Abstract
Background: Patient records should both transfer and create knowledge about patients and their health care. A standardized care plan could be a way to implement evidence-based care directly in practice and improve the documentation in patient records. The aim of this study is to investigate and compare the development and implementation process of a standardized care plan in hospital and primary health care. A further aim is to evaluate the effects on the quality of documentation and the care given in two contexts. Methods and Analysis: Realistic evaluation will be used as a framework to investigate the implementation process. According to this framework, possible contexts, mechanisms, and outcomes in the study will be considered. The study will be performed in two contexts: an orthopedic clinic and primary health care centers. In both contexts, the two key mechanisms will be the same: the implementation process will be driven by internal facilitators (practitioners at the units) and the process will be guided by the Rules and Regulations for interoperability in the Health and Social Care specification, “National information structure for standardized care plans”. Two outcomes of the study will be studied: to investigate the development and implementation process by an evaluation of fidelity and to evaluate how a standardized care plan affects the quality of documentation and the use of evidence-based care. Discussion: Implementation of the SCP will probably meet the same resistance as implementation of guidelines. Documentation of care is an important but resource-consuming requirement in health care, a more standardized method of documenting is requested by health professionals. This project can provide insight into the complex process of developing and implement an SCP in different contexts, which will be useful in further implementation processes.
Highlights
To implement evidence-based knowledge in health care is a responsibility and a challenge [1,2,3]
The aim of this study is to investigate and compare the development and implementation process of standardized care plan (SCP) in hospital and primary health care
Electronic patient record will be collected during a 3-month period before the start of the project and for a 3-month period 1 year after the SCP has been implemented in the electronic record
Summary
To implement evidence-based knowledge in health care is a responsibility and a challenge [1,2,3]. Reasons for the defective use of guidelines can be poor knowledge, lack of information, lack of personal experience, lack of feedback, lack of leadership, and/or lack of a culture to improve care [7] Patient records should both transfer and create knowledge about patients and their health care. Two outcomes of the study will be studied: to investigate the development and implementation process by an evaluation of fidelity and to evaluate how a standardized care plan affects the quality of documentation and the use of evidence-based care. Documentation of care is an important but resource-consuming requirement in health care, a more standardized method of documenting is requested by health professionals This project can provide insight into the complex process of developing and implement an SCP in different contexts, which will be useful in further implementation processes
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