Evidence-based Practice Change Research Articles

Evaluating hospital quiet time from engineering, medical, and nursing perspectives

A healthy hospital soundscape is crucial to promote healing for patients and a healthy workplace for staff. Unfortunately, the occupant-generated sounds, building systems, and medical equipment required to care for patients can create high noise levels. Rising concern has led to an increase in hospital noise studies exploring noise reduction strategies. One major issue is the gap existing between the acoustical and medical contributions necessary to solving the problem. This talk will document how our team is focusing on bridging that gap through the interdisciplinary collaboration of individuals from architectural engineering, medicine, nursing, psychology, and statistics. The project includes an 18-month longitudinal study aiming to improve Neonatal Intensive Care Unit (NICU) soundscapes through the implementation of a Quiet Time (QT) evidence-based practice change. Detailed acoustic measurements and staff surveys were collected to document the objective and subjective effects of QT. The acoustical impact of QT on the soundscape and its occupants is currently being explored through the engineering and medical perspectives. In ongoing phases, infant physiological data are being analyzed to understand the infants’ response to the altered soundscape resulting from QT. The collaborative efforts required to plan, execute, and evaluate this type of interdisciplinary study will be discussed.

(269) Children's Comfort Promise; successfully implementing an evidence based pain protocol for needle procedures throughout a large children's hospital and clinic system

Evidence supports the use of, topical anesthetic, comfort positioning, distraction techniques, and sucrose or breastfeeding to minimize pain for pediatric needle procedures. Despite the availability of knowledge and resources, however, most hospitals and clinicians do not utilize these methods routinely. The aim of this quality improvement initiative was to translate the current evidence around pain management for needle procedures into standard clinical practice. In a single-day, hospital-wide survey at our organization, patients and families identified needle procedures as the worst pain they experienced. We used this data to target initial quality improvement efforts in the outpatient phlebotomy setting, where a small number of staff performs needle procedures on 30,000 children per year. Compliance goals were set at 95% for offering the four strategies with appropriate education. After 10 months we had successfully implemented and sustained these evidence based practice changes. The same standards were then implemented throughout the organization, with direct participation from front line staff in each are in creating and planning the implementation process. Within the first three months of implementation several clinical areas demonstrated compliance with the new standard in the range of 80-100%. With strong leadership support and engagement from staff, barriers were identified and eliminated, making it easier for staff to follow the new standard. Despite initial concerns from staff, patient wait times and procedure time did not increase. Further, patient satisfaction around pain increased 1.6 % from first to second quarter 2015, as measured by NRC Picker. In sum, organizational change is difficult, but by using quality improvement methodology, we were able to change practice and culture organization-wide. Next steps will include expanding our methodology to other pediatric hospitals through grant funding, and developing a tool kit to assist them in establishing an evidence-based pain protocol for needle procedures. National Research Corporation, 2015.

Abstract IA27: NCORP cancer care delivery research: A new opportunity for studying cancer disparities

Abstract Limitations in the availability and quality of cancer care have been associated with poor outcomes in medically underserved populations, independent of any biological factors. Differential access and care variation have been documented for many types of cancer and in all phases of care from screening through end-of-life. Patient-level interventions have had a modest impact on cancer disparities that arise in the process of care delivery. Challenges to further understanding and addressing care disparities include reliance on secondary use of data collected for other purposes (e.g., SEER-Medicare) and primary data collection in settings not reflective of the community (e.g., integrated delivery systems). The NCI Community Oncology Research Program (NCORP) integrates a cancer care delivery component offering a new opportunity to study cancer disparities. Cancer care delivery research is defined as the development of “new and generalizable knowledge about the effectiveness, acceptability, cost, optimal delivery mode, active ingredients, and causal mechanisms that influence outcomes and affect the value of cancer care, across diverse settings and populations” (Kent EE et al. J Clin Oncol 2015; 33:2705-11). The ultimate goal is “evidence-based practice change [that will] improve clinical outcomes, enhance patient experiences, and optimize value” (Kent et al.). As is the case for all NCORP efforts, cancer care delivery research considers issues of the medically underserved, particularly racial/ethnic minorities and rural residents, a particular focus. This presentation will describe cancer care delivery research and provide examples of cancer care disparities research that could be conducted within NCORP. Citation Format: Ann M. Geiger. NCORP cancer care delivery research: A new opportunity for studying cancer disparities. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr IA27.

Reduction of Catheter-Associated Urinary Tract Infections Through the Use of an Evidence-Based Nursing Algorithm and the Implementation of Shift Nursing Rounds: A Quality Improvement Project.

Catheter-associated urinary tract infections (CAUTIs) are the most common hospital-acquired infections. The purpose of this quality improvement (QI) project was to successfully implement a nurse-led evidence-based practice change designed to reduce CAUTIs in a cardiac intensive care and step-down unit. The QI project was implemented using a convenience sample of patients admitted to the cardiac intensive care and step-down unit.Evaluation data were collected 3 months preimplementation and 9 months postimplementation. We used Wick's Check-Plan-Do-Check-Act model of continuous QI to guide the project. A statistically significant change in the number of CAUTIs (P = .009) and CAUTI occurrences (P = .005) was observed following the intervention. The number of indwelling catheter days and indwelling catheter utilization did not significantly differ following implementation of the intervention. Nurse compliance with the intervention was computed for each month; the average compliance rate was 91%. Findings from this project indicate that a nurse-led evidence-based practice project exerted a positive influence on CAUTI occurrences.

Graves' Disease Pharmacotherapy in Women of Reproductive Age.

Graves' disease is an autoimmune disorder in which inappropriate stimulation of the thyroid gland results in unregulated secretion of thyroid hormones resulting in hyperthyroidism. Graves' disease is the most common cause of autoimmune hyperthyroidism during pregnancy. Treatment options for Graves' disease include thioamide therapy, partial or total thyroidectomy, and radioactive iodine. In this article, we review guideline recommendations for Graves' disease treatment in women of reproductive age including the recent guideline from the American College of Obstetricians and Gynecologists. Controversy regarding appropriate thioamide therapy before, during, and after pregnancy is reviewed. Surgical and radioactive iodine therapy considerations in this patient population are also reviewed. In patients who may find themselves pregnant during therapy or develop Graves' disease during their pregnancy, consideration should be given to the most appropriate treatment course for the mother and fetus. Thioamide therapy should be used with either propylthiouracil or methimazole at appropriate doses that target the upper range of normal to slightly hyperthyroid to avoid creating hypothyroidism in the fetus. Consideration should also be given to the adverse effects of thioamide, such as agranulocytosis and hepatotoxicity, with appropriate patient consultation regarding signs and symptoms. Individuals who wish to breastfeed their infants while taking thioamide should receive the lowest effective dose. Surgery should be reserved for extreme cases and limited to the second trimester, if possible. Radioactive iodine therapy may be used in nonpregnant individuals, with limited harm to future fertility. Radioactive iodine therapy should be withheld in pregnant women and those who are actively breastfeeding. Clinicians should keep abreast of developments in clinical trials and evidence-based recommendations regarding Graves' disease in reproductive-age women for any changes in evidence-based practice.

Educational Intervention for an Evidence-Based Nursing Practice of Skin-to-Skin Contact at Birth.

This article presents the development and evaluation of an educational intervention aiming at an evidence-based practice of skin-to-skin contact at birth among nurses of a maternity care unit. Based on the Iowa Model of Evidence-Based Practice to Promote Quality Care, four educational sessions were developed according to an active-learning pedagogy. Even if the nurses' practice did not fully meet the recommendations for skin-to-skin contact, a pre- and postintervention evaluation showed some positive results, such as a longer duration of skin-to-skin contact immediately after birth, delivery of some routine care directly on mothers' chest, and improved parent education. The educational intervention seems to have enacted some evidence-based nursing practice changes regarding skin-to-skin contact at birth.

Readiness for practice change: Evaluation of a tool for the Australian midwifery context.

Midwifery is a research-informed profession with a mandated requirement to utilise latest best evidence. It is now recognised, however, that the introduction of new evidence into practice is complicated and uncertain. Growing awareness of this fact has led to the establishment of a new discipline, Implementation Science (IS), which is focused on developing ways to expedite the timely movement of evidence into practice. To date though, the wider midwifery profession has yet to make use of IS change-facilitation tools and methods. The aim of this study was to determine the fitness for use in midwifery of one established IS tool: the UK NHS Spread & Adoption tool, which is designed to enable clinicians to assess their organisational context for change readiness. A qualitative descriptive methodology was used for this study, which was set in two Australian states. Focus groups were used to collect data. The sample comprised ten Australian change-leader midwifery teams who had led evidence-based practice change initiatives in the previous 12 months. Three themes emerged from the data which together convey that although poor internet access was problematic for some, and some of the language was found to be inappropriate, the tool was ultimately viewed as very useful for helping the implementation of practice change in midwifery settings. This study provides valuable information about the broad suitability of the tested tool for Australian midwifery settings. Further research is required to evaluate a revised version.

Initiating the use of non-invasive respiratory support following delivery of 27–30 week gestation infants in a Level III NICU

Historically it has been common practice to intubate and give surfactant to extremely premature infants. The most recent evidence-based literature has shown this practice results in similar outcomes to infants treated with non-invasive respiratory support (NIRS) with selective surfactant administration following delivery. The need for an evidence-based practice change was identified at Integris Baptist Medical Center-Neonatal Intensive Care Unit (IBMC-NICU) and steps taken to implement new practice following the delivery of extremely premature infants. To date seventeen infants have been managed with the new practice in place. The new practice has resulted in a culture change in the unit leading to more evidence-based changes.

Measuring quiet time in neonatal intensive care units

The soundscape of critical care wards such as Neonatal Intensive Care Units (NICUs) are of particular concern due to the extremely sensitive nature of the patient population. NICUs must be conducive to providing care that enables infants to adapt to the extrauterine world without undue environmental stressors. Although the American Academy of Pediatrics (AAP) and others have set recommended noise limits in the NICU, studies consistently show units exceeding these standards. More nuanced aspects of NICU noise, such as source type, spectral content, fluctuations, and speech intelligibility are also of concern. A long-term study is being conducted that aims to improve NICU soundscapes, including measuring the impact of a Quiet Time (QT) evidence-based practice change. The study is a unique collaboration between engineering, architecture, nursing, and medicine. Detailed acoustic measurements were taken over a 18-month period to assess the soundscape in pre-QT, short-, mid-, and long-term post QT implementation periods. The study methodologies and results will be discussed, including considerations for the complexities of measuring sound fields in NICUs. Results are being used to identify and evaluate soundscape interventions and therefore advance understanding of how to design, measure, and implement healthy NICU soundscapes.

Methods to Improve the Selection and Tailoring of Implementation Strategies.

Implementing behavioral health interventions is a complicated process. It has been suggested that implementation strategies should be selected and tailored to address the contextual needs of a given change effort; however, there is limited guidance as to how to do this. This article proposes four methods (concept mapping, group model building, conjoint analysis, and intervention mapping) that could be used to match implementation strategies to identified barriers and facilitators for a particular evidence-based practice or process change being implemented in a given setting. Each method is reviewed, examples of their use are provided, and their strengths and weaknesses are discussed. The discussion includes suggestions for future research pertaining to implementation strategies and highlights these methods' relevance to behavioral health services and research.

The implementation of best practice in medication administration across a health network: a multisite evidence-based audit and feedback project.

Medication errors present a significant risk to patient safety. The "rights" of medication administration represent one approach to potentially reducing this risk. The aim of this project was to implement an evidence-based audit and feedback project to improve compliance with best practice in this area across a health network. A baseline audit was conducted to determine compliance with evidence-based standards by trained observers. The results of this audit were analysed and fed back to staff. An analysis of barriers to compliance was undertaken by key staff within the organization, which was followed by the implementation of targeted strategies to improve compliance. A follow-up audit was conducted and the results compared to the baseline audit. There were improvements in the percentage of compliance across all of the eight criteria audited, with statistically significant improvements found in six of the eight. In general, compliance with the criteria was high in both the baseline and follow-up audits. This audit and feedback implementation project was successful in increasing compliance and knowledge in this area and providing future direction for sustaining evidence-based practice change. It is now planned to use this approach for rolling out future implementation projects within this health system.

Facilitating the implementation of evidence-based practice through contextual support and nursing leadership

Background/purposeNurse managers (NMs) play an important role promoting evidence-based practice (EBP) on clinical units within hospitals. However, there is a dearth of research focused on NM perspectives about institutional contextual factors to support the goal of EBP on the clinical unit. The purpose of this article is to identify contextual factors described by NMs to drive change and facilitate EBP at the unit level, comparing and contrasting these perspectives across nursing units.MethodsThis study employed a qualitative descriptive design using interviews with nine NMs who were participating in a large effectiveness study. To stratify the sample, NMs were selected from nursing units designated as high or low performing based on implementation of EBP interventions, scores on the Meyer and Goes research use scale, and fall rates. Descriptive content analysis was used to identify themes that reflect the complex nature of infrastructure described by NMs and contextual influences that supported or hindered their promotion of EBP on the clinical unit.ResultsNMs perceived workplace culture, structure, and resources as facilitators or barriers to empowering nurses under their supervision to use EBP and drive change. A workplace culture that provides clear communication of EBP goals or regulatory changes, direct contact with CEOs, and clear expectations supported NMs in their promotion of EBP on their units. High-performing unit NMs described a structure that included nursing-specific committees, allowing nurses to drive change and EBP from within the unit. NMs from high-performing units were more likely to articulate internal resources, such as quality-monitoring departments, as critical to the implementation of EBP on their units. This study contributes to a deeper understanding of institutional contextual factors that can be used to support NMs in their efforts to drive EBP changes at the unit level.

Daily 2% chlorhexidine gluconate bath wash in a tertiary adult intensive care and high dependency units to reduce risk of hospital acquired multi resistant organisms: a best practice implementation project

Background There is growing evidence that the incidence of hospital acquired multi resistant organisms are increasing worldwide. Intensive care patients are particularly prone to hospital-acquired infections. In an effort to combat increasing nosocomial infections rates within the intensive care/high dependency unit (ICU/HDU) setting, Canberra Hospital has implemented a daily 2% chlorhexidine gluconate bath wash in combination as part of a best practice policy to reduce hospital acquired multi resistant organism rates of colonization. This project focused on auditing the extent to which the protocol was implemented and on promoting its implementation. Objectives The primaryaim of this evidence implementation project was to promote best practice in the use of 2% chlorhexidine gluconate body cleansing in the Canberra Hospital ICU and HDU settings. A secondary aim was to improve ICU/HDU patient outcomes and resource utilization. Methods The project used the Joanna Briggs Institute's Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) audit tools for promoting change in 2% chlorhexidine gluconate wash health practice. A baseline audit was conducted followed by a three-prong education approach strategy targeted at clinicians and finalized using a follow-up audit. Results There was an improvement in best practice for all criteria monitored in the follow-up audit compared to the initial audit. The most significant improvement was education and allergy assessment with 90% and 46% improvements respectively. Wipe application compliance improved by 28% to 55%, suggesting a need for continual education. Minor decreases in compliance were also noted in allergy documentation and application technique by 2% and 7% respectively. Conclusions The project was successful in increasing knowledge surrounding 2% chlorhexidine gluconate wash administration and has provided a future direction for sustaining evidence-based practice change. Further audits will need to be carried out in order to maintain the practice change and support sustained implementation of the best practice protocol.

Daily 2% chlorhexidine gluconate bath wash in a tertiary adult intensive care and high dependency units to reduce risk of hospital acquired multi resistant organisms: a best practice implementation project.

There is growing evidence that the incidence of hospital acquired multi resistant organisms are increasing worldwide. Intensive care patients are particularly prone to hospital-acquired infections. In an effort to combat increasing nosocomial infections rates within the intensive care/high dependency unit setting, Canberra Hospital has implemented a daily 2% chlorhexidine gluconate bath wash in combination as part of a best practice policy to reduce hospital acquired multi resistant organism rates of colonization. This project focused on auditing the extent to which the protocol was implemented and on promoting its implementation. The primary aim of this evidence implementation project was to promote best practice in the use of 2% chlorhexidine gluconate body cleansing in the Canberra Hospital intensive care unit and high dependency unit settings. A secondary aim was to improve intensive care/high dependency unit patient outcomes and resource utilization. The project used the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit tools for promoting change in 2% chlorhexidine gluconate wash health practice. A baseline audit was conducted followed by a three-prong education approach strategy targeted at clinicians and finalized using a follow-up audit. There was an improvement in best practice for all criteria monitored in the follow-up audit compared to the initial audit. The most significant improvement was education and allergy assessment with 90% and 46% improvements respectively. Wipe application compliance improved by 28% to 55%, suggesting a need for continual education. Minor decreases in compliance were also noted in allergy documentation and application technique by 2% and 7% respectively. The project was successful in increasing knowledge surrounding 2% chlorhexidine gluconate wash administration and has provided a future direction for sustaining evidence-based practice change. Further audits will need to be carried out in order to maintain the practice change and support sustained implementation of the best practice protocol.

Surveillance of infection in ICU

In this paper, we describe and discuss evidence implementation as a venture in global human collaboration within the framework of “people, process, evidence, and technology” as a roadmap for navigating implementation. At its core implementation is not a technological, or theoretical process, it is a human process. That health professionals central to implementation activities may not have had formal training in implementation, highlights the need for processes and programs that can be integrated within healthcare organization structures. Audit with feedback is an accessible implementation approach that includes the capacity to embed theory, frameworks, and bottom-up change processes to improve the quality of care. In this third paper in the JBI series, we discuss how four overarching principals necessary for sustainability (Culture, Capacity, Communication, and Collaboration) are combined with evidence, technology, and resources for evidence-based practice change. This approach has been successfully used across hundreds of evidence implementation projects around the globe for over 15 years. We present healthcare practitioner-led evidence-based practice improvement as sustainable and achievable in collaborative environments such as the global JBI network as a primary interest of the practicing professions and provide an overview of the JBI approach to evidence implementation.

Effects of a strategy to improve offender assessment practices: Staff perceptions of implementation outcomes

BackgroundThis implementation study examined the impact of an organizational process improvement intervention (OPII) on a continuum of evidence based practices related to assessment and community reentry of drug-involved offenders: Measurement/Instrumentation, Case Plan Integration, Conveyance/Utility, and Service Activation/Delivery. MethodsTo assess implementation outcomes (staff perceptions of evidence-based assessment practices), a survey was administered to correctional and treatment staff (n=1509) at 21 sites randomly assigned to an Early- or Delayed-Start condition. Hierarchical linear models with repeated measures were used to examine changes in evidence-based assessment practices over time, and organizational characteristics were examined as covariates to control for differences across the 21 research sites. ResultsResults demonstrated significant intervention and sustainability effects for three of the four assessment domains examined, although stronger effects were obtained for intra- than inter-agency outcomes. No significant effects were found for Conveyance/Utility. ConclusionsImplementation interventions such as the OPII represent an important tool to enhance the use of evidence-based assessment practices in large and diverse correctional systems. Intra-agency assessment activities that were more directly under the control of correctional agencies were implemented most effectively. Activities in domains that required cross-systems collaboration were not as successfully implemented, although longer follow-up periods might afford detection of stronger effects.

Improving transition of care for veterans after total joint replacement.

Patients transitioning from hospital to home are at risk for readmission to the hospital. Readmissions are costly and occur too often. Standardized discharge education processes have shown to decrease readmissions. The purpose of this quality improvement project was to utilize evidence-based practice changes to decrease 30-day all-cause readmissions after total joint replacement. Review of literature revealed that improved discharge education can decrease unnecessary readmissions after discharge. A quality improvement project was developed including standardized total joint replacement discharge education, teach-back education methodology, and improved postdischarge telephone follow-up. The quality improvement project was initiated and outcomes were evaluated. Improving coordination of the discharge process, enhanced education for patients/caregivers, and postdischarge follow-up decreased total joint replacement readmissions.

Leading change: evidence-based transition.

The purpose of this article was to provide a framework for evidence-based transition of patient populations within an acute care pediatric institution. Transition within a hospital is foreseeable, given the ever-changing needs of the patients within an evolving healthcare system. These changes include moving patient populations because of expansion, renovation, or cohorting similar patient diagnoses to provide care across a continuum. Over the past 1 to 2 years, Children's Health Children's Medical Center Dallas has experienced a wide variety of transition. To provide a smooth transition for patients and families into new care areas resulting in a healthy work environment for all team members. The planning phase for patient population moves, and transition should address key aspects to include physical location and care flow, supplies and equipment, staffing model and human resources (HR), education and orientation, change process and integrating teams, and family preparation. It is imperative to consider these aspects in order for transitions within a healthcare system to be successful. During a time of such transitions, the clinical nurse specialist (CNS) is a highly valuable team member offering a unique perspective and methodological approach, which is central to the new initiative's overall success. The themes addressed in this article on evidence-based transition are organized according to the CNS spheres of influence: system/organization, patient/family, and nursing. An evidence-based transition plan was developed and implemented successfully with the support from the CNS for 3 patient populations. Organizational leadership gained an increased awareness of the CNS role at the conclusion of each successful transition. The CNS plays a pivotal role as clinical experts and proponents of evidence-based practice and effects change in the system/organization, nursing, and patient/family spheres of influence. While transitions can be a source of stress for leaders and bedside staff, it is also a time that allows for growth and new opportunities for staff and may result in development of a healthier work environment. The CNS is able to provide leadership while working collaboratively to oversee the moves with a forward-thinking approach. There are key components to consider during times of transition. These include (1) organize, plan, and improve work efficiencies during a construction build; (2) identify the key elements for improvement in nurse and patient satisfaction; (3) develop or maintain healthy work environment standards; (4) establish adequate staffing levels and staff education to successfully care for patient populations following transition; and (5) support the staff and patients during transition.

Evidence-based practice beliefs and implementation before and after an initiative to promote evidence-based nursing in an ambulatory oncology setting.

The purpose of evidence-based practice (EBP) in nursing is to improve patient outcomes, providing the best and most up-to-date care practices. In 2011, a nurse-led committee convened to develop an institute-wide initiative to promote EBP with oncology nurses at the Dana-Farber Cancer Institute. Compare and describe oncology nurse beliefs and perceived implementation of EBP and explore beliefs and implementation before and after implementing an institutional EBP initiative. Based on the Advancing Research and Clinical practice through close Collaboration (ARCC) Model, the Evidence-Based Practice Beliefs (EBP-B) and Implementation (EBP-I) scales were distributed to all Dana-Farber Cancer Institute registered and advanced practice nurses through an online survey in 2011 (T1) and again in 2013 (T2) after the implementation of an institute-wide nursing EBP initiative (orientation, poster presentations, education). Descriptive and correlation statistics were completed on total scores and demographics. Differences in beliefs and implementation scores based on demographics were analyzed with Mann-Whitney U tests. Open-ended item responses at each time point (T) were summarized for EBP barriers and promoters. Thirty-two percent (n = 112 at T1; n = 113 at T2) of 350 nurses began the survey. A history of formal EBP education and nurse role were associated with higher EBP-B and EBP-I scores (p < .05). Highest level of education was significantly correlated with both EBP-B (r = .25; p = .03) and EBP-I (r = .32; p = .01). Narrative responses to open-ended questions described perceived personal and environmental barriers to engaging in EBP. Although no significant differences were noted in beliefs and implementation after the EBP initiative, nurses reported valuing EBP. Respondents acknowledged a lack of full preparation in the EBP process to engage in and implement EBP consistently. Nurse role, formal EBP education, and highest level of education were associated with perceptions of EBP beliefs and implementation. Nurses should be provided the mentorship and support to obtain continuing education about how to engage in EBP and about implementing EBP change.

The “5Rs of Reorganization”: A Case Report on Service Delivery Reorganization within a Pediatric Rehabilitation Organization

ABSTRACTAims: Pediatric rehabilitation centers constantly reorganize services to accommodate changes in funding, client needs, evidence-based practices, accountability requirements, theoretical models, and values. However, there are few service delivery models or descriptions of how organizations plan for change to guide organizations through this complex task. Methods: This case report presents the “5Rs of Reorganization,” a novel process for planning service delivery reorganization projects in pediatric rehabilitation centers. The 5Rs include: 1. Recognize the need for change, 2. Reallocate resources for project management, 3. Review the reality of clients, service delivery, and the community, 4. Reconstruct reality, and 5. Report results. Results: The implementation and outcomes of the “5Rs of Reorganization” process are described for one pediatric rehabilitation center to illustrate how use of this process led to effective service delivery reorganization planning. The resulting multi-component customized service delivery plan reflects high levels of stakeholder involvement. Conclusions: Principles of project management can be applied to support service delivery reorganization planning within pediatric rehabilitation centers using the “5Rs of Reorganization.” Strong communication throughout the planning phase is key to developing and sharing a plan for service delivery reorganization. Communication can be supported through use of the 5R process.