Local Implementation Teams Research Articles

Childhood Cancer in Cameroon and Kenya: Preliminary findings of an implementation effectiveness study for early detection of childhood cancer.

e23096 Background: Early childhood cancer detection reduces mortality, particularly in LMIC contexts where an improved understanding of early warning signs and symptoms (EWSS) and integration of vital referral pathways into existing health systems are crucial to improved childhood cancer outcomes. Our project seeks to adapt and implement a Ghanaian-developed EWSS intervention for Kenya and Cameroon using implementation science frameworks to move beyond the common but ineffective train-and-hope approach. Cameroon operates on a three-tiered sub-sector health system, with the intermediate level consisting of regional delegations that support districts1. In Kenya a six-tiered health system delivers primary care (1-2), mid-level care (3-4), advanced care with centers of excellence (5-6) 2. Health system contexts will inform implementation planning and execution. Methods: Health system stakeholders convened in each country to launch their EWSS initiative. Two-day meetings were collaboratively led by local stakeholders and the research team, guided by The Implementation Roadmap3, a multi-implementation framework resource. They discussed l) local barriers to childhood cancer detection, 2) referral pathways, 3) leadership and operational implementation teams, 4) sustainable EWSS training, and 4) target settings. Results: Stakeholders endorsed the EWSS program and identified individuals to form implementation teams to plan and execute implementation reflective of health system organization and realities. Both countries engaged in an evidence-based implementation planning process, reviewed EWSS core components and training logistics, and endorsed a sustainable tiered training model targeting clinicians and oncologists across system levels and institutional providers. Training content will be adapted for country, region, and county contexts. Both countries endorsed and identified district childhood cancer champions to facilitate training and coordinate timely referrals. Common implementation barriers identified included high healthcare worker turnover, transportation logistics for in-person training, and remuneration options for trainees. Conclusions: Health system leaders in Kenya and Cameroon endorsed an evidence-based EWSS implementation and sustainment approach and identified adaptations responsive to the health system contexts. Implementation will be locally led to ensure effectiveness, sustainability, and appropriate cultural EWSS adaptation. Moving forward, local implementation teams will work with researcher-facilitators to implement EWSS toward improved cancer detection rates.

A community-embedded approach to increasing the health literacy of Aboriginal children in a regional area: processes of co-design and local implementation.

This research explores the implementation of a child-centred, co-designed, community-embedded program called 'Young Doctors for Life' (YDFL). YDFL is designed to improve health and wellbeing outcomes for Aboriginal children in the middle childhood years. Focus is given in this paper to the processes of program adaptation of the YDFL to ensure local cultural relevance, drawing on the experiences and perspectives of children, parents, schoolteachers, and the implementation team. Two focus groups with program stakeholders were convened. The first group consisted of three members from the local Aboriginal implementation team, and the second group comprised two members of the program design team. Children (n = 22) and schoolteachers (n = 2) participated in semi-structured interviews. Parent survey data (n = 16) were also collected and included. The data was analysed, guided by the five elements of implementation as outlined in the Hexagon Implementation framework (Capacity; Fit; Need; Usability; Support; and Evidence), which served as a priori themes. YDFL provides a promising example of how programs can be adapted with and for Aboriginal communities to support child health. Successful adaptation and implementation of this program required a co-design approach engaging program designers and the local implementation team. Community collaboration was also essential to identifying and addressing local community goals and aligning new programs with local service and cultural contexts. Health programs to support positive child outcomes are more likely to be successful when they share their focus between the risks and challenges within a community, and the positive, protective factors that can be leveraged to support children to flourish. Stakeholder engagement and community leadership are necessary to achieve meaningful program adaptation and implementation in Aboriginal communities.

Poster (Health Services, Economics and Policy Change) ID 1985397

Background The Spinal Cord Injury Implementation and Evaluation Quality Care Consortium (SCI-IEQCC) is a quality improvement initiative (began in 2019) with a mission to provide optimal and equitable rehabilitation services for all Canadians regardless of where they live, and to ensure the functional recovery, health and well-being for individuals living with spinal cord injury and disease (SCI/D). Objective To highlight the growing needs of an expanding multisite network and the importance of governance and organizational structures to support the execution of current deliverables while addressing emerging challenges. Design/Methods The SCI-IEQCC has a central team for network management. Administrators/leaders, clinicians with implementation science training, local site implementation teams, and individuals with lived experience comprise the SCI-IEQCC. Implementation and evaluation of indicators and best practices across 10 participating organizations requires: operational oversite; monitoring of project milestones; adherence to regulatory requirements; sustained data quality with linkage for analyses; report card dissemination; information sharing and network updates; strategic planning to map future directions; identification of priorities; and, meeting academic/funding deliverables. Results/Findings SCI-IEQCC has driven improvements in rehabilitation service delivery, performance, utilization of best practices, and increments in staff engagement, training, and knowledge exchange. SCI-IEQCC challenges are derived from the diversity of participating organizations, turnover in leaders, staff shortages, reducing variation in documentation and data management, and ensuring resource continuity. Conclusion The growing complexity of this multisite network necessitate innovative approaches to streamline processes across sites, ensure uniform adherence to regulatory requirements, disseminate innovations in informatics, and assure dedication to its mission and vision.

Collaborating for longleaf pine: A case study

Since the mid 1990′s collaborative landscape management, involving varied land users and interest groups, has increased substantially but the utilization of this practice on private land has been sparsely studied. Alongside this increase in collaborative landscape management, there has been an increase in attention on longleaf pine restoration. Once spanning over 93 million acres in the southeastern United States, these trees were reduced to an estimated 3% of their historic range. In response, in 2009, 22 government agencies and independent organizations formed America’s Longleaf Restoration Initiative. The initiative functions in part through local implementation teams, established throughout the range and focused on private as well as public land. To learn more about collaboration and private land, we studied one of the teams, the Sewee Longleaf Conservation Cooperative, in South Carolina.Drawing on the Advocacy Coalition Framework, a well-established model for analysing policy structures and change, we conducted a series of semi-structured interviews with partner organizations to analyze the group’s functions and the frames through which stakeholders view the coalition, their role, and the mission. We found that it has successfully made itself into the policy subsystem for the area and a venue that encompasses all relevant stakeholders. The stakeholders frame longleaf restoration as a positive, at least a secondary belief, and there is minimal conflict surrounding core beliefs. These stakeholders see the collaboration as positive, laud the group’s ability to facilitate access to resources, and utilize the relationship to establish connections, broaden outreach, and develop policy. But while this is a successful collaboration, its successes may be challenged by future events from outside the policy subsystem

Community implementation of contingency management to address stimulant use

IntroductionContingency management (CM) is efficacious for reinforcing stimulant abstinence, and technical assistance (TA) is increasingly sought to aid its community-based implementation. In an interagency partnership involving a sponsoring single-state authority and statewide treatment agency in Oregon, an intermediary purveyor organization provided a robust TA package to support design, implementation, and evaluation of CM programming for an opioid treatment program (OTP) over the course of a 12-month implementation service project. MethodsIn addition to an online training offering OTP leaders and staff conceptual foundation for CM, the TA package included purveyor-led activities to: 1) engage leaders in collaborative design to customize CM programming; 2) assemble a local implementation team to logistically prepare OTP systems for CM delivery; 3) provide virtual coaching-to-criterion to assure readiness of counseling staff to deliver CM programming; 4) compile a tailored CM resource library of implementation support materials; and 5) avail ongoing consultation during implementation. Stimulant abstinence was targeted via a voucher-based protocol with escalating reinforcement, for which gift cards from local vendors served as reinforcers. Virtual coaching eventuated in individual role-play assessments, wherein staff delivery of CM programming with a standardized patient was scored via Likert scale (1 = Very Poor, 7 = Excellent) on six CM fidelity dimensions. This observational cohort design subsequently assessed clinical effectiveness during active implementation via OTP records review for CM-exposed and comparison client groups. ResultsIn role-play assessments, all counseling staff exceeded an a priori fidelity benchmark signifying implementation readiness (M = 31.33, SD = 3.72). Among 73 clients enrolled in the CM programming, rate of stimulant-free urine drug screens was 11 % greater than among 120 clients serving as historical controls (p < .01; Cohen's D = 0.40). The study also identified secondary therapeutic benefit in six-month treatment retention, with clients enrolled in CM retained at a 14 % greater rate than 162 CM-ineligible clients concurrently enrolled in OTP services (p < .05). ConclusionsFindings from this interagency partnership offer reason for optimism regarding community-based implementation. Beyond the demonstrated empirical support for this TA package and resulting clinical effectiveness of the CM programming, an eventual sustainment decision by OTP leadership strengthens the rationale for customizing CM to clinical settings' local needs and resources.

Barriers and facilitators when implementing family involvement for persons with psychotic disorders in community mental health centres – a nested qualitative study

BackgroundThe uptake of family involvement in health care services for patients with psychotic disorders is poor, despite a clear evidence base, socio-economic and moral justifications, policy, and guideline recommendations. To respond to this knowledge-practice gap, we established the cluster randomised controlled trial: Implementation of guidelines on Family Involvement for persons with Psychotic disorders in community mental health centres (IFIP). Nested in the IFIP trial, this sub-study aims to explore what organisational and clinical barriers and facilitators local implementation teams and clinicians experience when implementing family involvement in mental health care for persons with psychotic disorders.MethodsWe performed 21 semi-structured focus groups, including 75 participants in total. Implementation team members were interviewed at the initial and middle phases of the intervention period, while clinicians who were not in the implementation team were interviewed in the late phase. A purposive sampling approach was used to recruit participants with various engagement in the implementation process. Data were analysed using manifest content analysis.ResultsOrganisational barriers to involvement included: 1) Lack of shared knowledge, perceptions, and practice 2) Lack of routines 3) Lack of resources and logistics. Clinical barriers included: 4) Patient-related factors 5) Relative-related factors 6) Provider-related factors. Organisational facilitators for involvement included: 1) Whole-ward approach 2) Appointed and dedicated roles 3) Standardisation and routines. Clinical facilitators included: 4) External implementation support 5) Understanding, skills, and self-efficacy among mental health professionals 6) Awareness and attitudes among mental health professionals.ConclusionsImplementing family involvement in health care services for persons with psychotic disorders is possible through a whole-ward and multi-level approach, ensured by organisational- and leadership commitment. Providing training in family psychoeducation to all staff, establishing routines to offer a basic level of family involvement to all patients, and ensuring that clinicians get experience with family involvement, reduce or dissolve core barriers. Having access to external implementation support appears decisive to initiate, promote and evaluate implementation. Our findings also point to future policy, practice and implementation developments to offer adequate treatment and support to all patients with severe mental illness and their families.Trial registrationClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Self-Organization of Interprofessional Staff to Improve Mobility of Hospitalized Patients with STRIDE: a Complexity Science-Informed Qualitative Study.

Inpatient mobility programs can help older adults maintain function during hospitalization. Changing hospital practice can be complex and require engagement of various staff levels and disciplines; however, we know little about how interprofessional teams organize around implementing such interventions. Complexity science can inform approaches to understanding and improving multidisciplinary collaboration to implement clinical programs. To examine, through a complexity science lens, how clinical staff's understanding about roles in promoting inpatient mobility evolved during implementation of the STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) hospital mobility program. Qualitative study using semi-structured interviews. Ninety-two clinical staff at eight Veterans Affairs hospitals. STRIDE is a supervised walking program for hospitalized older adults designed to maintain patients' mobility and function. We interviewed key staff involved in inpatient mobility efforts at each STRIDE site in pre- and post-implementation periods. Interviews elicited staff's perception of complexity-science aspects of inpatient mobility teams (e.g., roles over time, team composition). We analyzed data using complexity science-informed qualitative content analysis. We identified three key themes related to patterns of self-organization: (1) individuals outside of the "core" STRIDE team voluntarily assumed roles as STRIDE advocates, (2) leader-champions adapted their engagement level to match local implementation team needs during implementation, and (3) continued leadership support and physical therapy involvement were key factors for sustainment. Staff self-organized around implementation of a new clinical program in ways that were responsive to changing program and contextual needs. These findings demonstrate the importance of effective self-organization for clinical program implementation. Researchers and practitioners implementing clinical programs should allow for, and encourage, flexibility in staff roles in planning for implementation of a new clinical program, encourage the development of advocates, and engage leaders in program planning and sustainment efforts.

Maximizing Scalability in Literacy Game App Design for Minority Languages

Minority language communities lack access to educational technology that facilitates literacy skill building. The approach currently taken by most educational game app developers privileges widely spoken languages and often requires intensive resource investment. In response, a new game app was designed to provide easily localized, pedagogically appropriate games for literacy skill building. Scalability to multiple minority languages was possible through a programming design based on language packs that could be compiled by local implementation teams without specialized technical skills and without significant resource investment. We describe the scalability issues encountered when localizing the app for the initial ten minority language pilot groups and how a language-neutral app design that relies on language packs to specify language-specific content and parameters can adequately address these issues. When it comes to meeting the demands of growing education technology markets in underserved Indigenous and minority communities, localizing an app initially designed for maximum scalability is more feasible than investing significant resources converting apps custom designed for one language into new languages.

Implementation of pain best practices as part of the spinal cord injury knowledge mobilization network

Context/objective: The spinal cord injury (SCI) knowledge mobilization network (KMN) is a community of practice formed in 2011 as part of a national best practice implementation (BPI) effort to improve SCI care. This study objective was to determine whether completion and documentation of pain practices could be improved in a neurorehabilitation setting using the KMN implementation approach.Design: Single site, pre–post intervention study.Setting: Neurorehabilitation hospital.Participants: Twenty sequential consenting inpatients with SCI, with retrospective comparative analysis of 50 sequential SCI admissions pre-KMN.Interventions: A local Site Implementation Team (SIT) was formed to develop an implementation plan, including acceptable timeframes for completion and documentation of four specific pain best practices: (1) pain assessment on admission, (2) development of an Inter-Professional Pain Treatment Plan (IPTP), (3) pain monitoring throughout admission, and (4) a pain discharge plan.Outcomes: Provider adherences to pain best practices were the primary outcomes. The secondary outcome was patient satisfaction.Results: Provider adherence for most outcomes exceeded 70% completion within acceptable timeframes, with improvements found for all outcomes as compared to the retrospective cohort. Notably, pain education as part of the IPTP improved from 12% completion to 74%, documenting pain onset from 4.5% to 80% and pain discharge plan from 40% to 74%. Overall, participants were satisfied with their pain management.Conclusions: Pain best practices were more consistently documented after the KMN implementation. Pain practices in all four areas have now been expanded to all inpatient diagnoses using the same forms and framework created in the implementation process.

Testing a Motivational Interviewing Implementation Intervention in Adolescent HIV Clinics: Protocol for a Type 3, Hybrid Implementation-Effectiveness Trial.

BackgroundMotivational interviewing (MI) has been shown to effectively improve self-management for youth living with HIV (YLH) and has demonstrated success across the youth HIV care cascade—currently, the only behavioral intervention to do so. Substantial barriers prevent the effective implementation of MI in real-world settings. Thus, there is a critical need to understand how to implement evidence-based practices (EBPs), such as MI, and promote behavior change in youth HIV treatment settings as risk-taking behaviors peak during adolescence and young adulthood.ObjectiveThis study aims to describe the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) protocol of a tailored MI (TMI) implementation-effectiveness trial (ATN 146 TMI) to scale up an EBP in multidisciplinary adolescent HIV settings while balancing flexibility and fidelity. This protocol is part of the Scale It Up program described in this issue.MethodsThis study is a type 3, hybrid implementation-effectiveness trial that tests the effect of TMI on fidelity (MI competency and adherence to program requirements) while integrating findings from two other ATN protocols described in this issue—ATN 153 Exploration, Preparations, Implementation, Sustainment and ATN 154 Cascade Monitoring. ATN 153 guides the mixed methods investigation of barriers and facilitators of implementation, while ATN 154 provides effectiveness outcomes. The TMI study population consists of providers at 10 adolescent HIV care sites around the United States. These 10 clinics are randomly assigned to 5 blocks to receive the TMI implementation intervention (workshop and trigger-based coaching guided by local implementation teams) utilizing the dynamic wait-listed controlled design. After 12 months of implementation, a second randomization compares a combination of internal facilitator coaching with the encouragement of communities of practice (CoPs) to CoPs alone. Participants receive MI competency assessments on a quarterly basis during preimplementation, during the 12 months of implementation and during the sustainment period for a total of 36 months. We hypothesize that MI competency ratings will be higher among providers during the TMI implementation phase compared with the standard care phase, and successful implementation will be associated with improved cascade-related outcomes, namely undetectable viral load and a greater number of clinic visits among YLH.ResultsParticipant recruitment began in August 2017 and is ongoing. As of mid-May 2018, TMI has 150 active participants.ConclusionsThis protocol describes the underlying theoretical framework, study design, measures, and lessons learned for TMI, a type 3, hybrid implementation-effectiveness trial, which has the potential to scale up MI and improve patient outcomes in adolescent HIV settings.Trial RegistrationClinicalTrials.gov NCT03681912; https://clinicaltrials.gov/ct2/show/NCT03681912 (Archived by WebCite at http://www.webcitation.org/754oT7Khx)International Registered Report Identifier (IRRID)DERR1-10.2196/11200

Results of the implementation of a Spanish computerized guideline for depression in primary care

A new computerized CPG for Major Depression (e-CPG-MD) was integrated in electronic medical records of primary care in a 7 million population in Catalonia (Spain). An integrated design allows precise access in each patient visit, improving diagnosis, treatment and follow-up. It facilitates an evaluation of suicide risk in depressed patients.ObjectiveTo evaluate the effects of a multifactor process of implementation of the e-CPG MD, analyzing its use and the key clinical outcomes.MethodsA cluster randomized clinical trial was performed in 10 primary care centers (PCC) in Barcelona. In five of ten centers a multifaceted implementation process of the e-CPG-MD was developed during 6 month. The others five PCCs received only an usual diffusion. The multifaceted process includes an establishment of local implementation teams, an interactive training program, regular feedback audits, educational outreach visits and periodic reminders.ResultsAt six month, a greater proportion of new MD patients from active PCCs were included in the e- CPG-DEP (4.1% + 3.1% vs. 52.7% + 7.3%, p &lt; 0.001); the incidence of MD diagnostics of Major Depression increased significantly (rate quotient = 1.56, p &lt; 0.001) and the proportion of cases with moderate and severe MD too (13.6% vs 41.1%, p = 0.002).ConclusionsA multifaceted implementation method of an e-CPG-MD increased significantly its uses, the registered incidence of MD and improved the capacity of recognizing severity. Further analysis is necessary in order to determine the impact on clinical outcomes.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Developing and Field Testing a Community Based Youth Initiative to Increase Tuberculosis Awareness in Remote Arctic Inuit Communities.

BackgroundInuit in Canada have the highest reported tuberculosis (TB) incidence rate in Canada, even higher than other Canadian Indigenous groups. The aim of this study was to increase TB awareness among Inuit youth and their communities by equipping those who can best reach this population with a community based, youth focused, education initiative built on interventions adapted from a previous TB awareness study.MethodsThe Taima TB Youth Education Initiative was a field test case study of a knowledge translation (KT) strategy aimed at community members who provide health education in these communities. In the first stage of this study, interventions from a larger TB awareness campaign were adapted to focus on youth living in remote Inuit communities. During the second stage of the study, investigators field tested the initiative in two isolated Inuit communities. It was then applied by local implementation teams in two other communities. Evaluation criteria included feasibility, acceptability, knowledge uptake and health behavior change.ResultsImplementation of the adapted KT interventions resulted in participation of a total of 41 youth (19 females, 22 males) with an average age of 16 years (range 12–21 years) in four different communities in Nunavut. Community celebration events were attended by 271 community members where TB messaging were presented and discussed. All of the health care workers and community members surveyed reported that the adapted interventions were acceptable and a useful way of learning to some extent. Knowledge uptake measures indicated an average TB knowledge score of 64 out of 100. Local partners in all four communities indicated that they would use the Taima TB Youth Education Initiative again to raise awareness about TB among youth in their communities.ConclusionsThe TB awareness interventions adapted for the Taima TB Youth Education Initiative were acceptable to the Inuit communities involved in the study. They resulted in uptake of knowledge among participants. Implementation by local implementation teams was feasible as evidenced by the participation and attendance of youth and community members in all communities. The ability to implement the interventions by local implementation teams indicates there is potential to scale up in other remote communities in the arctic setting.

The AMS DataStreme Earth's Climate System Teacher Professional Development Course: Results from a Three-Year Study

ABSTRACTThe DataStreme Earth's Climate System (DataStreme ECS) course implementation has been built on 20 years of American Meteorological Society (AMS) in-service K–12 teacher professional development experience, and is supported by educational research. Using the Targeting Outcomes of Programs model, DataStreme ECS was evaluated over a three-year, six-semester (spring 2011–fall 2013) study period through content and pedagogical focused pre- and posttests, a postcourse assessment, and an environmental literacy evaluation. During the NASA and NSF-supported study period the course prepared 1,027 teachers, via 25 Local Implementation Teams serving 35 states, to lead and assist their students and peers in understanding climate and global change issues. Notable evaluation results include an average 28% grade increase for teacher participants from pre- to posttest, as well as an average of 98% of participants reporting that their environmental literacy had increased (some or much) as a result of the course. There was a 99% completion rate for registered participants, demonstrating the value teachers placed on the course. Additionally, in a spring 2011 evaluation of peer-training workshops given by a specialized group of DataStreme ECS-trained teachers, 94% of attendees gave the highest possible response when assessing workshop content, and 98% recommended that the workshop be offered to others. DataStreme ECS can serve as a curriculum and instruction model for those designing long-duration teacher professional development courses to work with a network of educators and scientists to increase program reach and build public scientific literacy.

Electronic health records and transgender patients--practical recommendations for the collection of gender identity data.

Transgender (Trans, Trans*) persons may have a gender identity and a preferred name that differ from those assigned at birth, and/or those listed on their current legal identification (Gender ID, Birth-assigned Sex, Legal Sex). Transgender people who are referred to in a clinical setting using the wrong pronoun or name may suffer distress, ridicule or even assault by others in the waiting area, and may not return for further care. Furthermore, failure to accurately document (and therefore count) transgender identities has negative implications on quality improvement and research efforts, funding priorities and policy activities. The recent announcement that gender identity data may be included in Meaningful Use Stage 3 has accelerated the need for guidance for both vendors and local implementation teams on how to best record and store these data. A recent study demonstrated wide variation in current practices. This manuscript provides a description of identifiers associated with gender identity, and makes practical and evidence based recommendations for implementation and front-end functionality.

Implementation of the World Health Organization Surgical Safety Checklist, Including Introduction of Pulse Oximetry, in a Resource-Limited Setting

To introduce the World Health Organization Surgical Safety Checklist into every operating room within a severely resource-limited hospital located in a developing country and to measure its impact on surgical hazards and complications. The checklist has been shown to reduce surgical morbidity and mortality, but the ability to successfully implement the checklist program hospital-wide in lower income settings without basic resources is unknown. We conducted a pre- versus postintervention study of the implementation of the checklist, including the introduction of universal pulse oximetry at a hospital in Chisinau, Moldova, where only 3 oximeters were available for their 22 operating stations. We supplied data-recording oximeters for all operating stations and trained a local checklist implementation team. The primary outcomes were process adherence, major complications, and rates of hypoxemia (SpO2 <90%). Propensity score weighing was conducted to adjust process and outcome measures. Regression models were used to evaluate adherence to process measures and hypoxemia trends over time. Data from 2145 pre- and 2212 postintervention cases were collected. Adherence to all safety processes increased significantly from 0.0% to 66.9% (P < 0.001). After checklist implementation, the overall complication rate decreased from 21.5% to 8.8% (P < 0.001). Infectious and noninfectious complications decreased significantly after checklist implementation from 17.7% to 6.7% (P < 0.001) and from 2.6% to 1.5% (P = 0.018), respectively. The number of hypoxemic episodes lasting 2 minutes or longer per 100 hours of oximetry decreased from 11.5 to 6.4 (P < 0.002). Successful hospital-wide Surgery Safety Checklist implementation can be achieved in a resource-limited setting and can significantly reduce surgical hazards and complications.

Open Access in the Patient-Centered Medical Home: Lessons from the Veterans Health Administration

The Veterans Health Administration (VHA) has undertaken a 5-year initiative to transform to a patient-centered medical home model. An early focus of implementation was on creating open access, defined as continuity and capacity in primary care. We describe the impact of readiness for implementation on efforts of pilot teams to make changes to improve access and identify successful strategies used by early adopters to overcome barriers to change. A qualitative, formative evaluation of the first 18 months of implementation in one Veterans Integrated Service Network (VISN) spread across six states. Members of local implementation teams including administrators, primary care providers, and staff from primary care clinics located at 10 medical centers and 45 outpatient clinics. We conducted site visits during the first 6 months of implementation, observations at Learning Collaboratives, semi-structured interviews, and review of internal organizational documents. All data collection took place between April 2010 and December 2011. Early adopters employed various strategies to enhance access, with a focus on decreasing demand for face-to-face care, increasing supply of different types of primary care encounters, and improving clinic efficiencies. Our interviews with key contacts revealed three important areas where readiness for implementation (or lack thereof) had an impact on interventions to improve access: leadership engagement, staffing resources, and access to information and knowledge. Key factors related to readiness for implementation had an impact on which interventions pilot teams could put into place, as well as the viability and sustainability of access gains. Wide variations in interventions to improve access occurring across sites situated within one organization have important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems-level indicators of the Medical Home.

Physical and Virtual Environment for Automation Education of Engineers and Technicians, Part 3: Improvement of joint distant laboratory activities in process control and automation based on past experience

Current industrial software technology offers the possibility for the plant staff to operate production systems without an obligate need to be present on the production floor. Our project, which earlier phases were presented in the last CEEA conference, proposed joint learning activities related to this reality for the training of future engineers and technicians. It is a collaboration between the Université du Québec à Rimouski (UQAR) and the Cégep de Rivière-du-Loup (CEGEP), both located in the eastern Quebec region. Activities were conducted under two different themes: (i) process control activities using a hydraulic training setup, and (ii) sequential automation activities using individual units of a mini-plant designed for recycling beverage bottles and cans. The third phase of the project, being the subject of this paper, was to improve the virtual environment and laboratory activities from past experience results, and evaluate the effectiveness of these modifications. To state a few modifications as examples, the activities contexts were modified from a customer-client relation between the teams to a more cooperative scenario, as distant and local implementation teams from the same service provider. The sequential automation activity was conducted on a more complete and operational mini-plant, and the student teams were involved in a more interactive work, involving exchange of files and sharing common work objectives. All activities started with a physical encounter between the student teams, which effectively helped to improve comradeship. Results once again showed that students from both institutions successfully worked and communicated together despite their different skills and backgrounds. Training objectives for this phase were successfully attained and the lessons learned were exploited to effectively enhance the training level and the studentacquired skills through the activities.

Knowledge-to-action processes in SHRTN collaborative communities of practice: A study protocol

BackgroundThe Seniors Health Research Transfer Network (SHRTN) Collaborative is a network of networks that work together to improve the health and health care of Ontario seniors. The collaborative facilitates knowledge exchange through a library service, knowledge brokers (KBs), local implementation teams, collaborative technology, and, most importantly, Communities of Practice (CoPs) whose members work together to identify innovations, translate evidence, and help implement changes.This project aims to increase our understanding of knowledge-to-action (KTA) processes mobilized through SHRTN CoPs that are working to improve the health of Ontario seniors. For this research, KTA refers to the movement of research and experience-based knowledge between social contexts, and the use of that knowledge to improve practice. We will examine the KTA processes themselves, as well as the role of human agents within those processes. The conceptual framework we have adopted to inform our research is the Promoting Action on Research Implementation in Health Services (PARIHS) framework.Methods/designThis study will use a multiple case study design (minimum of nine cases over three years) to investigate how SHRTN CoPs work and pursue knowledge exchange in different situations. Each case will yield a unique narrative, framed around the three PARIHS dimensions: evidence, context, and facilitation. Together, the cases will shed light on how SHRTN CoPs approach their knowledge exchange initiatives, and how they respond to challenges and achieve their objectives. Data will be collected using interviews, document analysis, and ethnographic observation.DiscussionThis research will generate new knowledge about the defining characteristics of CoPs operating in the health system, on leadership roles in CoPs, and on the nature of interaction processes, relationships, and knowledge exchange mechanisms. Our work will yield a better understanding of the factors that contribute to the success or failure of KTA initiatives, and create a better understanding of how local caregiving contexts interact with specific initiatives. Our participatory design will allow stakeholders to influence the practical usefulness of our findings and contribute to improved health services delivery for seniors.

The Seniors Health Research Transfer Network Knowledge Network Model: System-Wide Implementation for Health and Healthcare of Seniors

The Ontario Seniors Health Research Transfer Network (SHRTN) aims to improve the health of older adults through increasing the knowledge capacity of 850 community care agencies and 620 long-term care homes. The SHRTN includes caregivers, researchers, policy makers, administrators, educators, and organizations. The SHRTN comprises communities of practice, a library service, a network of 7 research institutes, and local implementation teams. The SHRTN combines face-to-face meetings with information technology to promote change at the client care level in organizational and provincial policies and in the promotion of health services research.

Supported local implementation of clinical guidelines in psychiatry: a two-year follow-up.

BackgroundThe gap between evidence-based guidelines for clinical care and their use in medical settings is well recognized and widespread. Only a few implementation studies of psychiatric guidelines have been carried out, and there is a lack of studies on their long-term effects.The aim of this study was to measure compliance to clinical guidelines for treatment of patients with depression and patients with suicidal behaviours, two years after an actively supported implementation.MethodsSix psychiatric clinics in Stockholm, Sweden, participated in an implementation of the guidelines. The guidelines were actively implemented at four of them, and the other two only received the guidelines and served as controls. The implementation activities included local implementation teams, seminars, regular feedback, and academic outreach visits. Compliance to guidelines was measured using quality indicators derived from the guidelines. At baseline, measurements of quality indicators, part of the guidelines, were abstracted from medical records in order to analyze the gap between clinical guidelines and current practice. On the basis of this, a series of seminars was conducted to introduce the guidelines according to local needs. Local multidisciplinary teams were established to monitor the process. Data collection took place after 6, 12, and 24 months and a total of 2,165 patient records were included in the study.ResultsThe documentation of the quality indicators improved from baseline in the four clinics with an active implementation, whereas there were no changes, or a decline, in the two control clinics. The increase was recorded at six months, and persisted over 12 and 24 months.ConclusionsCompliance to the guidelines increased after active implementation and was sustained over the two-year follow-up. These results indicate that active local implementation of clinical guidelines involving clinicians can change behaviour and maintain compliance.