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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↗

PubMed2006

Rapid implementation of therapeutic hypothermia in comatose out-of-hospital cardiac arrest survivors.

BACKGROUND: The implementation of therapeutic hypothermia (TH) into daily clinical practice appears to be slow. We present our experiences with rapid implementation of a simple protocol for TH in comatose out-of-hospital cardiac arrest (OHCA) survivors. METHODS: From June 2002, we started cooling pre-hospitally with sport ice packs in the groin and over the neck. In the intensive care unit (ICU), we used ice-water soaked towels over the torso. All patients were endotracheally intubated, on mechanical ventilation and sedated and paralysed. The target temperature was 33 +/- 1 degrees C to be maintained for 12-24 h. We used simple inclusion criteria: (i) no response to verbal command during the ambulance transport independent of initial rhythm and cause of CA; (ii) age 18-80 years; and (iii) absence of cardiogenic shock (SBP < 90 mmHg despite vasopressors). We compared the first 27 comatose survivors with a presumed cardiac origin of their OHCA with 34 historic controls treated just before implementation. RESULTS: TH was initiated in all 27 eligible patients. The target temperature was reached in 24 patients (89% success rate). ICU- and hospital- length of stay did not differ significantly before and after implementation of TH. Hypokalemia (P= 0.001) and insulin resistance (P= 0.025) were more common and seizures (P= 0.01) less frequently reported with the use of TH. The implementation of TH was associated with a higher hospital survival rate (16/27; 59% vs. 11/34; 32%, respectively; P< or = 0.05). Our results indicate a population-based need of approximately seven cooling patients per 100,000 person-years served. CONCLUSION: Our simple, external cooling protocol can be implemented overnight in any system already treating post-resuscitation patients. It was well accepted, feasible and safe, but not optimal in terms of cooling rate. Neither safety concerns nor costs should be a barrier for implementation of TH.

Adult↗

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↗

PubMed1992

Closing institutions in New York State: implementation and management lessons.

This article examines the lessons learned about implementation and management from the closing of six large institutions for people with mental retardation in New York State. Unanticipated problems occurred, despite special attention to implementation issues in policy design and demonstrated management capacity in similar circumstances. A study of the closure experience showed that subtle but important changes in policy as well as changes in the context of implementation confounded the reasonable expectations of success that policymakers, managers, and analysts would normally have under these circumstances. A closer look, however, suggests that this experience should not be surprising. A more appropriate understanding of the role of policy, policymakers, and managers in implementation suggests that the burden falls heavily on middle managers, and that policy management capacity and an intergovernmental management perspective are crucial to implementation success. Moreover, this experience suggests that a broader definition of success that encompasses this normal turbulence of implementation provides a better appreciation of the requirements of implementation.

Community Mental Health Centers↗

PubMedDate not supplied

Implementation of the electronic medical record: the team approach.

The implementation of the electronic medical record (EMR) is a process that involves knowledge and skills of technology and group dynamics. The literature was reviewed to identify the most effective methodology for EMR implementation. Integral to the success of any EMR implementation is the 'buy-in' of the organization. To facilitate the implementation the use of a tiered team approach is advantageous. There must be an executive steering team whose role is to provide the vision, the approval, and the money for the project. The project steering team makes major policy decisions based on user needs and requirements, organization infrastructure, and general implementation strategies. The project work team has the responsibility of ensuring the implementation is satisfactory to the organization. This article discusses the membership, roles, and functions of the three EMR implementation teams.

Decision Making, Organizational↗

PubMed2004

Electronic curriculum implementation at North American dental schools.

Electronic curriculum, or E-curriculum, refers to computer-based learning including educational materials available on CD or DVD, online courses, electronic mechanisms to search the literature, email, and various applications of instructional technology including providing laptops to students, multimedia projection systems, and Internet-compatible classrooms. In spite of enthusiasm about the potential for E-curriculum to enhance dental education, there is minimal guidance in the literature to assist schools with implementation. The study objectives were: 1) identify U.S. and Canadian dental schools that have initiated mandatory laptop programs and assess cost, faculty development issues, extent of curricular use, problems, and qualitative perceptions; 2) determine the extent to which twenty-two other E-curriculum resources were available and used at North American dental schools; and 3) identify factors that influenced E-curriculum implementation. A twenty-six item questionnaire, known as the Electronic Curriculum Implementation Survey (ECIS), was mailed to all sixty-six North American dental schools (ten Canadian and fifty-six U.S. schools) during 2002-03 with a response rate of 100 percent. Twenty-five of the twenty-six ECIS questions employed a menu-driven, forced choice format, but respondents could provide amplifying comments. Fifty-three questionnaires were completed by associate deans for academic affairs, three by deans, and ten by instructional technology (IT) managers, IT committee chairs, or directors of dental informatics departments. The survey found that E-curriculum implementation among North American dental schools is following the classic innovation pattern in which a few early adopting institutions proceed rapidly while the majority of potential adopters make modifications slowly. Fourteen U.S. dental schools have established mandatory laptop programs for students. Ten of these laptop programs were created in the past two years; respondents reported numerous growing pains but were generally pleased with their progress. Other E-curriculum capabilities were incorporated into courses more frequently at laptop schools than the fifty-two non-laptop schools including websites, online course evaluations, and instructor use of email to communicate with students. Few dental schools use online courses, and at most schools, few faculty have received training in online instructional techniques. Virtually all North American dental schools have provided substantial instructional technology resources to their faculty, but use of twenty-two components and capabilities of E-curriculum was limited, especially at schools without laptop programs. Various faculty-related issues were reported as implementation barriers including lack of time, skill, and incentive to develop educational software. We conclude that many North American dental schools, especially those with laptop programs, are functioning at the "learn by doing" phase of initial implementation in a four-stage innovation adoption model. E-curriculum planners should pay close attention to implementation problems that occur at this stage where many innovation efforts break down.

Canada↗

PubMed2004

Variation in implementation and use of computerized clinical reminders in an integrated healthcare system.

OBJECTIVES: To identify patterns of use of computerized clinical reminders (CCRs) across an integrated healthcare system and describe institutional factors associated with their implementation. STUDY DESIGN: Cross-sectional study. METHODS: At a national electronic health record (EHR) meeting, we surveyed 261 participants from 104 Veterans Health Administration (VHA) healthcare facilities regarding the number and types of CCRs available at each facility. Potential explanatory measures included perceived utility and ease of use of CCRs, training and personnel support for computer use, EHR functionalities, and performance data feedback to providers at each facility. RESULTS: The number of conditions with CCRs in use at a facility ranged from 1 to 15; most reported implementation of reminders for 10 of the 15 conditions surveyed. The most commonly implemented CCRs, used in more than 85% of facilities, were for conditions with VHA national performance measures (eg, tobacco cessation, immunizations, diabetes mellitus). The least commonly implemented CCRs were for post-deployment health evaluation and management, medically unexplained symptoms, and erectile dysfunction. Facilities that had implemented greater numbers of clinical reminders had providers who reported greater ease of use and utility of the reminders (P= .01). CONCLUSIONS: VHA facilities vary markedly in their implementation of CCRs. This effect may be partly explained by greater incorporation of clinical reminders for conditions with performance measures. Further study is needed to determine how to best implement clinical reminders and the institutional factors important in their use.

Attitude of Health Personnel↗

PubMed1995

Assessing the impact of continuous quality improvement/total quality management: concept versus implementation.

OBJECTIVE: This study examines the relationships among organizational culture, quality improvement processes and selected outcomes for a sample of up to 61 U. S. hospitals. DATA SOURCES AND STUDY SETTING: Primary data were collected from 61 U. S. hospitals (located primarily in the midwest and the west) on measures related to continuous quality improvement/total quality management (CQI/TQM), organizational culture, implementation approaches, and degree of quality improvement implementation based on the Baldrige Award criteria. These data were combined with independently collected data on perceived impact and objective measures of clinical efficiency (i.e., charges and length of stay) for six clinical conditions. STUDY DESIGN: The study involved cross-sectional examination of the named relationships. DATA COLLECTION/EXTRACTION METHODS: Reliable and valid scales for the organizational culture and quality improvement implementation measures were developed based on responses from over 7,000 individuals across the 61 hospitals with an overall completion rate of 72 percent. Independent data on perceived impact were collected from a national survey and independent data on clinical efficiency from a companion study of managed care. PRINCIPAL FINDINGS: A participative, flexible, risk-taking organizational culture was significantly related to quality improvement implementation. Quality improvement implementation, in turn, was positively associated with greater perceived patient outcomes and human resource development. Larger-size hospitals experienced lower clinical efficiency with regard to higher charges and higher length of stay, due in part to having more bureaucratic and hierarchical cultures that serve as a barrier to quality improvement implementation. CONCLUSIONS: What really matters is whether or not a hospital has a culture that supports quality improvement work and an approach that encourages flexible implementation. Larger-size hospitals face more difficult challenges in this regard.

Cross-Sectional Studies↗