Implementation Efforts Research Articles

Contributing Factors to the Progress of Inclusive Education Implementation in Indonesia

Indonesia made its commitment clear to obtain education for all its citizen without discrimination. However, the research-to-practice gap remains in terms of the implementation of inclusive education in the country. Therefore, this scoping review aimed to describe the current progress of the country’s inclusive education implementation efforts through the previous literature. A total of 20 articles were included in this review. The findings showed that an increasing number of studies report on Indonesia’s progress in the implementation of inclusive education in terms of inclusive, innovative, and integrated learning programs, improvement of teachers’ competence, collaboration efforts, society’s respect towards persons with special needs and disabilities, and several challenges serve as a room for improvement. Factors contributing to the gradual progress of the country’s inclusive education implementation are teacher competence and awareness about inclusive education, good government support, multi-sectoral collaboration and coordination, profound legal support, and student-focused strategies.

How the experiences of implementation support recipients contribute to implementation outcomes.

There is a growing body of literature on the activities and competencies of implementation support practitioners (ISPs) and the outcomes of engaging ISPs to support implementation efforts. However, there remains limited knowledge about the experiences of implementation support recipients who engage with ISPs and how these experiences shape the trajectory of implementation and contribute to implementation outcomes. This study aimed to extend the research on ISPs by describing the experiences of professionals who received implementation support and inform our understanding of the mechanisms by which ISPs produce behavior change and contribute to implementation outcomes. Thirteen individuals with roles in supporting implementation efforts at a private foundation participated in semi-structured interviews. Data were analyzed using qualitative narrative analysis and episode profile analysis approaches. Iterative diagramming was used to visualize the pathway of experiences of implementation support recipients evidenced by the interview data. The majority of recipients described how positive experiences and trusting relationships with ISPs increased acceptance of implementation science throughout the foundation and increased the perception of implementation science as both an appropriate and feasible approach for strengthening the impact of foundation strategies. As perceptions of appropriateness and feasibility increased, recipients of implementation support described increasing knowledge and application of implementation science in their funding engagements and internal foundation strategies. Finally, recipients reported that the application of implementation science across the foundation led to sustained implementation capacity and better outcomes. The experiences of implementation support recipients described in this paper provide a source for further understanding the mechanisms of change for delivering effective implementation support leading to better implementation quality. Insights from these experiences can enhance our understanding for building implementation capacity and the rationales for evolving approaches that emphasize the dynamic, emotional, and highly relational nature of supporting others to use evidence in practice.

Implementation frameworks, strategies and outcomes in optimizing central venous access device practice in paediatrics: A scoping review.

This scoping review aimed to explore recent interventional research in CVAD management through an implementation lens. This scoping review used the Arksey and O'Malley framework. Studies were included if they were written in English, published in 2012 to July 2023, involved children and were relevant to the study aims. Risk of bias was appraised by the Mixed Methods Appraisal Tool. Searches were undertaken in EMBASE, CINAHL (Ebsco), PubMed, Web of Science and Cochrane Library (CENTRAL). Of the 1769 studies identified in a systematic search, 46 studies were included. Studies mostly focused on health professionals and central venous access device maintenance and had quantitative pre-post study designs. Adherence to implementation frameworks was lacking, with many studies employing quality improvement approaches. Implementation strategies were typically multipronged, using health-professional education, bundles and working groups. Bundle compliance and reductions in central line-associated bloodstream infections were the most featured outcomes, with most studies primarily focusing on effectiveness outcomes. Translation of evidence-based practices to the clinical setting is difficult and current adoption of implementation frameworks (apart from 'quality improvement') is limited. Implementation strategies are diverse and dependent on the local context, and study outcomes typically focus on the effectiveness of the physical intervention, rather than measuring the implementation effort itself. Future intervention research requires a more uniform and deliberate application of implementation frameworks and strategies. Greater exploration of relationships between frameworks and strategies and implementation and service outcomes is required to increase understanding of their role in maximizing resources to improve health care. Adhered to best reporting guidelines as per PRISMA-ScR (Tricco etal., 2018). No patient or public contribution.

Understanding the Interrelationships Between Organizational Performance Measurement System Implementation Variables

Performance measurement (PM) systems are increasingly being adopted to manage and improve organizations’ effectiveness. However, a review of the research shows that there are a significant number of unsuccessful PM systems with indications of challenges arising during the implementation phase. A study involving subject-area experts was conducted and the analytic network process (ANP), for evaluating the multi-criteria decision model, was used to quantify the effects of the dynamic interrelationships among the model variables as well as the systemic effect of the factors on PM system implementation success (IS). The results show that Leadership Support and the Implementation Approach are the most important factors for successful implementation of PM systems. Meanwhile, factors related to training, participation, and an effective information technology system help users of PM understand the measures and identify their perceived benefits, thereby contributing to performance goals and objectives. This study provides a comprehensive and rigorous analysis by employing an expert study to evaluate and quantify the effects of model variables and their interrelationships on PM system implementation success using the ANP methodology. Managers and researchers can use the prioritization of the factors and insights regarding key interrelationships to develop more specific strategies and better manage resources of the implementation effort.

Missed Opportunities: A Narrative Review on Why Nonoccupational Postexposure Prophylaxis for HIV Is Underutilized.

Postexposure prophylaxis (PEP) is an important tool for preventing HIV infection but remains underutilized. In this narrative review, we aim to summarize the frequency of missed opportunities for prescribing PEP among studies from around the world, discuss the complexities of the challenges facing PEP provision, and describe possible solutions. We identified 20 studies published in the last 10 years among 43 832 individuals, of whom an estimated 41 477 were eligible for PEP. Of those eligible for PEP, PEP was prescribed among 27 705 (66.8%). There was a significant difference in PEP prescriptions in acute compared with non-acute care settings (63.5% vs 94.5%; P < .001). Emergent themes contributing to PEP underutilization included lack of provider and patient awareness, reduced PEP acceptability, HIV stigma and homophobia, lack of access (either to care or to medication), and stigmatizing policies. Each of those issues should be the focus of future PEP implementation efforts.

Comparison Between Disability, Physical Performance, and Other Biopsychosocial Factors in Full-Duty Career Firefighters Working With and Without Current Low Back Pain.

Low back pain (LBP) is highly prevalent and a top cause of disability-related early retirement in firefighters. Those with a lifetime history of LBP have various deficiencies that are associated with increased injury risk and absenteeism. However, the influence of working with current LBP on disability, physical performance, and other biopsychosocial factors has not been fully characterized in this population. The purpose of this study was to compare anthropometric measures, exercise habits, physical fitness/performance, disability/work ability, and other biopsychosocial factors of firefighters working with and without current LBP. A cross-sectional study was conducted using baseline assessments from 419 full-duty career firefighters without documented work restrictions (age: 37.6 ± 8.8 y; 5 F, 414 M) who were enrolled in a regional wellness initiative in Southern California, USA. Current LBP status was determined by a questionnaire and confirmed by an interview. Anthropometric measures, patient-reported outcomes, and physical fitness tests were used to assess body mass index; body fat %; waist circumference; strengthening, cardiovascular, and flexibility exercise frequency; back and core muscular endurance; functional movement quality, perceived back-related disability, lift and carry ability, and firefighter task ability; sleep quality; and perceptions of fear and fatigue and catastrophic injustice experience. Scores for participants with and without current LBP were compared using analysis of variance and chi-square analysis. The point prevalence of current LBP was 19.81% (83/419). For the entire cohort, those with current LBP had significantly worse scores than those without current LBP for all assessed variables, except core muscular endurance and functional movement quality. These trends held up when analyses were stratified by age and obesity categories, and approximately half of the comparisons retained statistical significance. A significantly greater percentage of participants with current LBP were working with some level of back-related disability and/or perceived physical demand characteristics of work level below the required very heavy job demands. Nearly one-fifth of full-duty career firefighters without documented work restrictions reported having current LBP, and these individuals had deficits in several modifiable biopsychosocial factors across five health domains. These findings can help guide future research and implementation efforts in the fire service designed to improve performance, resiliency, work readiness, recovery, and quality of life, as well as to reduce impairment, disability, and absenteeism and increase presenteeism.

Understanding Open Studio Process in School Settings: Facilitators’ Insights

The study explores facilitators’ experiences of the Open Studio Process (OSP) and its uses in school settings. Using a mixed method approach, the study conducted an online survey and six interviews of 27 OSP facilitators. Results underscore three general features of OSP: therapeutic rather than therapy; use for self-care; strengths and weaknesses. Facilitators also described applications, challenges, and potentials of OSP in schools. OSP emerges as a versatile preventative intervention, offering accessibility, meeting diverse needs, enhancing creativity, healing, autonomy, and self-esteem for facilitators and participants, and showing potential for use in schools. Practical implications include integrating OSP into therapeutic and educational settings. OSP exhibits promise in nurturing wellbeing and personal growth in diverse contexts, warranting continued exploration and implementation efforts.

The development of the Egyptian 24-h movement guidelines for adults aged 50 years and older: an integration of sleep, sedentary behavior, and physical activity by the Egyptian Academy of Bone and Muscle Health

BackgroundWith the vision of healthy aging, the Egyptian Academy of Bone and Muscle Health followed an established guideline development process to create the Egyptian 24-h movement clinical guideline for adults aged 50 years and older adults. This guideline highlights the significance of movement behaviors across the whole 24-h day. Online databases (PubMed, Embase, and Cochrane Library) were searched for relevant peer-reviewed studies that met the a priori inclusion criteria.ResultsA total of 53 studies met the inclusion criteria. Leveraging evidence from the review of the literature led to the development of 27 statements answering the 5 key questions. Results revealed a major change in the previous basic understandings as it shifts away from focussing on a sole movement behavior to the combination of all the movement behaviors. Based on this, the final guideline was developed providing evidence-based recommendations for a “Healthy 24-Hour Day”, comprising a mix of light-intensity and moderate-to-vigorous-intensity physical activity, sleep, and sedentary behavior.ConclusionThe developed guidelines are meant to help in the decision-making process and are intended for use by adults and older both nationally and internationally; also, for endorsement by the policy-makers. Dissemination and implementation efforts would impact positively on both health professionals and researchers and would also be useful to interested members of the public sector.

VOSviewer Analysis of Studies on Software Selection in the Logistics Sector

Abstract Outsourcing in logistics is an important step to reduce costs and increase operational efficiency. In this sense, it is possible to come across outsourcing in many areas of logistics processes. One of the outsourcing steps is the decision to select the software. Choosing the right software can affect the market share of the organization and the implementation time, effort, and cost. The findings of this research will help the marketing and sales teams of software product companies to develop key points and also enable end users to make informed decisions in selecting software packages for the organization. In this study, the studies in the literature were examined through the Scopus database, and co-citation analysis was performed using the VOSviewer program. As a result of the analysis, the articles analyzed were divided into four clusters and explained.

Utility of the Leadership and Organizational Change for Implementation-Systems Level (LOCI-SL) strategy for a statewide substance use treatment implementation effort

IntroductionMulti-level and cross-context implementation strategies are needed to support health systems, healthcare delivery organizations, and providers to adopt evidence-based practice (EBP) for substance use disorder (SUD) treatment. However, misalignment between state oversight agencies and healthcare organizations about which services to prioritize and which outcomes are reasonable to expect can hinder implementation success and widespread access to high-quality care. This study investigated the utility of the Leadership and Organizational Change for Implementation-System Level (LOCI-SL) strategy for supporting statewide EBP implementation for SUD treatment. MethodsNine community mental health centers (CMHCs) contracted by a state agency participated in a combined motivational-enhancement therapy and cognitive behavioral therapy (MET/CBT) implementation effort. Five of the CMHCs also received the LOCI-SL strategy to obtain ongoing implementation support. We conducted 21 individual interviews and three small group interviews with 30 participants across CMHCs and state health agencies to investigate the utility of LOCI-SL in supporting their EBP implementation efforts. Deductive thematic analysis was guided by the Exploration, Preparation, Implementation, Sustainment Framework. ResultsFive themes described CMHCs' LOCI-SL and broader contextual experiences implementing EBPs: (1) LOCI-SL supported executives in Preparation phase activities that holistically considered organizational needs and capacity to implement and sustain EBPs; (2) LOCI-SL facilitated trust and communication processes across Preparation, Implementation, and Sustainment phases to improve EBP uptake; (3) LOCI-SL increased CMHCs' use of implementation climate strengthening activities throughout the Implementation phase; (4) state contracts did not emphasize quality and thus were not sufficient bridging factors to enforce EBP fidelity during Implementation; and, (5) limited funding and low Medicaid reimbursement rates hindered EBP use throughout the Implementation and Sustainment phases. ConclusionsLOCI-SL was viewed as a favorable and useful implementation strategy for supporting statewide adoption of EBPs. However, outer context barriers, including limited financial investments in the treatment system, impeded implementation and sustainment efforts. While previous research suggests that contracts are viable alignment-promoting bridging factors, this study demonstrates the importance of articulating implementation outcome expectations to aid state-contracted organizations in achieving EBP implementation success. This study also highlights the need for multi-level implementation strategies to effectively align implementation expectations between outer- and inner-context entities.

Receipt of Medications for Alcohol Use Disorder in the Veterans Health Administration: Comparison of Rates at the Intersections of Racialized and Ethnic Identity With Both Sex and Transgender Status.

Medications for alcohol use disorder (MAUDs) are recommended for patients with alcohol use disorder yet are underprescribed. Consistent with Minority Stress and Intersectionality theories, persons with multiple sociodemographically marginalized identities (eg, Black women) often experience greater barriers to care and have poorer health outcomes. We use data from the Veterans Health Administration to assess disparities in Federal Drug Administration (FDA)-approved MAUDs and all effective MAUDs between the following groups: racialized and ethnic identity, sex, transgender status, and their intersections. Among all Veterans Health Administration outpatients between August 1, 2015, and July 31, 2017, with documented alcohol screenings and an International Classification of Diseases diagnosis for alcohol use disorder in the 0-365 days prior (N = 308,238), we estimated the prevalence and 95% confidence intervals of receiving FDA-approved MAUDs and any MAUDs in the following year and compared them using χ2 or Fisher's exact test. Analyses are unadjusted to present true prevalence and group differences. The overall prevalence for MAUDs was low (FDA-MAUDs = 8.7%, any MAUDs = 20.0%). Within sex, Black males had the lowest rate of FDA-MAUDs (7.3%, [7.1-7.5]), whereas American Indian/Alaskan Native females had the highest (18.4%, [13.8-23.0]). Among those identified as transgender, Asian and Black transgender persons had the lowest rates of FDA-MAUDs (0%; 4.3%, [1.8-8.5], respectively), whereas American Indian/Alaskan Native transgender patients had the highest (33.3%, [2.5-64.1]). Similar patterns were observed for any MAUDs, with higher rates overall. Substantial variation exists in MAUD prescribing, with marginalized veterans disproportionately receiving MAUDs at lower and higher rates than average. Implementation and quality improvement efforts are needed to improve MAUD prescribing practices and reduce disparities.

Implementation of Tasawwuf Values ​​in the Book of &lt;i&gt;Durratun Nashihin &lt;/i&gt;to Improve the Spirituality of Students at the Lubabul Fattah Islamic Boarding School Tulungagung

Efforts to increase the spirituality of students at the Lubabul Fattah Islamic Boarding School are actualized through daily activities based on the values ​​of Sufism in the book Durratun Nashihin. This implementation effort was carried out with the hope that there would be an improvement in the students' morals, self-awareness and empathy. This research uses descriptive qualitative methods. Thus, this research produces a conclusion that the Sufism values ​​contained in the book Durratun Nashihin which have been practiced by the students of the Lubabul Fattah Islamic Boarding School have had a positive impact in increasing spirituality, especially in terms of morals, morals, empathy and tolerant attitudes. These values ​​include patience, tawadhu', sadaqah fi sabilillah, congregational prayer, reading the Qur’an and dhikr. In the implementation process, the Lubabul Fattah Islamic Boarding School has done this through an educational curriculum, so that the students' understanding of Sufism is not only through spiritual practice, but also through educational pathways which have their own implications for the soul/spirituality of a student as evidenced by attitudes and behavior that show calm.

Adaptation and implementation of body project as a universal body image program in Mexico and Latin America

ABSTRACT The Body Project (BP) intervention for body image issues is supported by extensive efficacy and effectiveness research, most of which has been conducted in the United States. The BP uses cognitive dissonance to help participants critique the ideal appearance through written, verbal, and behavioral exercises. This reduces the internalization of the appearance ideal, which in turn decreases body dissatisfaction symptoms and, in some individuals, the onset of eating disorders. To broadly implement this program in Mexico and Latin America, Comenzar de Nuevo (CdN), a non-profit organization for eating disorder treatment, partnered with the Body Project Collaborative in 2014. Together, they created a training and implementation infrastructure. This paper explores the adaptation of BP and its implementation in Mexico and Latin America. We used sustainable business, marketing, and educational models to fulfill CdN’s mission to reduce eating disorder risk factors, including weight stigma, in the Latin American region. By integrating strategies to combat weight stigma within our program delivery, we strive to contribute to a more inclusive and supportive environment. We trained master trainers, regular trainers, and/or group facilitators from Argentina, Bolivia, Colombia, Costa Rica, Chile, Dominican Republic, El Salvador, Guatemala, Mexico, Panama, and Spain; and implemented the BP in 15 public schools supported by sponsorship programs. This paper provides crucial lessons learned, future directions, and implications for dissemination and implementation efforts in this region of the world.

Appraising perception, accessibility and uptake of DAT among patients with TB

&lt;sec&gt;&lt;title&gt;INTRODUCTION&lt;/title&gt;Poor adherence to TB treatment poses a significant public health threat to TB control programmes. The sustainability of directly observed treatment has been questioned because of its non-patient-centred approach and resource-intensive nature, and Digital Adherence Technologies (DATs) provide a suitable alternative. This study assessed the feasibility and acceptability of DATs among patients with TB.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;METHODS&lt;/title&gt;This descriptive study was conducted in eight states in Nigeria among all patients with drug-susceptible TB.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;RESULT&lt;/title&gt;A total of 230 patients (89.1%) own a phone that no one else uses, and 18 (7.0%) use a family phone. A higher proportion of 189 (73.3%) have airtime credit and 119 (46.1%) have internet credit on their phone. In addition, 216 (83.7%) stated that the reminders they received on their phone helped them remember to take their medicine. Only 11 (4.3%) patients missed a dose of the TB medicine. Equally, 11 (4.3%) patients had taken their TB medicine without using DAT. Of these, 7 (63.3%) did not use DATs because they forgot to text medication labels, and 3 (27.6%) did so because of poor network. Only four (1.6%) purchased additional items to support the use of DATs.&lt;/sec&gt;&lt;sec&gt;&lt;title&gt;CONCLUSION&lt;/title&gt;DATs are acceptable in a wide variety of settings, even with reported challenges. Implementation efforts should ensure access, address technical challenges, and minimise additional cost to patients.&lt;/sec&gt;

Using an evaluative lens to characterize the implementation outcomes of an NDBI within an early intervention system

A growing number of research studies are attempting to increase access to naturalistic developmental behavioral interventions (NDBIs) for autistic toddlers and their families by translating these approaches into Part C Early Intervention systems. As efforts to increase the use of NDBIs across EI systems grow, it is important to expand the scope of research to evaluate the implementation impact of this work. In order to address this gap, the current study was grounded in the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework (RE-AIM) to evaluate a broader range of implementation outcomes when a parent-mediated NDBI, Project ImPACT, was implemented within an Early Intervention system. Specific aims included examining: 1) the reach of Project ImPACT to children across the system; 2) the perceived effectiveness of Project ImPACT; 3) rates of provider participation in Project ImPACT training and consultation; 4) the delivery and adaptation of Project ImPACT by Early Intervention providers; and 5) providers’ intent to sustain their use of Project ImPACT. Forty-eight Early Intervention providers enrolled in Project ImPACT training, with a subsample participating in ongoing group consultation followed by an exit interview and a 6-month follow-up survey. Although there was a high level of interest in Project ImPACT training and good retention once enrolled, only half of EI providers who expressed interest in Project ImPACT training ultimately enrolled. Participating providers delivered Project ImPACT to families and children who were representative of state-level demographic information and perceived that Project ImPACT was effective for families and children on their caseload irrespective of whether children were autistic. Consistent with other research studies, providers’ fidelity to Project ImPACT was inconsistent, and providers reported a moderate level of adaptation to the program. At 6-month follow-up, providers reported high maintenance of Project ImPACT. The findings from this study have implications for how the RE-AIM framework could be used to more concisely characterize the impact of implementation efforts within public systems serving autistic toddlers and their families.

Microplastics: A One Health priority agenda

Interdisciplinary approaches are increasingly recognized as crucial for strengthening and integrating health systems. The implementation within One Health framework needs more guidelines for successful execution. Microplastics have become a growing environmental concern, as they are collectively found in all environmental sectors. Microplastics pose risks to crops, plants, animals, wildlife and human due to the persistence and bio–accumulative properties. Microplastics are directly and indirectly associated with climate change, not only threatening food security but also leading to the novel distribution of species that may transmit new pathogens. This article focused on the ubiquitous presence of microplastics in One Health, highlighting the necessity for further research and implementation efforts.

Exploring the impact of the first rule of Functional Analytic Psychotherapy on fear of intimacy, vulnerability, and responsiveness: An analog process analysis

Functional Analytic Psychotherapy (FAP) is an efficacious but complex treatment. Despite a solid empirical foundation, research on the treatment is limited. While five process-focused rules guide the treatment, developers made an early statement that they believed only the first rule of FAP, watching for the occurrence of daily life problems occurring in the therapy session, was needed to guide treatment effectively. The current study was designed to assess this claim through the use of a FAP analog procedure in hopes of increasing the accessibility of the treatment and thus facilitating implementation efforts. In this study, 81 undergraduate participants engaged in a closeness-generating class in which they were randomized into two groups. In the experimental condition, research assistants had access to a self-report measure regularly used to inform clinicians about potential daily life problems that may occur in the therapy room. No such information was available to the research assistants in the control condition. Findings indicated that while fear of intimacy, a core construct in FAP, decreased on average following the procedure, the experimental condition had no impact on this change. Further, when research assistants had access to the daily life problem information, participants found them less effective at responding to disclosures. These findings suggest the importance of a nuanced case conceptualization, the limitations of the first rule of FAP, and the strengths and limitations of the use of an analog paradigm to study FAP.

Do no harm: the impact of implementing cancer prevention strategies on other preventive health measures

BackgroundTranslational efforts to increase uptake of evidence-based practices typically look at those outcomes in isolation of their impact on other aspects of care delivery. If we are in fact to “do no harm”, we must consider the possible negative impact of improving use of one practice on other quality measures. Alternatively, a focus on one practice could lead to spread of effective strategies to other practices, which would be highly beneficial. We studied the impact of a colorectal cancer (CRC) screening initiative on delivery of other preventive care measures.MethodsWe used an interrupted time series design with implementation year as the interruption point. The initiative was conducted between 2015 and 2020, with three staggered cohorts. Main outcomes were quality measures for colorectal cancer screening, cervical cancer screening, hypertension management, diabetes management, weight screening and follow-up, tobacco use screening and cessation treatment, and depression screening and follow-up.ResultsThe initiative was associated with an increase in CRC screening (OR = 1.67, p ≤ 0.01; average marginal effect = 12.2% points), and did not reduce performance on other quality measures in the year of CRC program implementation or a change in their respective secular trends.ConclusionsThe initiative led to a clinically meaningful increase in CRC screening and was not associated with reductions in delivery of six other preventive services. Quality improvement (QI) initiatives typically approach implementation with an eye towards reducing unintended impact and leveraging existing staff and resources. Implementation research studies may benefit from considering how QI initiatives factor in the local context in implementation efforts.

"Right now, it's kind of haphazard"-Pediatric emergency care coordinators and quality of emergency care for children: A qualitative study.

Pediatric readiness varies widely among emergency departments (EDs). The presence of a pediatric emergency care coordinator (PECC) has been associated with improved pediatric readiness and decreased mortality, but adoption of PECCs has been limited. Our objective was to understand factors associated with PECC implementation in general EDs. We conducted semistructured qualitative interviews with a purposively sampled set of EDs with and without PECCs. Interviews were completed, transcribed, and coded until thematic saturation was reached. Themes were identified through a consensus process and mapped to the Consolidated Framework for Implementation Research (CFIR). Twenty-four interviews were conducted and mapped to themes related to innovation, individuals and implementation process, outer setting (health system), and inner setting (hospital/ED). Addressing innovation, individuals, and implementation process, the primary theme was variability in how the PECC role was defined and who was responsible for implementing it. Regarding the outer setting, participants reported that limited system resources affected their ability to implement the PECC role. Key inner setting themes included concerns about limited visit volume, a lack of systems for measuring pediatric quality of care, and significant tension around change. Implementation of the PECC role appears to be limited by heterogeneous interpretations of the PECC, de-prioritization of pediatrics, and limited system resources. However, many participants described motivation to improve pediatric care and implement the PECC role in context of increasing pediatric visits; they offered strategies for future implementation efforts.

Digital Shipbuilding – Needs, challenges, and opportunities

Ship design firms, shipyards, and ship equipment manufacturers – the shipbuilding industry or just shipbuilding, must adapt their products and services' deliverables to the steadily evolving expectations of the stakeholders in the market. Digitalization and the use of computational tools have been suggested as the effective means to meet such challenges. However, many anecdotal statements and industry recognitions have expressed concern that such efforts have proven less effective than should be expected and promised, and opposite to what many application suppliers advertise. It is argued by this paper that such a situation is experienced because of, among other explanatory factors, incompatibility, lack of proper protocols for information sharing and isolated implementation efforts in single departments rather than a holistic organizational approach. The lack of full understanding of the ship designer's role and responsibility as the main facilitator of such a change process is also recognized as a clear weakness in the effort of successful digitalization of shipbuilding. It is argued that such a vital transformation process cannot be left alone to the software application providers, despite their size and dominance. This paper explains and discusses why this situation is experienced and indicates what improvement measures could be introduced to counteract the opportunity loss. The article addresses five potential digital service deliverables that could complement the existing service delivery of shipbuilding operations and thereby increase competitiveness and market attractiveness. These services include a) vessel support and control centres, b) performance monitoring, c) maintenance management, d) spare part handling, and e) life cycle assessment (LCA). The article also reflects on what implications and consequences this development has on the ship designers' work and their firm's adaptation to new services' demand in the shipbuilding market. The paper concludes with some reflections on the actual implementation of these services, highlighting challenges and further opportunities.