Confronting actual practice with practice guidelines in oncology.

Improving health care quality requires the availability of data to identify and eliminate unnecessary variations in the care process. Variations can be caused by an ineffective implementation of research findings or by obstacles to the translation of research into clinical practice. The analysis of current patterns of care by the use of routine data from electronic patient records or clinical registries may help highlight these deficiencies in actual care. The growing infrastructure of information technologies and the knowledge about clinically relevant variations of routine practice may help us understand the mechanisms that are impeding the translation of research into practice. There is a need to scrutinize these variations of practice and the barriers to guideline implementation. We think that an understanding and open discussion of such reasons may help, to continuously improve the quality of patient care. This process facilitates efforts and strategies to implement evidence-based medicine in the daily routine.     

Discipline-based approaches to evidence-based practice: a view from nursing.

BACKGROUND: Research carried out by nurses or by others on patient problems of concern to nurses is contributing to the development of evidence-based nursing practice. In the past few decades, there has been a dramatic increase in clinical research, in health services research, and in the content and process of informatics, all focused on nursing care. The translation of findings of this research into clinical practice and the organization of nursing is less dramatic. The opportunity to implement research-based practice is great, but requires attention, methods, and resources. Also required are a database and an information system which include terms essential to nursing practice. DIMENSIONS OF NURSES' INVOLVEMENT IN EVIDENCE-BASED PRACTICE: The importance of nurses' involvement in evidence-based practice (EBP) can be viewed from three perspectives: (1) nurses' participation in medical problems and medical interventions, (2) nursing problems and nursing interventions, and (3) development and use of a standardized language that describes the problems, interventions, and outcomes important to nursing. APPLYING EBP TO COMBINED MEDICAL AND NURSING PROBLEMS: The best outcomes for a specific patient population are achieved through a combination of the medical and nursing problems and evidence-based interventions. Examples of problems of importance to nursing practice and research include pain, dehydration, incontinence, lifestyle change, confusion, immobility, knowledge deficit, noncompliance, anxiety, skin breakdown, inappropriate use of restraints, and falls. Interventions for prevention and treatment of the individual problem or combination of problems comprise the focus of nursing research and EBP.     

Implementing evidence-based recommendations for health care: a roundtable comparing European and American experiences

BACKGROUND: A roundtable held October 5-6 1999, in Maidstone, Kent, United Kingdom, was convened to identify current strategies and ongoing challenges in implementing evidence-based practice guidelines in health care. Despite numerous new medical research findings for improving health care and despite the dissemination of many practice guidelines, the recommendations from these efforts are not being uniformly adopted. Overuse, underuse, and misuse plague the practice of medicine today. IMPLEMENTING GUIDELINES: Multiple implementation strategies are more likely to succeed that a single implementation method; local selection and adaptation of guidelines are critical; and reminders, educational outreach (for prescribing), and interactive educational workshops are generally effective. EXPERIENCE IN EUROPE: In most countries, guideline development has progressed from consensus conference, to evidence-based statements, and finally to evidence-based guidelines that also consider cost-effectiveness. Guideline development is the most advanced in The Netherlands, where physicians have coordinated their efforts with the government to achieve more uniformity than is found elsewhere. EXPERIENCE IN THE UNITED STATES: Designing systems that will facilitate change--not changing physician behavior--should be the focus. The concern for effecting improvement in health care is now more acute because of the increased attention being given to medical errors and patient safety. SUMMARY STATEMENT: Multifaceted approaches are clearly the most important method for improving care. Such approaches may include many improvement methods, none of which work well alone most of the time or any of the time.     

Issues in the development, dissemination, and effect of an evidence-based guideline for managing sore throat in adults

BACKGROUND: In October 1995 the University of Michigan Healthcare System initiated a program to develop and implement guidelines for primary care in an effort to improve the quality and cost-effectiveness of care for common conditions associated with wide variations in clinical practice. One of these conditions was Group A beta-hemolytic streptococcus (GABHS), present in 5% to 20% of adults complaining of sore throat. METHODS: A draft guideline was developed on the basis of a theoretical model of sore throat management, local data, and research evidence. The guideline was revised to reflect physicians' beliefs and practices regarding sore throat management. Guideline recommendations depended only on the number of clinical signs experienced by the patient and included testing only if it was likely to provide additional information about the probability of GABHS. Data on pre- and postdissemination data on patients presenting with sore throat were collected. RESULTS: When physicians believed testing or antibiotics were unnecessary, only 7% of patients demanded screening and only 6% of patients wanted antibiotics. Physician beliefs about a patient's need for testing agreed with guideline recommendations in 63% of patients both before and after guideline dissemination. DISCUSSION: Disseminating locally modified, evidence-based guidelines may not be sufficient to produce practice changes. If the guideline had been followed, the amount of testing would have been reduced by 17% and the appropriateness of testing improved for 32% of sore throat patients. The results indicate the need for implementation efforts that go beyond presenting evidence, even when that evidence is from both the literature and the local practice setting.     

One size does not fit all: questions to answer before intervening to change physician behavior.

BACKGROUND: Many interventions have been conducted to change physician behavior, but there is not much evidence regarding their effectiveness. A list of questions is proposed for those who would attempt such interventions: 1. Does the behavior (or decision making) need to be changed? This implies the next two questions. 1a. Is there a logical, evidence-based argument that one decision alternative is preferable for a particular situation? If the would-be behavior changer cannot make an evidence-based argument for changing behavior, there is little moral authority to intervene. 1b. Is there evidence that physicians are not choosing this decision alternative when they should? Interventions are often prompted by evidence that utilization of an alternative was too high or low, but physicians' decisions are not the only determinants of utilization. 2. What is the problem with the decision making? Common sense suggests that different problems require different solutions. Yet interventions are often pursued in the absence of clear information about the reasons physicians did not exhibit the preferred behavior. 3. How could the decision making best be changed? Finding the cognitive problems that caused "wrong" behavior should directly lead to the design of simple, targeted, effective interventions to change this behavior. The judgment and decision making psychology literature suggests that general instruction in reasoning and probability may improve judgments and decision processes. SUMMARY: Physicians' behavior appears to be resistant to change. Understanding why the behavior should be changed and what caused it may make the process of designing interventions more complicated. The resulting interventions, however, are more likely to be simple and successful.     

Taking the national guideline for care of acute myocardial infarction to the bedside: developing the guideline applied in practice (GAP) initiative in Southeast Michigan.

BACKGROUND: The Guideline Applied in Practice (GAP) program was developed in 2000 to improve the quality of care by improving adherence to clinical practice guidelines. For the first GAP project, the American College of Cardiology (ACC) partnered with the Southeast Michigan Quality Forum Cardiovascular Subgroup and the Michigan Peer Review Organization (MPRO) to develop interventions that might facilitate the use of the ACC/AHA Acute Myocardial Infarction (AMI) guideline in the practice setting. Ten Michigan hospitals participated in implementing the project, which began in March 2000. DESIGNING THE PROJECT: The project developed a multifaceted intervention aimed at key players in the care delivery triangle: the physician, nurse, and patient. Intervention components included a project kick-off presentation and dinner, creation and implementation of a customized tool kit, identification and assignment of local nurse and physician opinion leaders, grand rounds site visits, and measurement before and after the intervention. IMPLEMENTING THE PROJECT: The GAP project experience suggests that hospitals are enthusiastic about partnering with ACC to improve quality of care; partners can work together to develop a program for guideline implementation; rapid-cycle implementation is possible with the GAP model; guidelines and quality indicators for AMI are well accepted; and hospitals can adapt the national guideline for care into usable tools focused on physicians, nurses, and patients. DISCUSSION: Important structure and process changes--both of which are required for successful QI efforts--have been demonstrated in this project. Ultimately, the failure or success of this initiative will depend on an indication that the demonstrated improvement in the quality indicators is sustained over time.     

Effecting and leading change in health care organizations

BACKGROUND: Understanding change is crucial to implementing quality improvement (QI) initiatives. Widespread change will be required to correct what many consider to be outmoded and deficient systems of care. This article summarizes the current literature--within both health care and the fields of business and management--regarding how change occurs at the individual and organizational levels. Part 1 focuses on changing clinician behavior, which is instrumental to any effort directed in the health care setting. Part 2 examines the culture of change. Part 3 addresses issues of leadership, along with the necessary steps to guide change in an organization. Part 4 summarizes key elements of change. Finally, Part 5 provides three case examples of QI initiatives reported in the recent literature to illustrate how the application of the knowledge of change management can assist in the successful implementation of QI programs. KEY ELEMENTS OF CHANGE: The knowledge base regarding successful change in health care organizations can be summarized in eight crucial strategies or principles: (1) develop a vision for change, (2) focus on the change process, (3) analyze which individuals in the organization must respond to the proposed change and what barriers exist, (4) build partnerships between physicians and the administration, (5) create a culture of continuous commitment to change, (6) ensure that change begins with leadership, (7) ensure that change is well communicated, and (8) build in accountability for change. CONCLUSION: A knowledge of change management can help leaders of QI programs in health care organizations successfully apply these concepts to bring about much-needed transformations in health care.     

可持续行为设计研究综述

目的 探索可持续行为设计的理论基础、发展现状及其设计策略的实现机制。方法 通过文献回顾,梳理了行为改变的理论基础,分析了“为行为改变而设计”的理论与方法的研究现状,讨论了可持续行为设计策略,最后对相关案例进行了归纳、梳理。结果 明晰了可持续行为设计的理论基础、研究现状和设计策略,提出了可持续行为设计策略下可视化、游戏化和情境计算等说服技术的实现机制。结论 可持续行为设计经过多年发展和研究,具备扎实的理论基础,形成了系统的、层次分明的设计策略。在可视化、游戏化、情境计算等新技术的加持下,可持续行为设计策略的实现机制正日渐完善。未来还应重视社会对个体行为改变的影响以及对可持续性指标的测量。     

Information technology diffusion in higher education

This project examines information technology (IT) planning, implementation, and diffusion in an academic environment, that of Portland Community College (PCC), the largest college in Oregon. PCC tries to keep pace with the latest technologies by anticipating and implementing new technology solutions in efficient and effective deployments. IT managers and employees at PCC were asked to complete a survey that included questions about IT planning, implementation, and diffusion. This paper proposes a conceptual framework based on previous models of technology adoption. The integrated, three-stage framework involves IT planning, actual IT implementation, and IT diffusion. The study identified adequate training and resistance to change as leading obstacles to IT deployment processes.     

Guideline implementation: what the literature doesn't tell us

BACKGROUND: Despite large numbers of studies and literature reviews about guideline implementation, it remains unclear whether and how clinical guidelines can be used to improve the quality of medical care. This study sought to learn whether these studies and reviews have recognized the importance of systems thinking and organizational change for implementation. METHODS: A literature search was conducted for systematic reviews of guideline implementation or practice improvement studies. Each review was studied for the extent to which it identified or discussed the value of systems changes, organizational support, practice environmental factors, and use of a change process. RESULTS: Forty-seven good-quality systematic reviews were found. They largely concurred that using reminders and perhaps using feedback in the course of clinical encounters were the most effective ways of implementing guidelines. However, these same reviews rarely identified these strategies as systems changes, and there was little discussion about any need for organizational support or attention to various environmental variables that might affect implementation. The change process required to introduce a new or changed practice system received even less attention. CONCLUSION: Reviews of guideline implementation trials have focused on how to change the behavior of individual clinicians. There has been little attention to the impact of practice systems or organizational support of clinician behavior, the process by which change is produced, or the role of the practice environmental context within which change is being attempted. New attention to these issues may help us to better understand and undertake the process of improving medical care delivery.     

A quality improvement approach to reducing use of meperidine

BACKGROUND: In 1991 the University of Wisconsin Hospital and Clinics formed a pain management QI team whose goal was to improve pain management through education, outcome monitoring, and the development of programs intended to improve clinical practice. Longitudinal monitoring mechanisms were established to audit medical records and survey patients to examine both staff practice patterns and patient outcomes. The QI team targeted use of meperidine, one of the most widely used opioid analgesics for the treatment of moderate to severe pain, which is now discouraged as a first-line agent for most painful conditions. IMPLEMENTING THE QI PROCESS: A QI process was implemented using a traditional plan-do-check-act (PDCA) model, resulting in a successful and sustained reduction of inappropriate meperidine use. A cause-and-effect diagram helped highlight the multiple factors contributing to the drug's overuse and was used to prioritize targets for action. A flow chart helped to uncover some of the interrelationships between the myths about meperidine and the resultant customary prescribing and administration practices. While most of the strategies were implemented in 1996 (formulary guideline release, change in stock supply and physician orders, staff education and feedback), a significant impact in practice was not seen until late 1997. Ongoing tracking and feedback loops were established to ensure continued low use of meperidine. CONCLUSION: Use of a QI approach in pain management has been shown to affect the visibility of pain as a clinical priority, enhance interdisciplinary collaboration, facilitate the implementation of clinical guidelines at the bedside, and improve the quality of care for patients.     

Applying quality improvement principles to achieve healthy work organizations

BACKGROUND: Health care has used total quality management (TQM)/quality improvement (QI) methods to improve quality of care and patient safety. Research on healthy work organizations (HWOs) shows that some of the same work organization factors that affect employee outcomes such as quality of life and safety can also affect organizational outcomes such as profits and performance. An HWO is an organization that has both financial success and a healthy workforce. For a health care organization to have financial success it must provide high-quality care with efficient use of scarce resources. To have a healthy workforce, the workplace must be safe, provide good ergonomic design, and provide working conditions that help to mitigate the stress of health care work. INTEGRATING TQM/QI INTO THE HWO PARADIGM: If properly implemented and institutionalized, TQM/QI can serve as the mechanism by which to transform a health care organization into an HWO. To guide future research, a framework is proposed that links research on QI with research on HWOs in the belief that QI methods and interventions might be an effective means by which to create an HWO. Specific areas of research should focus on identifying the work organization, cultural, technological, and environmental factors that affect care processes; affect patient health, safety, and satisfaction; and indirectly affect patient health, safety, and satisfaction through their effects on staff and care process variables. SUMMARY: Integrating QI techniques within the paradigm of the HWO paradigm will make it possible to achieve greater improvements in the health of health care organizations and the populations they serve.     

Conference report. Measuring and improving the quality of care in health plans.

BACKGROUND: More than 200 health care policymakers and researchers, clinicians, quality professionals, and other representatives of managed care organizations, government, and academia, attended the fifth annual Building Bridges conference, "The Health Care Puzzle: Using Research to Bridge the Gap Between Perception and Reality," in Chicago, April 11-13, 1999. Sponsored by the American Association of Health Plans and the Agency for Health Care Policy and Research--and now, the Centers for Disease Control and Prevention--these annual conferences are intended to promote research in measuring the quality and effectiveness of the services health plans provide. Selected plenary sessions from the conference are represented in this report. KEYNOTE ADDRESS: "Three worthy objectives" for managed care-harmonize practice guidelines, develop evidence-based copays or price structure for drugs, and demystify medical necessity--were discussed. PLENARY: A POPULATION HEALTH PERSPECTIVE: Population-based care is designed to identify effective clinical and service interventions and ensure their efficient delivery, identify ineffective interventions and minimize their use, and monitor outcomes and change practice if outcomes are suboptimal. Yet certain questions need to be asked about how to put this strategy in place, especially Why should any individual or potential patient be willing to be treated in a population-based delivery system? THE FINANCIAL AND SCIENTIFIC EVIDENCE BEHIND PREVENTION: The concepts of scientific evidence and financial evidence for prevention were reviewed and applied in scenarios of the effectiveness and cost-effectiveness of selected preventive care services. Education efforts are needed to promote the use of effective interventions and encourage questioning of interventions with unproven or less important effectiveness and poor cost-effectiveness.     

基于行为体验的交互式酒包装设计研究

目的 将行为体验理论应用于酒包装设计实践,以降低用户对交互式包装的理解和学习成本,探索理论用于实际的有效方法,寻求生产装配与设计之间的潜在联系。方法 从行为体验中行动的几个阶段框架出发,提炼出用户行为阶段中的无意识阶段、交互的执行和评估鸿沟。将理论与设计实践结合,着重对无意识阶段、执行鸿沟、评估鸿沟进行设计,将理论融入产品的设计全流程。结果 得到了一款基本满足用户要求的交互式酒包装,用户行为的无意识阶段能够减少用户的操作步骤,降低学习使用的成本。结论 行为体验理论的基本框架可以有效提炼出用户的无意识阶段、执行鸿沟、评估鸿沟,对产品交互设计能够起到较好的设计指导,探索出交互式包装设计的新方法,不仅为同行在包装设计上提供了理论研究参考,也对行为体验的理论应用研究有一定扩展。     

智能家居综合实验平台设计研究与应用实践

目的 梳理和分析智能家居相关实验平台现状,探究智能家居综合实验平台的设计研究方法,对平台的构建展开应用实践。方法 以智能家居理论框架为基础,从传感器网络、数据、场景、被试等多个角度出发,对智能家居综合实验平台的设计方法和应用实践进行阐释。结果 提出智能家居综合实验平台中围绕“感知”“思考”“执行”3个层面的理论框架、应用实践研究方法和实践案例。结论 智能家居综合实验平台的理论构架对于智能家居领域的科研问题具有一定的理论影响力,3个层次在建设时相互独立,在理论中相互印证,在实践中相互支撑。建立智能家居综合实验平台,可以为智能家居及其相关领域的科研和产业问题提供实验场地、关键数据、核心算法等支撑,使相关研究可以在更完备、更集成及鲁棒性更强的框架下展开。智能家居综合实验平台的研究和实践整合了现有知识体系,从顶层设计、传感网络、数据研究、算法模型、用户研究、人机交互等多学科多领域交叉的角度为学术界和产业界提供参考,全面地推动智能家居领域的技术进步和设计创新。     

From book to bedside: putting evidence to use in the care of the elderly.

BACKGROUND: Infusion of research findings into clinical practice is a challenging part of the research process. Because the length of time between discovery and use of knowledge averages 20 years, methods are needed to speed translation of research findings into practice. Few efforts have been made to coordinate the generation of new knowledge with the dissemination of findings from research to improve care of the elderly. RESEARCH-BASED PRACTICE PROTOCOLS: The Research Development and Dissemination Core (RDDC) of the Gerontological Nursing Interventions Research Center (GNIRC) at the University of Iowa emphasizes development of research-based (RB) protocols, which requires collecting relevant literature, critiquing studies, and synthesizing research findings for practice. GNIRC-generated research is disseminated to nurses in practice, and the RDDC links nurses who identify clinical problems in care of the elderly with GNIRC scientists. Currently, 19 RB protocols are offered for dissemination through the RDDC, and 5 protocols are under development. Implementation and evaluation of research-based practices on "Split Thickness Skin Graft Donor Site Care" and "Nasogastric/Nasointestinal Tube Placement" are described. CONCLUSIONS: Lessons learned on the basis of experience in disseminating and implementing research-based practices include the necessity of tailoring them to the local needs of various clinical settings in which they are used, reinfusing them periodically to keep staff motivated, and making them consumer friendly. The challenge remains to integrate these practices into the fiber of organizations and to keep staff educated and motivated to carry out research-based practices to improve the care of the elderly.     

Injury and risk-taking behavior-a systematic review

There is a substantial body of work in the scientific literature discussing the role of risk-taking behavior in the causation of injury. Despite the quantity of diverse writings on the subject most is in the form of theoretical commentaries. This review was conducted to critically assess the empirical evidence supporting the association between injury and risk-taking behavior. The review found six case-control studies and one retrospective cohort study, which met all the inclusion criteria. Meta-analysis was not possible due to the diversity of the independent and outcome variables in each of the studies reviewed. Overall the review found that risk-taking behavior, however it is measured, is associated with an increased chance of sustaining an injury except in the case of high skilled, risk-taking sports where the effect may be in the other direction. Drawing specific conclusions from the research presented in this review is difficult without an agreed conceptual framework for examining risk-taking behavior and injury. Considerable work needs to be done to provide a convincing evidence base on which to build public health interventions around risk behavior. However, sufficient evidence exists to suggest that effort in this area may be beneficial for the health of the community.     

屏幕字体设计的四层次理论研究

目的 拓展原本字体设计的专业领域,将其置入更广阔的语境中进行探讨,以一种宏观视角建立起适用于屏幕媒介的新型字体理论框架。方法 在对传统字体设计理论进行梳理的基础上,结合布坎南所提出的设计四层次理论,归纳总结出包含符号语言、信息载体、阅读方式、意义构建的屏幕字体设计的理论框架。结论 通过研究发现,传统字体理论不仅对屏幕字体中新的物理属性如动态、空间、视觉、声音等元素缺乏研究,也不足以用来解释与分析在屏幕阅读中新的观看方式及行为方式。本文建立起的框架系统为屏幕字体实践与教学提供了一个新的依据,同时为字体理论研究提供了一个新的视域。     

The influence of instructional variables on the effectiveness of traffic education†

Experiments in teaching children safe traffic behavior vary widely in objectives, methods, design and subjects. To induce generalisation of the experimental findings a model has been developed in which the factors influencing the effectiveness of the traffic training can be identified. Within the framework of this model the experimental data concerning the instructional variables are discussed in terms of instructional situations, methods and audio-visual media. Instructional stiuations may be divided in real traffic situations, real street situations without traffic, semi-real situations, simulated street situations and the classroom. The real traffic situation appears to be the most suitable for traffic training, whereas classroom training may be effective if certain methods are used in conjunction with audiovisual aids. The methods used in traffic training may be described as theoretical instruction, demonstrations, practical training and behavior modification. There is littel evidence that theoretical instruction is effective in influencing road safety behavior. The best results seem to be obtained from demonstrations and behavior modification. Media play an increasingly important role in traffic training, the studies mainly focus on table-top models, slides, film/video and print material. The most promising results are found in experiments using film or video, especially when these films are based on demonstrations following imitation-learning principles. Finally, some conclusions are drawn concerning further research and the practical implementation of the findings.     

Quality improvement in a managed care organization from a medical director's perspective: an interview with Bruce Perry. Interview by Douglas Roblin

BACKGROUND: In late 1994 the Quality Forum commissioned the Interdisciplinary Prevention Committee [IPC]. One of the IPC's charges was to identify priorities for QI in preventive health services. The IPC established priorities through a review of scientific literature, identification of national and state health initiative priorities, and consideration of what services to establish as priorities and of the practicality of implementing low-cost interventions to achieve specific QI goals. Breast cancer screening was selected as a top-ten priority for guideline development and for focused intervention because of the disease's prevalence, morbidity, and mortality and because of the fact that it is most treatable and curable when it is found early through routine screening. The national HEDIS (Health Plan Employer Data and Information Set; National Committee on Quality Assurance (NCQA), Washington, DC] result of 71%, reported in May 1995, provided our baseline performance measurement. This result fell short of our goal of being in the 90th percentile of performance on each HEDIS effectiveness of care measure. In August 1995 the Quality Forum accepted the IPC's recommendations, which had been endorsed by the department of medicine. These recommendations emphasized the importance of annual clinical breast exam and mammography for women of targeted age groups. In November 1997, a new "Excellence in Quality: HEDIS Improvement Team" began work. Its charge was to undertake analyses of underlying causes of reduced performance and to develop additional steps to improve performance by changes in care delivery processes in 1998. In March 1998 the Quality Forum's executive committee designated breast cancer screening one of the six organizationwide quality priorities for 1998 and designated two "owners" who would be accountable for this performance--the chief and director of radiology. RESULTS: The screening rate increased from 73.8% in 1996 to 84.0% in 1999. National benchmarks [90th percentile] in 1998 were 81% for commercially insured members and 84% for Medicare members. The 84% screening rate made the Georgia region the Kaiser Permanente national leader and put the region in the top 10% of all health plans in the United States. CONCLUSIONS: The program has achieved these results with a broad array of activities: Saturday hours, mobile mammography, medical record reminders (fuschia-colored inserts), patient and physician reminders, call-center outreach, provider feedback on performance, and provider financial incentives. Several of these innovations demonstrate the ability to integrate improved care management into evolving service delivery in Kaiser Permanente--such as use of call-center technologies and redesign of primary care delivery. While we cannot point to any one of these innovations as a key driver of improvement, it is clear that substantial improvements in care delivery can be achieved. All these activities are relatively low cost and easily implemented in other managed care organizations and in other areas of medical care.