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PubMedDate not supplied

Wrap-around services: an analysis of community-based mental health services for children.

TOPIC: Wrap-around services-individualized, community-based mental health services for children in their homes and schools-for children with severe emotional and behavioral disorders. PURPOSE: To conduct an analysis of the social policy antecedents that culminated in wrap-around services in one state and consider the development of one state's implementation and relevant value issues. SOURCES: Policy and historical literature; the first author's experience as a director of a large wrap-around program. CONCLUSIONS: While the advent of wrap-around services and the expansion of Medicaid represent significant steps forward in the treatment of children with mental health problems, outcome studies of these services are sorely needed.

Affective Symptoms↗
PubMed2000

The creation of strategic alliances: the experience of the London Health Sciences Centre and southwestern Ontario.

This article describes the framework and strategies that the London Health Sciences Centre has developed to foster trusting and collaborative relationships with its regional partners in Southwestern Ontario. A four-phase approach was used to identify, implement and evaluate system-wide opportunities to improve the integration of clinical care in Southwestern Ontario. Specific case studies are illustrated that used this framework to improve both access to patient services and length of stay, while positively affecting operating resources.

Academic Medical Centers↗
PubMed1995

[Modification of rehabilitation possibilities by psychiatric disorders. Concepts and explanations in implementing section 35 of the child and adolescent welfare regulation].

Giving integration assistance to children and youths whose chances of integration are longterm impaired due to the effects of mental disturbances require that the helping systems involved--especially the youth aid of children and youth psychiatrics (as a part of the health services)--cooperate. This presupposes that the terms and procedures have been clarified as discussed in this article.

Adolescent↗
PubMedDate not supplied

Challenges to intervention implementation: lessons learned in the Bathing Persons with Alzheimer's Disease at Home study.

BACKGROUND: The pressing need for interventions to improve outcomes for vulnerable caregivers of individuals with Alzheimer's disease (AD) is hindered by inadequate knowledge of variables affecting intervention delivery, receipt, and enactment. OBJECTIVE: To analyze intervention implementation issues encountered within the Bathing Persons with Alzheimer's Disease at Home (BATH) study. METHODS: The BATH study, a home-based, randomized, controlled trial of interventions to improve behavioral symptoms and caregiver self-efficacy, consisted of 130 intervention visits to 42 care recipients-caregiver dyads. Data include direct observation, nurse interventionist field notes, case analyses, and caregiver journals, reflecting various perspectives. Content analysis was used to identify key treatment process themes. RESULTS: Issues that affected the delivery, receipt, and enactment of interventions reflect the intersection of in vivo caregiving and research design. DISCUSSION: The primary lessons learned were: (a) early identification of caring dyads prior to crisis must be improved; (b) in vivo observation is essential to individualized interventions targeting behavioral etiologies and developing caregiver skills; (c) intervention delivery depends on the nurse interventionist's skills and a flexible, trusting researcher-dyad relationship; (d) complex caregiver situations affect treatment receipt and enactment; and (e) intervention enactment requires coaching, practice, and support over time. These findings help to explain issues impacting intervention implementation to a vulnerable population. Recommendations for intervention research design to maximize internal and external validity in real-life care contexts can inform future outcome studies, aid in the search for improved care, and lead to supportive public policy for families living with AD.

Adult↗
PubMed2002

[Quality management and experiences with the "cancer center"].

BACKGROUND: The goal of quality management in oncology is to achieve the best possible therapeutic outcome. Improved diagnostic methods, more sophisticated therapies in various fields of specialisation and the increased implementation of multimodal therapies have led to considerable advances in the treatment of certain tumors in recent years. However, these advances depend on an interdisciplinary approach necessitating an increased division of labour. These in turn, because of the more complex organizational requirements within hospitals, make greater demands on quality management. METHODS: In October 1999 first steps were taken in the Klinikum rechts der Isar der TU München to organisationally integrate the various institutions involved in the treatment of patients with gastro-intestinal tumors. All the oncologic competence available was bundled in a Cancer Center thus creating the structural prerequisites for interdisciplinary quality management. A daily multidisciplinary Tumor Board, a computer-supported interdisciplinary information and communications system, an interdisciplinary Disease Management Team, an outpatients department and a study centre were all called into life. RESULTS: By the time the outpatients department went into service in November 2001 all the other structural innovations underlying interdisciplinary quality management had already been implemented. Since October 1999 2438 patients had been presented to the Tumor Board, 74% of them with primarily curative intent. CONCLUSIONS: The disease-oriented structure of the Cancer Center has proved worthwhile. The impact of the structure on the quality of processes and results, however, has yet to be evaluated.

Ambulatory Care↗
PubMed2006

Models, strategies, and tools. Theory in implementing evidence-based findings into health care practice.

This paper presents a case for careful consideration of theory in planning to implement evidence-based practices into clinical care. As described, theory should be tightly linked to strategic planning through careful choice or creation of an implementation framework. Strategies should be linked to specific interventions and/or intervention components to be implemented, and the choice of tools should match the interventions and overall strategy, linking back to the original theory and framework. The thesis advanced is that in most studies where there is an attempt to implement planned change in clinical processes, theory is used loosely. An example of linking theory to intervention design is presented from a Mental Health Quality Enhancement Research Initiative effort to increase appropriate use of antipsychotic medication among patients with schizophrenia in the Veterans Health Administration.

Antipsychotic Agents↗
PubMed2003

Evaluation, development, and implementation of potentially better practices in neonatal intensive care nutrition.

OBJECTIVE: The desire for evidence-based clinical guidelines for nutritional support of the preterm infant has been identified. Published evidence has not yielded clear guidelines about the best method of delivery, substrate use, or appropriate outcome measure to evaluate nutrition support. In addition, reports on research of nutrition support often fail to give the most rudimentary process necessary to improve quality in various unit settings. METHODS: The Vermont Oxford Network "Got Milk" focus group developed eight potentially better practices for nutrition support, implementation strategies for these practices, and a comprehensive appraisal process to measure nutrition outcome in preterm infants. RESULTS: After implementation of the potentially better practices, all participating institutions showed earlier initiation of nutrition support, earlier attainment of adequate energy intakes, reduced delay in reaching full enteral feeds, more consistent nutrition support practice, decreased length of stay, cost savings, and improved growth at time of discharge. CONCLUSIONS: Development and implementation of evidence-based better nutrition support practices in neonates led to improved nutrient intake and growth with reduced length of stay and related costs. Consistent, comprehensive, multidisciplinary appraisal of practice is an integral component of improving nutrition outcomes in the neonatal population.

Benchmarking↗
PubMedDate not supplied

Implementing a comprehensive child restraint program in a pediatric hospital: an effective model.

Motor vehicle crashes remain a leading cause of death and injury to young children. Appropriate child safety seats and child safety restraints can provide life-saving protection to children riding in motor vehicles. Many children, however, travel unrestrained or improperly restrained. Consideration of appropriate child safety restraint systems for children is an important aspect of discharge planning and can provide families with the means to prevent unintentional injuries and deaths resulting from motor vehicle crashes.

Child↗
PubMed2001

Introduction of the new Centers for Disease Control and Prevention group B streptococcal prevention guideline at a large West Coast health maintenance organization.

OBJECTIVE: Our purpose was to assess the impact of new consensus guidelines issued by the Centers for Disease Control and Prevention, The American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics to prevent perinatal group B streptococcal disease. STUDY DESIGN: We performed a descriptive analysis and a before-and-after analysis of implementation of the group B streptococcal disease prevention guidelines among singleton-birth pregnancies in 2 Group Health Cooperative hospitals from October 1, 1995, through December 31, 1997. We studied the speed and completeness of implementation and the effect on pregnancy care practices including intrapartum antibiotic use, test ordering, and maternal and neonatal health. RESULTS: Guideline implementation occurred rapidly. The proportion of term pregnancies screened according to the guideline increased markedly, and overall intrapartum antibiotic use more than doubled. Among group B streptococci-positive women, intrapartum antibiotic prophylaxis increased from 24% before to 74% after guideline implementation. Median duration of treatment before delivery increased from 1.8 to 4.3 hours. The rate of rash did not increase, and there were no cases of anaphylaxis or pseudomembranous colitis. The proportion of infants undergoing evaluation decreased after implementation of the neonatal guidelines; among infants of group B streptococci-negative women, test ordering dropped by almost 40%. CONCLUSIONS: Implementation of the new guidelines is feasible and can be accomplished rapidly. The guidelines were associated with increased maternal intrapartum antibiotic use, particularly among women at highest risk, and with a decrease in laboratory use for infants.

Adult↗
PubMed2001

The benefit of implementing a heart failure disease management program.

BACKGROUND: To handle the increasing complexity of congestive heart failure (CHF) care, several new models for the care of patients with CHF have been developed to replace traditional strategies. We undertook this study to evaluate the potential benefit of implementing a CHF disease management program at a tertiary care center, particularly in terms of beta-blocker use and cost to the health care system. METHODS: After reviewing the literature regarding therapies and management strategies for patients with CHF, we developed the Duke Heart Failure Program. All enrolled patients had 1 of the following: recent CHF hospitalization, ejection fraction less than 20%, or symptoms consistent with New York Heart Association class III or IV. We compared preenrollment and postenrollment medication use and resource utilization. RESULTS: We enrolled 117 patients from July 1998 to April 1999. Mean enrollment time was 4.7 months. beta-Blocker use and dose significantly increased (52% vs 76% for beta-blocker, P<.01; 6% vs 13% of target dose, P<.01). The hospitalization rate decreased (1.5 vs 0 hospitalizations per patient-year, P<.01), while the number of clinic visits increased (4.3 vs 9.8 clinic visits per patient-year, P<.01). The Duke University Health System saved a median of $8571 per patient-year. CONCLUSIONS: Implementing a CHF disease management program was associated with improved CHF medication dosing and with decreased hospitalization for patients with CHF. A CHF disease management program is an effective method for a health care system to care for patients with CHF.

Adrenergic beta-Antagonists↗
PubMed2004

[Experiences and difficulties in implementing immunization registries in Saxony-Anhalt].

In the German Federal State of Saxony-Anhalt, the Health Department must be notified of vaccines administered to children <7 years of age including their names. The goal of this mandatory notification is to improve and stabilize the age-appropriate vaccination coverage. However, difficulties have been encountered in implementing mandatory notification. Therefore, the Health Departments of Magdeburg and Halle have launched a model project focusing on analysing and eliminating these problems. Mandatory notification requires parents' approval, endorsement of vaccantors, and availability of human and technicely resources in the Health Department. An enquiry among paediatricians and family doctors in private practice revealed widespread reservations about mandatory notification because of privacy issues related to data and legal protection. Furthermore, family doctors believed that parents disapproved of notification by name. However, a survey among young mothers revealed this not to be the case. Winning young mothers' approval depends largely on the positive attitude of the vaccinators. To implement the mandatory notification of vaccinations to the Health Department, it is necessary to dispel physicians' concerns and to inform young parents about the practical benefits. However, this places high demands on the Health Departments for maintaining immunization registries, communicating with physicians and notifying parents when immunisations are due or late.

Adult↗
PubMed1995

Implementation of a criteria-based antimicrobial formulary system.

The development of a criteria-based antimicrobial formulary system for use in a 432-bed university-based tertiary-care hospital is described. A subcommittee of the hospital's pharmacy and therapeutics committee developed prescribing criteria for antimicrobials thought to have a specific place in the treatment of various infections. The criteria were based primarily on patient needs, but when two therapies were thought to have similar effectiveness and similar toxicity profiles, cost became the deciding factor in drug selection. Educational packets were designed to assist physicians in prescribing criteria-based antimicrobials. An antimicrobial order form was also developed. The program was implemented after an extensive orientation and education period; data on antimicrobial use were collected for the first year of the program. Hospitalwide compliance with the criteria was 89%, although compliance in certain departments was poorer. The database was formulated to be both service- and physician-specific for the purposes of reporting and education.

Anti-Infective Agents↗
PubMed2006

Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC's emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement. OBJECTIVE: To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO. DESIGN: Six Sigma Project with pre-post design. PARTICIPANTS: Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals. MEASUREMENTS: Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire. RESULTS: Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products. CONCLUSIONS: The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC's evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.

Centers for Disease Control and Prevention, U.S.↗
PubMed2004

Bethesda 2001 implementation and reporting rates: 2003 practices of participants in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology.

CONTEXT: The 2001 Bethesda System for the reporting of cervical cytology specimens and the use of new liquid-based and human papillomavirus testing technologies have led to changes in cervical cytology reporting practices. OBJECTIVES: To analyze current laboratory reporting practices using Bethesda 2001 terminology and to compare results with previous survey data from 1996. DESIGN: Questionnaire survey mailed to 1751 laboratories in mid-2003. PARTICIPANTS: Laboratories enrolled in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology. RESULTS: Of the 759 responding laboratories, most (85.5%) had implemented Bethesda 2001 terminology, and the majority had adopted major changes, such as elimination of the benign cellular changes category and the satisfactory but limited category. The median reporting rate for low-grade squamous intraepithelial lesion was 2.1%, compared to a 1996 median rate of 1.6%, but the increase was confined to liquid-based preparations. Reporting rates for high-grade squamous intraepithelial lesion (median, 0.5%) and atypical squamous cells (ASC) had changed little. Most ASC cases were subclassified as "undetermined significance" (median, 3.9%) with ASC, cannot exclude high-grade SIL accounting for a minority (median, 0.2%). The median ratio of ASC to squamous intraepithelial lesions and carcinomas (SIL+) was 1.4 and was lower than the 1996 median ratio of 2.0. Median reporting rates for squamous abnormalities for 2002 were noted to be significantly higher for liquid-based preparations than for conventional smears, while median ASC/SIL+ ratios were lower. Most laboratories offer human papillomavirus testing, but almost half (47%) of laboratories do not know the percentage of positive testing results in patients with ASC. CONCLUSIONS: Most laboratories have implemented Bethesda 2001 terminology. New criteria and liquid-based methods have led to an increase in low-grade squamous intraepithelial lesion reporting rates and a decrease in ASC/ SIL+ ratios when compared with 1996 data. Liquid-based preparations have higher median squamous intraepithelial lesion rates and lower ASC/SIL+ ratios than conventional smears.

Cervix Uteri↗
PubMed2003

Update on population-based preconception and prenatal cystic fibrosis carrier screening.

Implementation of population-based cystic fibrosis (CF) carrier screening for all preconception and prenatal patients has encountered numerous challenges. Continuing education of the practitioner and patient is critical for ensuring the successful implementation of CF population-based carrier screening as well as other anticipated population-based molecular screening tests resulting from the completion of the Human Genome Project. To assist the practitioner, this article provides a brief review of cystic fibrosis genetics, the recommended screening guidelines and benefits of carrier screening, in addition to highlighting clinical dilemmas that have arisen since widespread CF carrier screening was initiated.

Cystic Fibrosis↗
PubMed2000

Implementation of risk adjustment for Medicare.

The Health Care Financing Administration (HCFA) implemented risk adjustment for Medicare capitated organizations January 2000. The risk adjustment system used, the Principal Inpatient Diagnostic Cost Group (PIPDCG) method, had to be incorporated into the payment structure mandated by the Balanced Budget Act of 1997 (BBA). This article describes how risk adjustment was integrated into the payment system within the rules of the BBA, and how fee-for-service (FFS) and health maintenance organization (HMO) data are collected and used in the determination of payment.

Adolescent↗
PubMed2004

The feasibility of universal influenza vaccination for infants and toddlers.

BACKGROUND: Physicians' opinions on the feasibility of routine influenza vaccination of infants and toddlers are unknown. OBJECTIVE: To assess the opinions of primary care providers regarding (1) the feasibility of an expanded influenza vaccination recommendation, (2) potential barriers, and (3) current and projected use of immunization reminder systems for influenza vaccination. METHODS: In February 2001, we mailed a 20-item, self-administered survey to a national random sample of pediatricians and family physicians (FPs). The survey primarily focused on a scenario of routine influenza vaccination for children aged 12 through 35 months using either injected or intranasal spray vaccine. RESULTS: Four hundred fifty-eight eligible physicians completed the survey (eligible response rate: pediatricians, 72%; FPs, 52%). Regarding the scenario mentioned above, most physicians agreed that implementation would be feasible (pediatricians, 80%; FPs, 69%); would significantly decrease illness visits during influenza season (pediatricians, 67%; FPs, 57%); and was justified by influenza's severity and complications (pediatricians, 61%; FPs, 41%). When considering a scenario that extended down to 6 months of age and only allowed use of injectable vaccine for infants, fewer physicians (pediatricians, 50%; FPs, 40%) considered implementation feasible. The issues most frequently cited as important potential barriers for practices were costs (77%), vaccine safety issues (52%), and the inability to identify eligible children (46%). CONCLUSION: To make widespread implementation feasible, the following are needed: minimizing costs for families and physician practices, educational campaigns on key issues, and primary care system changes (eg, tracking of eligible children, reminder and/or recall systems, and immunization clinics).

Appointments and Schedules↗
PubMed2005

Active error management: use of a Web-based reporting system to support patient safety initiatives.

The authors examine the implementation of a Web-based reporting system in a rural academic medical center to support patient safety initiatives. Discussion centers on how an online support system can support active error management and help identify latent errors. This strategy can help administrators in their efforts to develop and institute improvements to prevent subsequent errors. By making changes in clinical process and refinement in policies and procedures, administrators can uncover trends and patterns across settings.

Health Plan Implementation↗