951 resultados para Practice changes


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OBJECTIVE: The aim of this study was to assess the implementation process and economic impact of a new pharmaceutical care service provided since 2002 by pharmacists in Swiss nursing homes. SETTING: The setting was 42 nursing homes located in the canton of Fribourg, Switzerland under the responsibility of 22 pharmacists. METHOD: We developed different facilitators, such as a monitoring system, a coaching program, and a research project, to help pharmacists change their practice and to improve implementation of this new service. We evaluated the implementation rate of the service delivered in nursing homes. We assessed the economic impact of the service since its start in 2002 using statistical evaluation (Chow test) with retrospective analysis of the annual drug costs per resident over an 8-year period (1998-2005). MAIN OUTCOME MEASURES: The description of the facilitators and their implications in implementation of the service; the economic impact of the service since its start in 2002. RESULTS: In 2005, after a 4-year implementation period supported by the introduction of facilitators of practice change, all 42 nursing homes (2,214 residents) had implemented the pharmaceutical care service. The annual drug costs per resident decreased by about 16.4% between 2002 and 2005; this change proved to be highly significant. The performance of the pharmacists continuously improved using a specific coaching program including an annual expert comparative report, working groups, interdisciplinary continuing education symposia, and individual feedback. This research project also determined priorities to develop practice guidelines to prevent drug-related problems in nursing homes, especially in relation to the use of psychotropic drugs. CONCLUSION: The pharmaceutical care service was fully and successfully implemented in Fribourg's nursing homes within a period of 4 years. These findings highlight the importance of facilitators designed to assist pharmacists in the implementation of practice changes. The economic impact was confirmed on a large scale, and priorities for clinical and pharmacoeconomic research were identified in order to continue to improve the quality of integrated care for the elderly.

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Sustainability of change for improvement initiatives has been widely reported as a global challenge both within and outside health care settings. The purpose of this study was to examine the extent to which factors related to staff training and involvement, staff behaviour, and clinical leaders’ and senior leaders’ engagement and support impact the long term sustainability of practice changes for BPSO health care organizations who have implemented Registered Nursing Association of Ontario’s (RNAO) Best Practice Guidelines. Semi structured interviews with eleven organizational leaders’ from ten health care organizations were conducted to explore the unique experiences, views and perspectives on factors related to staff, clinical leaders and senior leaders and their involvement and impact on the long term sustainability of clinical practice changes within organizations who had implemented Registered Nursing Association of Ontario’s (RNAO) Best Practice Guidelines (BPGs). The interviews were coded and analyzed using thematic content analysis. Further analysis identified patterns and themes in relation to: 1. The National Health Service (NHS) Sustainability Model which was used as the theoretical framework for this research; and 2. Organizations found to have sustained practice changes longer term verses organizations that did not. Six organizations were found to have sustained practice changes while the remaining four were found to have been unsuccessful in their efforts to sustain the changes. Five major findings in relation to sustainability emerged from this study. First is the importance of early and sustained engagement and frontline staff, managers, and clinical leaders in planning, implementation and ongoing development of BPGs through use of working groups and champions models. Second is the importance of ongoing provision of formal training, tools and resources to all key stakeholders during and after the implementation phase and efforts made to embed changes in current processes whenever possible to ensure sustainability. Third is to ensure staff and management are receptive to the proposed change(s) and/or have been given the necessary background information and rationale so they understand and can support the need for the change. Fourth is the need for early and sustained fiscal and human resources dedicated to supporting BPG implementation and the ongoing use of the BPGs already in place. Fifth is ensuring clinical leaders are trusted, influential, respected and seen as clinical resources by frontline staff. The significance of this study lies in a greater understanding of the influence and impact of factors related to staff on the long term sustainability of implemented practice changes within health care organizations. This study has implications for clinical practice, policy, education and research in relation to sustainability in health care.

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This new cardiovascular policy, Changing Cardiovascular Health covering the period 2010-2019, comes a decade after the first national cardiovascular health strategy, entitled Building Healthier Hearts, was published by the Department of Health in 1999. The new policy is timely given the pace of scientific discovery and related changes in medical practice, changes in health service structures, and patterns and influences on population health behaviours in Ireland over the decade. Cardiovascular health and its maintenance is a microcosm of health more generally. A policy that can improve cardiovascular health and cardiovascular disease management will have beneficial effects for the whole healthcare system and population.Download this document

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1 Summary This dissertation deals with two major aspects of corporate governance that grew in importance during the last years: the internal audit function and financial accounting education. In three essays, I contribute to research on these topics which are embedded in the broader corporate governance literature. The first two essays consist of experimental investigations of internal auditors' judgments. They deal with two research issues for which accounting research lacks evidence: The effectiveness of internal controls and the potentially conflicting role of the internal audit function between management and the audit committee. The findings of the first two essays contribute to the literature on internal auditors' judgment and the role of the internal audit function as a major cornerstone of corporate governance. The third essay theoretically examines a broader issue but also relates to the overall research question of this dissertation: What contributes to effective corporate governance? This last essay takes the perspective that the root for quality corporate governance is appropriate financial accounting education. r develop a public interest approach to accounting education that contributes to the literature on adequate accounting education with respect to corporate governance and accounting harmonization. The increasing importance of both the internal audit function and accounting education for corporate governance can be explained by the same recent fundamental changes that still affect accounting research and practice. First, the Sarbanes-Oxley Act of 2002 (SOX, 2002) and the 8th EU Directive (EU, 2006) have led to a bigger role for the internal audit function in corporate governance. Their implications regarding the implementation of audit committees and their oversight over internal controls are extensive. As a consequence, the internal audit function has become increasingly important for corporate governance and serves a new master (i.e. the audit committee) within the company in addition to management. Second, the SOX (2002) and the 8th EU Directive introduced additional internal control mechanisms that are expected to contribute to the reliability of financial information. As a consequence, the internal audit function is expected to contribute to a greater extent to the reliability of financial statements. Therefore, effective internal control mechanisms that strengthen objective judgments and independence become important. This is especially true when external- auditors rely on the work of internal auditors in the context of the International Standard on Auditing (ISA) 610 and the equivalent US Statement on Auditing Standards (SAS) 65 (see IFAC, 2009 and AICPA, 1990). Third, the harmonization of international reporting standards is increasingly promoted by means of a principles-based approach. It is the leading approach since a study of the SEC (2003) that was required by the SOX (2002) in section 108(d) was in favor of this approach. As a result, the Financial Accounting Standards Board (FASB) and the International Accounting Standards Board (IASB) commit themselves to the development of compatible accounting standards based on a principles-based approach. Moreover, since the Norwalk Agreement of 2002, the two standard setters have developed exposure drafts for a common conceptual framework that will be the basis for accounting harmonization. The new .framework will be in favor of fair value measurement and accounting for real-world economic phenomena. These changes in terms of standard setting lead to a trend towards more professional judgment in the accounting process. They affect internal and external auditors, accountants, and managers in general. As a consequence, a new competency set for preparers and users of financial statements is required. The basil for this new competency set is adequate accounting education (Schipper, 2003). These three issues which affect corporate governance are the initial point of this dissertation and constitute its motivation. Two broad questions motivated a scientific examination in three essays: 1) What are major aspects to be examined regarding the new role of the internal audit function? 2) How should major changes in standard setting affect financial accounting education? The first question became apparent due to two published literature reviews by Gramling et al. (2004) and Cohen, Krishnamoorthy & Wright (2004). These studies raise various questions for future research that are still relevant and which motivate the first two essays of my dissertation. In the first essay, I focus on the role of the internal audit function as one cornerstone of corporate governance and its potentially conflicting role of serving both management and the audit committee (IIA, 2003). In an experimental study, I provide evidence on the challenges for internal auditors in their role as servant for two masters -the audit committee and management -and how this influences internal auditors' judgment (Gramling et al. 2004; Cohen, Krishnamoorthy & Wright, 2004). I ask if there is an expectation gap between what internal auditors should provide for corporate governance in theory compared to what internal auditors are able to provide in practice. In particular, I focus on the effect of serving two masters on the internal auditor's independence. I argue that independence is hardly achievable if the internal audit function serves two masters with conflicting priorities. The second essay provides evidence on the effectiveness of accountability as an internal control mechanism. In general, internal control mechanisms based on accountability were enforced by the SOX (2002) and the 8th EU Directive. Subsequently, many companies introduced sub-certification processes that should contribute to an objective judgment process. Thus, these mechanisms are important to strengthen the reliability of financial statements. Based on a need for evidence on the effectiveness of internal control mechanisms (Brennan & Solomon, 2008; Gramling et al. 2004; Cohen, Krishnamoorthy & Wright, 2004; Solomon & Trotman, 2003), I designed an experiment to examine the joint effect of accountability and obedience pressure in an internal audit setting. I argue that obedience pressure potentially can lead to a negative influence on accountants' objectivity (e.g. DeZoort & Lord, 1997) whereas accountability can mitigate this negative effect. My second main research question - How should major changes in standard setting affect financial accounting education? - is investigated in the third essay. It is motivated by the observation during my PhD that many conferences deal with the topic of accounting education but very little is published about what needs to be done. Moreover, the Endings in the first two essays of this thesis and their literature review suggest that financial accounting education can contribute significantly to quality corporate governance as argued elsewhere (Schipper, 2003; Boyce, 2004; Ghoshal, 2005). In the third essay of this thesis, I therefore focus on approaches to financial accounting education that account for the changes in standard setting and also contribute to corporate governance and accounting harmonization. I argue that the competency set that is required in practice changes due to major changes in standard setting. As the major contribution of the third article, I develop a public interest approach for financial accounting education. The major findings of this dissertation can be summarized as follows. The first essay provides evidence to an important research question raised by Gramling et al. (2004, p. 240): "If the audit committee and management have different visions for the corporate governance role of the IAF, which vision will dominate?" According to the results of the first essay, internal auditors do follow the priorities of either management or the audit committee based on the guidance provided by the Chief Audit executive. The study's results question whether the independence of the internal audit function is actually achievable. My findings contribute to research on internal auditors' judgment and the internal audit function's independence in the broader frame of corporate governance. The results are also important for practice because independence is a major justification for a positive contribution of the internal audit function to corporate governance. The major findings of the second essay indicate that the duty to sign work results - a means of holding people accountable -mitigates the negative effect of obedience pressure on reliability. Hence, I found evidence that control .mechanisms relying on certifications may enhance the reliability of financial information. These findings contribute to the literature on the effectiveness of internal control mechanisms. They are also important in the light of sub-certification processes that resulted from the Sarbanes-Oxley Act and the 8th EU Directive. The third essay contributes to the literature by developing a measurement framework that accounts for the consequences of major trends in standard setting. Moreovér, it shows how these trends affect the required .competency set of people dealing with accounting issues. Based on this work, my main contribution is the development of a public interest approach for the design of adequate financial accounting curricula. 2 Serving two masters: Experimental evidence on the independence of internal auditors Abstract Twenty nine internal auditors participated in a study that examines the independence of internal auditors in their potentially competing roles of serving two masters: the audit committee and management. Our main hypothesis suggests that internal auditors' independence is not achievable in an institutional setting in which internal auditors are accountable to two different parties with potentially differing priorities. We test our hypothesis in an experiment in which the treatment consisted of two different instructions of the Chief audit executive; one stressing the priority of management (cost reduction) and one stressing the priority of the audit committee (effectiveness). Internal auditors had to evaluate internal controls and their inherent costs of different processes which varied in their degree of task complexity. Our main results indicate that internal auditors' evaluation of the processes is significantly different when task complexity is high. Our findings suggest that internal auditors do follow the priorities of either management or the audit committee depending on the instructions of a superior internal auditor. The study's results question whether the independence of the internal audit function is actually achievable. With our findings, we contribute to research on internal auditors' judgment and the internal audit function's independence in the frame of corporate governance.

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Tutkielman tavoitteena oli selvittää millä kriteereillä vertaileva mainonta on sallittua ja milloin kiellettyä. Vertailevaa mainontaa käsitellään Keskuskauppakamarin liiketapalautakunnan antamien lausuntojen perusteella. Liiketapalautakunta antaa lausuntoja onko tietty markkinoinnissa suoritettu tai suunniteltu toimenpide hyvän liiketavan vastainen tai muutoin sopimatonta menettelyä elinkeinotoiminnassa. Tutkielma on laadittu olemassa olevaa tietoa keräämällä ja soveltamalla. Pääasiallisena lähteenä on käytetty liiketapalautakunnan lausuntoja. Niiden lisäksi on käytetty Kuluttaja-asiamiehen kannanottoja ja Markkinatuomioistuimen päätöksiä sekä aiheeseen liittyvää kirjallisuutta. Tärkeimpänä kriteerinä vertailevan mainonnan hyväksyttävyydelle voidaan pitää totuudenmukaisuutta. Vertaileva mainonta on sallittua kunhan vertailu suoritetaan totuudenmukaisesti. Jokaisen tapauksen yhteydessä on otettava kokonaisuus huomioon ja sallittavuus ratkaistaan tapauskohtaisesti. Vaikutusta hyväksyttävyyteen on mm. mainonnan kohderyhmällä. On huomioitava, että hyvän liiketavan käsite muuttuu ajan myötä. Tämän vuoksi aina ei voida nojautua vanhoihin päätöksiin.

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A inclusão de alunos com deficiência em ensino regular no Brasil é um movimento que vem denotando constante crescimento nos últimos anos. Embora muitos avanços sejam observados, por ser um processo que suscita mudanças conceituais, legais e de prática, traz consigo dúvidas, decorrentes das contradições existentes entre os discursos que proclamam a inclusão e a realidade educacional brasileira. Sob o prisma da docência, no contexto da escola inclusiva, são inúmeras as dificuldades que os professores vêm enfrentando na prática com esse alunado. Considerando essa problemática, apesar da produção já existente, faz-se necessário o aprofundamento de estudos deste tema do ponto de vista do professor. Portanto, esta pesquisa investiga a voz e a ótica dos professores das classes regulares que possuem alunos em situação de inclusão, mais especificamente os que têm deficiência, e aborda os diferentes aspectos da inclusão no cotidiano escolar e o apoio ao professor como uma das ações necessárias para a prática pedagógica inclusiva à luz de teóricos que discutem o processo inclusivo. O estudo, de caráter qualitativo, foi realizado em quatro escolas do Ensino Fundamental (séries iniciais) da rede pública municipal de São Bernardo do Campo, e contou com a participação de nove professores, quatro diretores e quatro famílias de alunos com deficiência. Considerando a análise dos aspectos observados, pode-se inferir que os professores têm buscado a ressignificação de suas práticas, mas desvelam a necessidade de um apoio constante, que lhes dê sustentação para o atendimento à diversidade dos seus alunos.(AU)

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A inclusão de alunos com deficiência em ensino regular no Brasil é um movimento que vem denotando constante crescimento nos últimos anos. Embora muitos avanços sejam observados, por ser um processo que suscita mudanças conceituais, legais e de prática, traz consigo dúvidas, decorrentes das contradições existentes entre os discursos que proclamam a inclusão e a realidade educacional brasileira. Sob o prisma da docência, no contexto da escola inclusiva, são inúmeras as dificuldades que os professores vêm enfrentando na prática com esse alunado. Considerando essa problemática, apesar da produção já existente, faz-se necessário o aprofundamento de estudos deste tema do ponto de vista do professor. Portanto, esta pesquisa investiga a voz e a ótica dos professores das classes regulares que possuem alunos em situação de inclusão, mais especificamente os que têm deficiência, e aborda os diferentes aspectos da inclusão no cotidiano escolar e o apoio ao professor como uma das ações necessárias para a prática pedagógica inclusiva à luz de teóricos que discutem o processo inclusivo. O estudo, de caráter qualitativo, foi realizado em quatro escolas do Ensino Fundamental (séries iniciais) da rede pública municipal de São Bernardo do Campo, e contou com a participação de nove professores, quatro diretores e quatro famílias de alunos com deficiência. Considerando a análise dos aspectos observados, pode-se inferir que os professores têm buscado a ressignificação de suas práticas, mas desvelam a necessidade de um apoio constante, que lhes dê sustentação para o atendimento à diversidade dos seus alunos.(AU)

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A inclusão de alunos com deficiência em ensino regular no Brasil é um movimento que vem denotando constante crescimento nos últimos anos. Embora muitos avanços sejam observados, por ser um processo que suscita mudanças conceituais, legais e de prática, traz consigo dúvidas, decorrentes das contradições existentes entre os discursos que proclamam a inclusão e a realidade educacional brasileira. Sob o prisma da docência, no contexto da escola inclusiva, são inúmeras as dificuldades que os professores vêm enfrentando na prática com esse alunado. Considerando essa problemática, apesar da produção já existente, faz-se necessário o aprofundamento de estudos deste tema do ponto de vista do professor. Portanto, esta pesquisa investiga a voz e a ótica dos professores das classes regulares que possuem alunos em situação de inclusão, mais especificamente os que têm deficiência, e aborda os diferentes aspectos da inclusão no cotidiano escolar e o apoio ao professor como uma das ações necessárias para a prática pedagógica inclusiva à luz de teóricos que discutem o processo inclusivo. O estudo, de caráter qualitativo, foi realizado em quatro escolas do Ensino Fundamental (séries iniciais) da rede pública municipal de São Bernardo do Campo, e contou com a participação de nove professores, quatro diretores e quatro famílias de alunos com deficiência. Considerando a análise dos aspectos observados, pode-se inferir que os professores têm buscado a ressignificação de suas práticas, mas desvelam a necessidade de um apoio constante, que lhes dê sustentação para o atendimento à diversidade dos seus alunos.(AU)

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The purpose of this paper is to theorise the changes surrounding the introduction of a management control innovation, total quality management (TQM) techniques, within Telecom Fiji Limited. Using institutional theory and drawing on empirical evidence from multiple sources including interviews, discussions and documents, the paper explicates the institutionalization of these TQM practices. The focus of the paper is the micro-processes and practice changes around TQM implementation, rather than the influence of the macro-level structures that are often linked with institutional theory. The change agents used Quality Action Teams and the National Quality Council to introduce new TQM routines. The present study extends the scope of institutional analysis by explaining how institutional contradictions impact to create and make space for institutional entrepreneurs, who in turn, modify existing routines or introduce new routines in fluid organizational environments which also exhibit evidence of resistance.

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The Upper Jefferson River is one of the most dewatered rivers in Montana. The river exists in an intermontane basin filled with sediment transported from the Highland Mountains to the west, the Tobacco Root Mountains to the east, and the Jefferson River from the south. The Upper Jefferson River Valley is highly dependent on the Jefferson River as the main industry in the valley is agriculture. A majority of the valley is irrigated and used to grow crops, and a good portion is also used for cattle grazing. The residents of the Upper Jefferson River Valley use the aquifer as the main source of potable water. The Jefferson River is also widely used for recreation. This study took place in the Waterloo area of the Upper Jefferson River Valley, approximately 20 miles south of Whitehall, Montana. The Waterloo area provides significant groundwater base flow to the Jefferson River, which is particularly important during the late irrigation season when the river is severely dewatered, and elevated surface-water temperatures occur, creating irrigation water shortages and poor trout habitat. This area contains two springfed streams, Willow Springs and Parson’s Slough, which discharge to the Jefferson River providing cool water in the late season as well as providing the most important trout spawning habitat in the valley. The area is bordered on both the east and west by irrigation ditches, and about 60% of the study area is irrigated. Tile drains were installed in the study area in close proximity to Parsons Slough causing some concern by neighboring residents. This study evaluated relationships between surface water, groundwater, and irrigation practices so that water managers and others can make informed management decisions about the Upper Jefferson River. Data was collected via a network of groundwater wells and surface-water sites. Additionally, water-quality samples were taken and an aquifer test was conducted to determine aquifer properties. The field data were analyzed and a groundwater budget was created in order to evaluate the aquifer. Results of the groundwater budget show that seepage from the irrigation canals and irrigation recharge have the biggest influence on recharge of the aquifer. There is significant groundwater outflow from the aquifer in the spring-fed streams as well as discharge to the Jefferson River. In comparing previous study results to this study’s results, there is no evidence of the water table decreasing due to irrigation practice changes or tile drain installation. However, given the amount of recharge irrigation practices contribute to the aquifer, if significant changes were made, they may affect groundwater elevations. Also lining the irrigation ditches would have a significant impact on the aquifer, as the amount of seepage would be greatly reduced.

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Aims and background. In 2002, a survey including 1759 patients treated from 1980 to 1998 established a "benchmark" Italian data source for prostate cancer radiotherapy. This report updates the previous one. Methods. Data on clinical management and outcomes of 3001 patients treated in 15 centers from 1999 through 2003 were analyzed and compared with those of the previous survey. Results. Significant differences in clinical management (-10% had abdominal ma-gnetic resonance imaging; +26% received ≥70 Gy, +48% conformal radiotherapy, -20% pelvic radiotherapy) and in G3-4 toxicity rates (-3.8%) were recorded. Actuarial 5-year overall, disease-specific, clinical relapse-free, and biochemical relapse-free survival rates were 88%, 96%, 96% and 88%, respectively. At multivariate analysis, D'Amico risk categories significantly impacted on all the outcomes; higher radiotherapy doses were significantly related with better overall survival rates, and a similar trend was evident for disease-specific and biochemical relapse-free survival; cumulative probability of 5-year late G1-4 toxicity was 24.8% and was significantly related to higher radiotherapy doses (P <0.001). Conclusions. The changing patterns of practice described seem related to an improvement in efficacy and safety of radiotherapy for prostate cancer. However, the impact of the new radiotherapy techniques should be prospectively evaluated.

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Aim: To describe how quantitative data obtained from applying a series of indicators for preventable drug related morbidity (PDRM) in the electronic patient record in English general practice can be used to facilitate changes aimed at helping to improve medicines management. Design: A multidisciplinary discussion forum held at each practice facilitated by a clinical researcher. Subjects and setting: Eight English general practices. Outcome measures: Issues discussed at the multidisciplinary discussion forum and ideas generated by practices for tackling these issues. Progress made by practices after 1, 3, and 6 months. Results: A number of clinical issues were raised by the practices and ideas for moving them forward were discussed. The issues that were easiest and most straightforward to deal with (for example, reviewing specific patient groups) were quickly addressed in most instances. Practices were less likely to have taken steps towards addressing issues at a systems level. Conclusions: Data generated from applying PDRM indicators can be used to facilitate practice-wide discussion on medicines management. Different practices place different priority levels on the issues they wish to pursue. Individual practice "ownership'' of these, together with having a central committed figure at the practice, is key to the success of the process.

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Changes to client requirements are inevitable during construction. Industry discourse is concerned with minimizing and controlling changes. However, accounts of practices involved in making changes are rare. In response to calls for more research into working practices, an ethnographic study of a live hospital project was undertaken to explore how changes are made. A vignette of a meeting exploring the investigation of changes illustrates the issues. This represents an example from the ethnographic fieldwork, which produced many observations. There was a strong emphasis on using change management procedures contained within the contract to investigate changes, even when it was known that the change was not required. For the practitioners, this was a way of demonstrating best practice, transparent and accountable decision-making regarding changes. Hence, concerns for following procedures sometimes overshadowed considerations about whether or not a change was required to improve the functionality of the building. However, the procedures acted as boundary objects between the communities of practice involved on the project by coordinating the work of managing changes. Insights suggest how contract procedures facilitate and impede the making of changes, which can inform policy guidance and contract drafting.

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Neuroimaging studies provide evidence for organized intrinsic activity under task-free conditions. This activity serves functionally relevant brain systems supporting cognition. Here, we analyze changes in resting-state functional connectivity after videogame practice applying a test–retest design. Twenty young females were selected from a group of 100 participants tested on four standardized cognitive ability tests. The practice and control groups were carefully matched on their ability scores. The practice group played during two sessions per week across 4 weeks (16 h total) under strict supervision in the laboratory, showing systematic performance improvements in the game. A group independent component analysis (GICA) applying multisession temporal concatenation on test–retest resting-state fMRI, jointly with a dual-regression approach, was computed. Supporting the main hypothesis, the key finding reveals an increased correlated activity during rest in certain predefined resting state networks (albeit using uncorrected statistics) attributable to practice with the cognitively demanding tasks of the videogame. Observed changes were mainly concentrated on parietofrontal networks involved in heterogeneous cognitive functions.