Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery.

BACKGROUND: Enhanced recovery protocols may reduce postoperative complications and length of hospital stay. However, the implementation of these protocols requires time and financial investment. This study evaluated the cost-effectiveness of enhanced recovery implementation. METHODS: The first 50 consecutive patients treated during implementation of an enhanced recovery programme were compared with 50 consecutive patients treated in the year before its introduction. The enhanced recovery protocol principally implemented preoperative counselling, reduced preoperative fasting, preoperative carbohydrate loading, avoidance of premedication, optimized fluid balance, standardized postoperative analgesia, use of a no-drain policy, as well as early nutrition and mobilization. Length of stay, readmissions and complications within 30 days were compared. A cost-minimization analysis was performed. RESULTS: Hospital stay was significantly shorter in the enhanced recovery group: median 7 (interquartile range 5-12) versus 10 (7-18) days (P = 0·003); two patients were readmitted in each group. The rate of severe complications was lower in the enhanced recovery group (12 versus 20 per cent), but there was no difference in overall morbidity. The mean saving per patient in the enhanced recovery group was euro1651. CONCLUSION: Enhanced recovery is cost-effective, with savings evident even in the initial implementation period.

Implementation of educational change in Finland: The case of the undivided basic education reform

For the past decades, educational large-scale reforms have been elaborated and implemented in many countries and often resulted in partial or complete failure. These results brought researchers to study policy processes in order to address this particular challenge. Studies on implementation processes brought to light an existing causal relationship between the implementation process and the effectiveness of a reform. This study aims to describe the implementation process of educational change in Finland, who produced efficient educational reforms over the last 50 years. The case study used for the purpose of this study is the national reform of undivided basic education (yhtenäinen peruskoulu) implemented in the end of the 1990s. Therefore, this research aims to describe how the Finnish undivided basic education reform was implemented. This research was carried out using a pluralist and structuralist approach of policy process and was analyzed according to the hybrid model of implementation process. The data were collected using a triangulation of methods, i.e. documentary research, interviews and questionnaires. The data were qualitative and were analyzed using content analysis methods. This study concludes that the undivided basic education reform was applied in a very decentralized manner, which is a reflection of the decentralized system present in Finland. Central authorities provided a clear vision of the purpose of the reform, but did not control the implementation process. They rather provided extensive support in the form of transmission of information and development of collaborative networks. Local authorities had complete autonomy in terms of decision-making and implementation process. Discussions, debates and decisions regarding implementation processes took place at the local level and included the participation of all actors present on the field. Implementation methods differ from a region to another, with is the consequence of the variation of the level of commitment of local actors but also the diversity of local realities. The reform was implemented according to existing structures and values, which means that it was in cohesion with the context in which it was implemented. These results cannot be generalized to all implementation processes of educational change in Finland but give a great insight of what could be the model used in Finland. Future studies could intent to confirm the model described here by studying other reforms that took place in Finland.

Implementation of educational change in Finland: The case of the undivided basic education reform

For the past decades, educational large-scale reforms have been elaborated and implemented in many countries and often resulted in partial or complete failure. These results brought researchers to study policy processes in order to address this particular challenge. Studies on implementation processes brought to light an existing causal relationship between the implementation process and the effectiveness of a reform. This study aims to describe the implementation process of educational change in Finland, who produced efficient educational reforms over the last 50 years. The case study used for the purpose of this study is the national reform of undivided basic education (yhtenäinen peruskoulu) implemented in the end of the 1990s. Therefore, this research aims to describe how the Finnish undivided basic education reform was implemented. This research was carried out using a pluralist and structuralist approach of policy process and was analyzed according to the hybrid model of implementation process. The data were collected using a triangulation of methods, i.e. documentary research, interviews and questionnaires. The data were qualitative and were analyzed using content analysis methods. This study concludes that the undivided basic education reform was applied in a very decentralized manner, which is a reflection of the decentralized system present in Finland. Central authorities provided a clear vision of the purpose of the reform, but did not control the implementation process. They rather provided extensive support in the form of transmission of information and development of collaborative networks. Local authorities had complete autonomy in terms of decision-making and implementation process. Discussions, debates and decisions regarding implementation processes took place at the local level and included the participation of all actors present on the field. Implementation methods differ from a region to another, with is the consequence of the variation of the level of commitment of local actors but also the diversity of local realities. The reform was implemented according to existing structures and values, which means that it was in cohesion with the context in which it was implemented. These results cannot be generalized to all implementation processes of educational change in Finland but give a great insight of what could be the model used in Finland. Future studies could intent to confirm the model described here by studying other reforms that took place in Finland.

Systematic work environment management : experiences from implementation in Swedish small-scale enterprises

Small-scale enterprises face difficulties in fulfilling the regulations for organising Systematic Work Environment Management. This study compared three groups of small-scale manufacturing enterprises with and without support for implementing the provision. Two implementation methods, supervised and network method, were used. The third group worked according to their own ideas. Twenty-three enterprises participated. The effects of the implementation were evaluated after one year by semi-structured dialogue with the manager and safety representative. Each enterprise was classified on compliance with ten demands concerning the provision. The work environment was estimated by the WEST-method. Impact of the implementation on daily work was also studied. At the follow-up, the enterprises in the supervised method reported slightly more improvements in the fulfilment of the demands in the provision than the enterprises in the network method and the enterprises working on their own did. The effect of the project reached the employees faster in the enterprises with the supervised method. In general, the work environment improved to some extent in all enterprises. Extensive support to small-scale enterprises in terms of advise and networking aimed to fulfil the regulations of Systematic Work Environment Management had limited effect especially considering the cost of applying these methods.

The Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders: recruitment, assessment instruments, methods for the development of multicenter collaborative studies and preliminary results

OBJETIVO: Descrever o recrutamento de pacientes, instrumentos de avaliação, métodos para o desenvolvimento de estudos colaborativos multicêntricos e os resultados preliminares do Consórcio Brasileiro de Pesquisa em Transtornos do Espectro Obsessivo-Compulsivo, que inclui sete centros universitários. MÉTODO: Este estudo transversal incluiu entrevistas semi-estruturadas (dados sociodemográficos, histórico médico e psiquiátrico, curso da doença e diagnósticos psiquiátricos comórbidos) e instrumentos que avaliam os sintomas do transtorno obsessivo-compulsivo (Escala para Sintomas Obsessivo-Compulsivos de Yale-Brown e Escala Dimensional para Sintomas Obsessivo-Compulsivos de Yale-Brown), sintomas depressivos (Inventário de Depressão de Beck), sintomas ansiosos (Inventário de Ansiedade de Beck), fenômenos sensoriais (Escala de Fenômenos Sensoriais da Universidade de São Paulo), juízo crítico (Escala de Avaliação de Crenças de Brown), tiques (Escala de Gravidade Global de Tiques de Yale) e qualidade de vida (questionário genérico de avaliação de qualidade de vida, Medical Outcome Quality of Life Scale Short-form-36 e Escala de Avaliação Social). O treinamento dos avaliadores consistiu em assistir cinco entrevistas filmadas e entrevistar cinco pacientes junto com um pesquisador mais experiente, antes de entrevistar pacientes sozinhos. A confiabilidade entre todos os líderes de grupo para os instrumentos mais importantes (Structured Clinical Interview for DSM-IV, Dimensional Yale-Brown Obsessive-Compulsive Scale, Universidade de São Paulo Sensory Phenomena Scale ) foi medida após seis entrevistas completas. RESULTADOS: A confiabilidade entre avaliadores foi de 96%. Até março de 2008, 630 pacientes com transtorno obsessivo-compulsivo tinham sido sistematicamente avaliados. A média de idade (±SE) foi de 34,7 (±0,51), 56,3% eram do sexo feminino e 84,6% caucasianos. Os sintomas obsessivo-compulsivos mais prevalentes foram os de simetria e os de contaminação. As comorbidades psiquiátricas mais comuns foram depressão maior, ansiedade generalizada e transtorno de ansiedade social. O transtorno de controle de impulsos mais comum foi escoriação neurótica. CONCLUSÃO: Este consórcio de pesquisa, pioneiro no Brasil, permitiu delinear o perfil sociodemográfico, clínico e terapêutico do paciente com transtorno obsessivo-compulsivo em uma grande amostra clínica de pacientes. O Consórcio Brasileiro de Pesquisa em Transtornos do Espectro Obsessivo-Compulsivo estabeleceu uma importante rede de colaboração de investigação clínica padronizada sobre o transtorno obsessivo-compulsivo e pode abrir o caminho para projetos semelhantes destinados a integrar outros grupos de pesquisa no Brasil e em todo o mundo.

Sexual Health Education from the Perspective of School Staff: Implications for Adoption and Implementation of Effective Programs in Middle School

Introduction: US teens are having sex early; however, the vast majority of schools do not implement evidence-based sexual health education (SHE) programs that could delay sexual behavior and/or reduce risky behavior. This study examines middle school staff’s knowledge, attitudes, barriers, self-efficacy, and perceived support (psychosocial factors known to influence SHE program adoption and implementation). Methods: Professional school staff from 33 southeast Texas middle schools completed an internet or paper-based survey. Prevalence estimates for psychosocial variables were computed for the total sample. Chi-square and t-test analyses examined variation by demographic factors. Results: Almost 70% of participants were female, 37% white, 42% black, 16% Hispanic; 20% administrators, 15% nurses/counselors, 31% non-physical education/non-health teachers, 28% physical education/health teachers; mean age = 42.78 years (SD = 10.9). Over 90% favored middle school SHE, and over 75% reported awareness of available SHE curricula or policies. More than 60% expressed confidence for discussing SHE. Staff perceived varying levels of administrator (28%-56%) support for SHE and varying levels of support for comprehensive sex education from outside stakeholders (e.g., parents, community leaders) (42%-85%). Overall, results were more favorable for physical education/health teachers, nurses/counselors, and administrators (when compared to non-physical education/non-health teachers) and individuals with experience teaching SHE. Few significant differences were observed by other demographic factors. Conclusions: Overall, study results were extremely positive, which may reflect a high level of readiness among school staff for adopting and implementing effective middle school SHE programs. Study results highlight the importance of several key action items for schools.

Universal Screening for Familial Colorectal Cancer Syndromes at Seattle Cancer Care Alliance: Qualitative Study of Providers involved in Implementation and Patients Experience with First Wave of Testing

Thesis (Master's)--University of Washington, 2016-06

Clinical decision support system for point of care use: ontology driven design and software implementation

OBJECTIVES: The objective of this research was to design a clinical decision support system (CDSS) that supports heterogeneous clinical decision problems and runs on multiple computing platforms. Meeting this objective required a novel design to create an extendable and easy to maintain clinical CDSS for point of care support. The proposed solution was evaluated in a proof of concept implementation. METHODS: Based on our earlier research with the design of a mobile CDSS for emergency triage we used ontology-driven design to represent essential components of a CDSS. Models of clinical decision problems were derived from the ontology and they were processed into executable applications during runtime. This allowed scaling applications' functionality to the capabilities of computing platforms. A prototype of the system was implemented using the extended client-server architecture and Web services to distribute the functions of the system and to make it operational in limited connectivity conditions. RESULTS: The proposed design provided a common framework that facilitated development of diversified clinical applications running seamlessly on a variety of computing platforms. It was prototyped for two clinical decision problems and settings (triage of acute pain in the emergency department and postoperative management of radical prostatectomy on the hospital ward) and implemented on two computing platforms-desktop and handheld computers. CONCLUSIONS: The requirement of the CDSS heterogeneity was satisfied with ontology-driven design. Processing of application models described with the help of ontological models allowed having a complex system running on multiple computing platforms with different capabilities. Finally, separation of models and runtime components contributed to improved extensibility and maintainability of the system.

Total productive maintenance implementation in the newspaper printing industry:an action research approach

The objective of Total Productive Maintenance (TPM) is to maximise plant and equipment effectiveness, to create a sense of ownership for operators, and promote continuous improvement through small group activities involving production, engineering and maintenance personnel. This paper describes and analyses a case study of TPM implementation at a newspaper printing house in Singapore. However, rather than adopting more conventional implementation methods such as employing consultants or through a project using external training, a unique approach was adopted based on Action Research using a spiral of cycles of planning, acting observing and reflecting. An Action Research team of company personnel was specially formed to undertake the necessary fieldwork. The team subsequently assisted with administering the resulting action plan. The main sources of maintenance and operational data were from interviews with shop floor workers, participative observation and reviews conducted with members of the team. Content analysis using appropriate statistical techniques was used to test the significance of changes in performance between the start and completion of the TPM programme. The paper identifies the characteristics associated with the Action Research method when used to implement TPM and discusses the applicability of the approach in related industries and processes.

Atividade física e Saúde Pública : políticas e estratégias de ação intersectorial na promoção de health-enhancing physical activity (HEPA) em Portugal

RESUMO - INTRODUÇÃO: A promoção de health-enhancing physical activity (HEPA), entendida como atividade física para a saúde, revela-se um dos aspectos fulcrais do trabalho de ação intersectorial da saúde pública e um dos principais desafios atuais no combate a esta pandemia da inatividade física de consequências na saúde, económicas, ambientais e sociais. A inatividade física está identificada como sendo um dos fatores de risco que contribui largamente para a mortalidade global. Análises às abordagens políticas de promoção da atividade física para a saúde são importantes instrumentos de sistematização da informação relacionada com o estudo deste problema. OBJETIVOS: É objetivo deste estudo analisar políticas e estratégias de ação intersectorial na promoção da atividade física para a saúde em Portugal. Em específico, elencar e analisar: 1) principais políticas e estratégias atuais dos diferentes sectores; 2) consideração de qual é o papel do sector da saúde no assunto; 3) fatores-chave e critérios de sucesso para a implementação de políticas de promoção de HEPA. METODOLOGIA: Estudo qualitativo, descritivo e transversal, por meio de entrevistas semiestruturadas e abertas pelos sectores da saúde, educação, desporto, transportes/planeamento urbano e ação social; análise documental, relativamente aos últimos 3 anos, com análise de conteúdo quanto aos critérios de sucesso presentes. RESULTADOS: Foram encontradas várias categorias nas dimensões macroambiente, microambiente e individual dos determinantes da atividade física no trabalho dos diferentes sectores; o sector da saúde não foi habitualmente considerado como devendo proporcionar administração para a ação intersectorial neste domínio; foram identificados os critérios: com menor expressão no material analisado, aos quais é atribuída maior importância e aqueles com menor aplicabilidade nos documentos analisados. CONCLUSÕES: Não podemos afirmar que exista uma abordagem política/estratégica integrada de abrangência nacional, operacional, no que respeita à promoção da atividade física para a saúde. São limitadas as conclusões pelas características inerentes ao tipo de estudo desenhado, no entanto, pensamos ter contribuído para descrever as principais políticas e estratégias de ação intersectorial na promoção de HEPA em Portugal. Estudos mais abrangentes em termos de níveis de governação, sectores envolvidos e período temporal deverão ser desenvolvidos de forma a potenciar o desenvolvimento da atividade física e saúde pública.

Mielipidekyselyjärjestelmän suunnittelu ja toteutus

Tämän työn tavoitteena on suunnitella yksinkertainen Internet-pohjainen mielipidekyselyjärjestelmä sekä esitellä yksityiskohtaisesti järjestelmän toteutus ja siihen liittyvät menetelmät. Menetelmistäesitellään ainoastaan ennalta valitut menetelmät järjestelmän toteutukseen, tietojen esittämiseen, esitystavan muotoiluun sekä tietojen varastointiin. Järjestelmä toteutetaan HTML- ja PHP-kielillä sekä käyttämällä CSS-menetelmän tyylimuotoiluja ja XML-kielen muotoiluun perustuvia tiedostoja tietovarastoina. Järjestelmän suunnitteluun liittyen työssä pyritään kuvaamaan järjestelmään toteutettavat kaksi erillistä käyttöliittymää, pääkäyttäjän käyttöliittymä ja normaalin käyttäjän käyttöliittymä, sekä näihin toteutettavat toiminnot. Pääkäyttäjän tärkeimmät toiminnot ovat mielipidekyselyiden luominen, käyttäjien lisääminen kyselyihin sekä kyselyiden tulosten seuranta. Normaalin käyttäjän toiminnot taas rajoittuvat kirjautumiseen ja kyselyyn vastaamiseen. Järjestelmän toteutuksen kuvauksessa kuvataan tarkasti edellä mainittujen kahden käyttöliittymän toiminnot sekä näiden toimintojen toteutustavat. Lisäksi toteutuksen kuvauksen yhteydessä määritellään tarkasti järjestelmän tietovarastoina toimivien tiedostojen sisällön muoto. Työn lopputuloksena syntyi valituilla toteutustavoilla toteutettu toimiva mielipidekyselyjärjestelmä sekä tämä järjestelmän suunnitteluun ja toteutuksen selvittämiseen keskittynyt dokumentti. Toteutetusta järjestelmästä ei tullut täydellinen vaan jatkokehityksessä voidaan harkita esimerkiksi tietokannan käyttämistä järjestelmän tietovarastoina sekä joidenkin lisäominaisuuksien toteuttamista. Tavoitteeseen päästiin kuitenkin, sillä toteutettu järjestelmä on toimiva ja käyttötarkoitukseensa sopiva.

Ohjelmistotuotannon toteutusmenetelmien yhtenäistäminen

Organisaatio, prosessimalli ja menetelmät vaikuttavat toisiinsa sekä suorasti että prosessien ja tavoitteiden kautta epäsuorasti. Prosessimallit vaihtelevat eri organisaatioiden välillä, mutta työkalut ja menetelmät, erityisesti toteutusmenetelmät, saattavat vaihdella jopa eri projektien ja sovelluskehittäjien välillä. Toteutusmenetelmien yhtenäistämisellä tavoitellaan ohjelmistokehityksen tehokkuuden parantamista, ohjelmistojen laatutason nostamista ja työmotivaation kohottamista. Tämän diplomityön käytännön osuudessa selvitettiin ohjelmistokehitysorganisaation asenteita ja edellytyksiä toteutusmenetelmien yhtenäistämistä kohtaan. Diplomityön tuloksena laadittiin suositus siitä, kuinka parhaat käytännöt -dokumentti voidaan toteuttaa. Suosituksen mukaan kyseinen dokumentti tulisi jakaa kahdeksi dokumentiksi siten, että toinen dokumenteista kattaisi käytännöllisimmät toteutusmenetelmät, toinen sisältäisi suunnittelumenetelmät.

Testing and Monitoring Mill Connection Messages

Tarve tälle työlle on noussut sanomapalvelinsoveluksissa (servers) esiintyvistä ongelmista. Sanomapalvelinsovelluksia käytetään lähettämään ja vastaanottamaan sanomia paperiteollisuuden myynnin ja jakelun järjestelmässä maantieteellisesti erillään olevista paperiteollisuuden tehtaista. Sanomapalvelinsovelusten kunnollinen toimivuus on tärkeää koko järjestelmän toimivuuden kannalta, koska nämä palvelimet käsittelevät päivittäin tuhansia sanomia, jotka sisältävät merkityksellistä järjestelmätietoa. Tässä työssä on tutkittu mahdollisia toteutustekniikoita ja näihin tutkimuksiin pohjautuen toteutettu työkalut sanomapalvelinsovellusten testaukseen ja valvontaan. Sovellus-arkkituuritekniikoita tutkittaessa tutkimus rajattiin 3-tasoarkkitehtuuritekniikkaan, erityisesti TUXEDOTM -järjestelmätekniikkaan, koska toteutettavaa sovellusta käytetään hajautetussa sovellusympäristössä. Sovellusasiakkaan (client) toteutusta varten tutkittiin ja vertailtiin XML-tekniikkaa ja Microsoft Visual C++ -tekniikkaa käytettynä Tieto-Enatorin Phobos Interaktiivisen C++ -luokkakirjaston kanssa. XML-tekniikoita sekä Visual C++ ja Phobos-luokkakirjasto –tekniikkaa tutkittiin niiltä osin, mitä tarvittiin sanomamerkkijonojen katseluun. XML-tietokantatekniikoita tutkittiin mahdollisena vaihtoehtona tietokanta ja sovelluspalvelintekniikalle. Työn ensimmäisenä tavoitteena oli toteuttaa työkalu sanomapalvelinsovellusten testaamiseen. Toisena tavoitteena oli toteuttaa työkalu sanomien sisällön oikeellisuuden valvontaan. Kolmantena tavoitteena oli analysoida olemassaolevaa sanomavirheiden valvontasovellusta ja kehittää sitä eteenpäin. Diplomityön tuloksena toteutettiin sovellus sanomapalvelinsovellusten testaamiseen ja valvontaan. Tutkituista asiakassovelustekniikoista valittiin toteutus-tekniikaksi MS Visual C++ käytettynä Phobos Interaktiivisen C++ luokkakirjaston kanssa tekniikan tunnettavuuden vuoksi. 3-taso TUXEDOTM-tekniikka valittiin sovelluksen arkkitehtuuriksi. Lisäksi löydettiin parannuksia olemassa oleviin sanoma-virheiden valvontatoimintoihin. Tutkitut toteutustekniikat ovat yleisiä ja niitä voidaan käyttää, kun toteutetaan samanlaisia sovelluksia samanlaisiin sovellusympäristöihin.

Facteurs associés à l’implantation d’un programme de formation interprofessionnelle au sein d’un Centre de santé et de services sociaux au Québec

INTRODUCTION: La collaboration interprofessionnelle a émergé comme étant l’un des aspects essentiels à consolider pour améliorer l’organisation de la première ligne de soins et assurer un accès adéquat aux ressources disponibles. Pour favoriser l’accroissement de la collaboration interprofessionnelle, il est suggéré que les professionnels des sciences de la santé soient formés en interdisciplinarité, particulièrement à l’occasion des stages cliniques. OBJECTIFS: Ce projet vise à mesurer le degré d’implantation du programme de formation interprofessionnelle (PFI) du Centre de santé et de services sociaux (CSSS) à l’étude comparativement au modèle proposé initialement. De plus, ce projet vise à comprendre comment les facteurs systémiques, les facteurs organisationnels et les caractéristiques du programme de formation mis en place influencent l’implantation du PFI. MÉTHODOLOGIE : Il s’agit d’une étude de cas unique effectuée au sein d’un CSSS situé dans la grande région de Montréal au Québec, Canada. Les données ont été recueillies à l’aide de 11 entrevues semi-dirigées qui ont été réalisées auprès de professionnels et administrateurs responsables de l’implantation du PFI et d’un étudiant en stage ayant participé au PFI. Une analyse des documents administratifs et cliniques écrits concernant l’implantation du PFI a également été effectuée. RÉSULTATS : L’implantation du PFI est toujours en évolution comme le traduit la présence des différentes composantes définissant la mise en œuvre du PFI qui est de moyenne à élevée et l’intensité des différentes composantes qui est généralement faible. Les facteurs systémiques, les facteurs organisationnels et les caractéristiques du programme de formation mis en place influencent l’implantation du PFI en milieu clinique et il existe des interrelations entre ces différents facteurs. L’analyse des facteurs influençant l’implantation d’un PFI en milieu clinique doit également s'attarder aux différents facteurs influençant le développement des pratiques collaboratives dans ce milieu.