. The ability of participants to act as leaders was influential in determining their ability both to facilitate local implementation and to encourage others to regard the Best Practice Statements as a priority for implementation. CONCLUSIONS: This exploratory study highlighted examples of patients and practitioners benefiting from the Best Practice Statements. Such findings suggest these statements could become a useful tool in promoting evidence-based nursing practice. However, implementation of the Best Practice Statements varied between participants and their organizations. Nurses who were most effective in promoting local implementation of the Best Practice Statements adopted facilitator and leadership roles within their organizations. RELEVANCE TO PRACTICE: By relating research findings to the literature on guideline and research utilization, this study gives further insight into the implementation of evidence-based practice by nurses. In particular, it supports the conclusion that to be truly effective, initiatives to promote evidence-based practice require nurses to act as local facilitators and leaders.

Attitude of Health Personnel↗

PubMed2005

Implementing family intervention following training: what can the matter be?

Family interventions (FI) have been established as an effective treatment for psychosis. Training in this intervention is now widely available in the UK. This paper reports a review of published literature that investigates whether, following this training, graduates provide this evidence-based treatment for individuals with psychosis and their caregivers. It further seeks to identify the barriers to implementation in cases where the treatment is not provided and assess benefits for service users and carers when it is. The review was conducted using the MEDline, PsycINFO, CINAHL and Embase databases. Studies that have attempted to evaluate the rates of implementation of FI by graduates of FI training programmes were identified, retrieved and reviewed. Six studies investigating the rates of implementation upon graduation were identified. The findings of these six studies were generally consistent. Rates of implementation by graduates of training programmes are usually low and a small number of graduates work with most of the families who are seen. The studies reviewed failed to assess service user and carer outcomes or consider the full range of likely impediments to the implementation of this evidence-based intervention. A key barrier to the implementation of FI is the reliance upon professionally developed and facilitated approaches. Alternative models that are service user and carer-led may provide a potential solution to the problem of implementation. Implications for future research and practice are considered.

Attitude of Health Personnel↗

PubMed2005

Kaiser Permanente's experience of implementing an electronic medical record: a qualitative study.

OBJECTIVE: To examine users' attitudes to implementation of an electronic medical record system in Kaiser Permanente Hawaii. DESIGN: Qualitative study based on semistructured interviews. SETTING: Four primary healthcare teams in four clinics, and four specialty departments in one hospital, on Oahu, Hawaii. Shortly before the interviews, Kaiser Permanente stopped implementation of the initial system in favour of a competing one. PARTICIPANTS: Twenty six senior clinicians, managers, and project team members. RESULTS: Seven key findings emerged: users perceived the decision to adopt the electronic medical record system as flawed; software design problems increased resistance; the system reduced doctors' productivity, especially during initial implementation, which fuelled resistance; the system required clarification of clinical roles and responsibilities, which was traumatic for some individuals; a cooperative culture created trade-offs at varying points in the implementation; no single leadership style was optimal--a participatory, consensus-building style may lead to more effective adoption decisions, whereas decisive leadership could help resolve barriers and resistance during implementation; the process fostered a counter climate of conflict, which was resolved by withdrawal of the initial system. CONCLUSIONS: Implementation involved several critical components, including perceptions of the system selection, early testing, adaptation of the system to the larger organisation, and adaptation of the organisation to the new electronic environment. Throughout, organisational factors such as leadership, culture, and professional ideals played complex roles, each facilitating and hindering implementation at various points. A transient climate of conflict was associated with adoption of the system.

Attitude of Health Personnel↗

PubMed2005

Words matter: increasing the implementation of clinical guidelines.

OBJECTIVES: To determine whether writing clinical guideline recommendations in behaviourally specified "plain English" language increases the likelihood of their implementation by service users (patients). DESIGN: Randomised controlled trial in which participants received either the original text of the National Institute for Clinical Excellence (NICE) public guidelines for the management of schizophrenia or a behaviourally specified text with the same content. SETTING: Mental health service user networks and voluntary sector organisations within two inner London boroughs. PARTICIPANTS: Eighty four mental health service users recruited by post or face to face contact at service user meetings. INTERVENTION: The section of the NICE public guidelines for schizophrenia concerning psychological and pharmacological treatments was rewritten to improve style and behavioural specificity by applying evidence-based and psychologically informed principles of good written communication. OUTCOME MEASURES: Cognitive predictors of behaviour, as specified by the evidence based theory of planned behaviour, constituted the primary outcome as it was not possible to measure the actual behaviour of guideline implementation. The predictors were behavioural intentions to implement the guidelines, attitudes towards implementation, and perceived behavioural control over implementation. Satisfaction with the guidelines and perceived comprehension were also measured. RESULTS: Behaviourally specified "plain English" guidelines led to stronger intentions to implement the guidelines, more positive attitudes towards them, and greater perceived behavioural control over using them. There was no difference in satisfaction or perceived comprehension. CONCLUSIONS: Writing guidelines with high behavioural specificity in conjunction with the use of "plain English" may be a simple and effective method of increasing their implementation. Evaluation with a behavioural outcome is now needed.

Adult↗

PubMed2005

Implementation intentions, perfectionism, and goal progress: perhaps the road to hell is paved with good intentions.

Two studies explored whether perfectionism moderates the impact of implementation intentions on goal progress. Study 1 used an implementation intention manipulation to examine the effects of these plans in interaction with perfectionism on the progress of New Year's resolutions. Study 2 added a repeated implementation intention condition and monitored affect and monthly goal progress. The results of both studies revealed a significant backfire effect of the implementation intentions on goal progress for participants high on a particular dimension of perfectionism (socially prescribed perfectionism). These perfectionists reported doing significantly worse at reaching their personal goals when they were asked to formulate implementation intentions than when they completed a control exercise. There also was evidence that implementation planning aroused negative affect for socially prescribed perfectionists. These results are the first to suggest that implementation planning may be contra-indicated for individuals with self-critical tendencies.

Adolescent↗

PubMedDate not supplied

Benchmarking implementation of a computerized system for long-term care.

The purpose of this study was to apply a benchmarking methodology to identify the most effective approaches used by long-term care facilities in implementing new computerized resident assessment instrument/minimum data set (RAI/MDS) systems and to develop implementation protocols based on these "best practices." Site visits were conducted with 3 long-term care facilities, selected on the basis of a national search. Facility directors, directors of nursing, information system managers, and frontline staff at each facility were targeted, and questionnaires were developed for each to assess factors viewed as important to successful implementation. A convergence was found in recommended action steps reported across sites to facilitate introduction and implementation of new RAI/MDS software. An example of how benchmarking results were used to develop an implementation plan is provided. Benchmarking provided a useful methodology for identifying best practices to guide implementation planing for adoption of a new computerized RAI/MDS system in the current trial. The benchmarking steps described are replicable and can be used to guide implementation of other new systems in the nursing home setting.

Benchmarking↗

PubMed2004

Program provider and observer ratings of school-based preventive intervention implementation: agreement and relation to youth outcomes.

Few prevention studies have examined the degree to which different measures of program implementation adherence predict youth outcomes. The current study was conducted with rural middle school youth participating in a longitudinal school-based preventive intervention program. Study participants' average age at the pretest assessment was 12.3 years. The association between program implementation ratings supplied by provider self-reports and trained independent observer reports were evaluated. In addition, the relationship between measures of implementation and youth outcomes were examined. Results indicated that although program providers tended to report higher implementation than independent observers, most ratings were correlated significantly across raters. Observer-reported implementation ratings significantly predicted several youth substance-related outcomes, while provider-reported self-ratings did not. Program provider characteristics predicted several youth outcomes. Findings suggest that there might be a social desirability bias in provider self-reported ratings of implementation and that caution must be used when interpreting self-reported ratings of implementation.

Adolescent↗

PubMed2003

Effectiveness of multifaceted implementation of guidelines in primary care.

OBJECTIVE: To evaluate the effectiveness of a tailored and multifaceted approach to the implementation of nationally recommended and evidence-based guidelines in primary care within existing systems and resources. METHODS: A non-randomised Latin square to compare guideline implementation in two neighbouring health districts covering 180 general practices. Evidence-based guidelines for the treatment of patients with asthma and angina were implemented actively in one district and passively disseminated in the other district. Outcome measures for asthma were smoking status and inhaler technique. For angina the outcome measures were: smoking status; blood pressure; aspirin prescribed, contraindicated or self-medicated; beta-blocker prescribed or contraindicated; routine hospital admission; prescribed drugs; self-reported change. RESULTS: There were improvements in all outcome criteria between baseline and follow-up audits, regardless of whether the guideline was actively implemented or passively disseminated. The estimated increase in the proportion of records complying with guidelines was 4% [95% confidence intervals (CI): 0, 8] and was higher in intervention than in control practices. Using only records not compliant at baseline, the corresponding difference was 15% (95% CI: 7, 24). The only significant improvement associated with active implementation was smoking status in angina patients. Both prescribing and hospital admission monthly totals changed during the period of the trial, but there was no significant difference between the pattern of changes in intervention and control districts. A significantly greater proportion of health professionals saw the intervention guideline compared with the control (75% versus 25%). There was a significant correlation between self-reported change and interventions steps (P < 0.05). CONCLUSIONS: Increases in quality markers occurred irrespective of the multifaceted implementation efforts. Some of this increase was due to the method of data collection. Nevertheless, national initiatives may have more influence than local implementation initiatives.

Adrenergic beta-Antagonists↗

PubMed2005

Changing nursing practice: evaluating the usefulness of a best-practice guideline implementation toolkit.

PURPOSE: This pilot study describes the evaluation of an 88-page Toolkit that was developed to guide nursing leaders, including advanced practice nurses, managers and steering committees, who were responsible for coordinating implementation of selected best-practice guidelines (BPG) in their respective agencies. METHODS: The self-administered questionnaire was mailed to all clinical resource nurses and steering committee members involved in implementing best-practice guidelines. The questionnaire evaluated the usefulness of the content of five chapters (and the case scenarios and worksheets included with each chapter). RESULTS: Sixty-eight percent of respondents returned the questionnaire. More than 85% of them found the Toolkit helpful during the implementation process; 83% reported using it, 80% said they would use it again. The Toolkit was used primarily to identify, analyze and engage stakehoLders, and to assess environmental readiness. Fifty-seven percent of respondents said they used the Toolkit to plan the implementation strategy. CONCLUSIONS: The Toolkit assessed in this evaluation shows promise as a useful guide for those charged with BPG implementation. Like other guidelines that are based on evidence, the Toolkit will require occasional updates to ensure that the strategies proposed reflect current evidence. Nursing leaders have a responsibility to keep up to date and to provide efficient and effective healthcare services. Best-practice guidelines or clinical practice guidelines are useful tools that synthesize the latest evidence and provide recommendations for care providers aiming to improve the quality of patient care (Grol 2001). Many leaders are challenged to know how and when to implement the increasing numbers of practice guidelines. The purpose of this article is to describe a pilot study to evaluate a Toolkit that was developed to guide nursing leaders in implementing selected best-practice guidelines (BPGs) in their respective agencies.

Benchmarking↗

PubMedDate not supplied

Implementing an electronic medical record in a family medicine practice: communication, decision making, and conflict.

PURPOSE: Electronic medical record (EMR) systems offer substantial opportunities to organize and manage clinical data in ways that can potentially improve preventive health care, the management of chronic illness, and the financial health of primary care practices. The functionality of EMRs as implemented, however, can vary substantially from that envisaged by their designers and even from those who purchase the programs. The purpose of this study was to explore how unique aspects of a family medicine office culture affect the initial implementation of an EMR. METHODS: As part of a larger study, we conducted a qualitative case study of a private family medicine practice that had recently purchased and implemented an EMR. We collected data using participant observation, in-depth interviews, and key informant interviews. After the initial data collection, we shared our observations with practice members and returned 1 year later to collect additional data. RESULTS: Dysfunctional communication patterns, the distribution of formal and informal decision-making power, and internal conflicts limited the effective implementation and use of the EMR. The implementation and use of the EMR made tracking and monitoring of preventive health and chronic illness unwieldy and offered little or no improvement when compared with paper charts. CONCLUSIONS: Implementing an EMR without an understanding of the systemic effects and communication and the decision-making processes within an office practice and without methods for bringing to the surface and addressing conflicts limits the opportunities for improved care offered by EMRs. Understanding how these common issues manifest within unique practice settings can enhance the effective implementation and use of EMRs.

Communication↗

PubMed1992

The classwide peer tutoring program: implementation factors moderating students' achievement.

We conducted a study designed to assess implementation of the classwide peer tutoring program and the relationship between implementation variation and student outcome. A clinical replication design was used. Five volunteer elementary teachers were trained to implement the program; their implementation was monitored for 19 consecutive weeks during 1 school year. Overall, the results indicated that specific variations in program implementation were associated with students' responses to treatment. It was also demonstrated that different teachers' applications of the program produced differential levels of student outcome. Implementation factors related to lower spelling achievement were (a) reduced opportunities to receive program sessions, (b) reduced probabilities of students' participation in program opportunities, (c) too many students assigned unchallenging spelling words, and (d) reduced rates of daily point earning reflecting lower levels of spelling practice during tutoring sessions. The implications of these findings and methods of preventing these implementation problems are discussed in the context of quality assurance and social validity.

Achievement↗

PubMed2000

Increasing intervention implementation in general education following consultation: a comparison of two follow-up strategies.

This study examined two strategies for increasing the accuracy with which general education teachers implemented a peer tutoring intervention for reading comprehension. The intervention was implemented for 5 elementary school students who had been referred for consultation services. Initial implementation of the intervention by the teachers was variable, and the data exhibited a downward trend. When consultants held brief daily meetings with the teachers to discuss the intervention, implementation improved for 2 of 5 participants. Four of the teachers implemented the intervention at levels substantially above baseline during the performance feedback condition, whereas implementation for 1 teacher increased following discussion of an upcoming follow-up meeting with the principal. Student reading comprehension scores improved markedly during the peer tutoring intervention. Three students maintained these gains 4 weeks after the intervention ended. The implications of these findings for the maintenance of accurate treatment implementation in applied settings are discussed.

Adult↗

PubMedDate not supplied

Diffusion of innovations in schools: a study of adoption and implementation of school-based tobacco prevention curricula.

PURPOSE: The purpose of this study was to determine the extent of implementation of school health education curricula, to identify factors which enhanced or impeded implementation, and to examine the link between the adoption and implementation phases of the diffusion process. DESIGN: The study used an experimental design; 22 school districts were randomly assigned to intervention and control conditions. SETTING: The study was conducted in North Carolina. SUBJECTS: All teachers in the study districts identified by their schools as "eligible to teach health" were included in the sample. INTERVENTION: An in-depth training was conducted on the use of the middle school tobacco prevention curriculum that had been adopted. MEASURES: Three measures were used to assess implementation of the curricula. Independent variables of interest included organizational size and climate, teacher training, how long it took to make the adoption decision, and attitudes toward tobacco use prevention curricula. Response rates for these measures ranged from 44% to 78%. RESULTS: Nonparametric correlations and regression modeling indicated that larger organizational size and teacher training were the strongest predictors of curricula implementation. A favorable organizational climate within school districts also improved implementation. CONCLUSIONS: While interventions to increase adoption of school health education curricula should focus on larger school districts, the majority of efforts to improve implementation should focus on smaller districts.

Adolescent↗