May 13, 2013


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Abstracts

New article by Greta Cummings, Anastasia Mallidou, and Carole Estabrooks
On becoming a coach: A pilot intervention study with managers in long-term care.
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Cummings G, Mallidou AA, Masaoud E, Kumbamu A, Schalm C, Spence Laschinger HK, et al.
Health care management review 2013 Apr 25

BACKGROUND: Health care leaders have called for the development of communication and leadership skills to improve manager-employee relationships, employee job satisfaction, quality care, and work environments. PURPOSES:: The aim of the study reported here was to pilot how a 2-day coaching workshop (“Coaching for Impressive CARE”) conducted as a leadership development strategy influenced frontline care managers’ coaching practices in residential long-term care (LTC) settings. We had four objectives: (a) to identify managers’ perceptions of their role as a coach of employee performance in LTC facilities, (b) to understand managers’ intentions to coach employee performance, (c) to examine opportunities and factors that contributed to or challenged implementation of workshop coaching skills in daily leadership/management practice, and (d) to examine managers’ reports of using coaching practices and employee responses after the workshop. METHODS: We used an exploratory/descriptive design involving pre-/post-workshop surveys, e-mail reminders, and focus groups to examine participation of 21 LTC managers in a 2-day coaching workshop and their use of coaching practices in the workplace. FINDINGS: Focus group findings provided examples of how participants used their coaching skills in practice (e.g., communicating empathy) and how staff responded. Factors contributing to and challenging implementation of these coaching skills in the workplace were identified. Attitudes and intentions to be a coach increased significantly, and some coaching skills were used more frequently after the workshop, specifically planning for performance change with employees. PRACTICE IMPLICATIONS: The coaching workshop was feasible to implement, well received by participants, influenced their willingness to become coaches, and had some noted impact on their use of coaching behaviors in the workplace. Coaching skills by managers to improve staff performance with residents in LTC facilities can be learned.

New article by Shannon Scott
Social media use among patients and caregivers: a scoping review
Hamm MP, Chisholm A, Shulhan J, Milne A, Scott SD, Given LM, et al.
BMJ Open 2013 January 01;3(5)

Objective To map the state of the existing literature evaluating the use of social media in patient and caregiver populations. Design Scoping review. Data sources Medline, CENTRAL, ERIC, PubMed, CINAHL Plus Full Text, Academic Search Complete, Alt Health Watch, Health Source, Communication and Mass Media Complete, Web of Knowledge and ProQuest (2000–2012). Study selection Studies reporting primary research on the use of social media (collaborative projects, blogs/microblogs, content communities, social networking sites, virtual worlds) by patients or caregivers. Data extraction Two reviewers screened studies for eligibility; one reviewer extracted data from relevant studies and a second performed verification for accuracy and completeness on a 10% sample. Data were analysed to describe which social media tools are being used, by whom, for what purpose and how they are being evaluated. Results Two hundred eighty-four studies were included. Discussion forums were highly prevalent and constitute 66.6% of the sample. Social networking sites (14.8%) and blogs/microblogs (14.1%) were the next most commonly used tools. The intended purpose of the tool was to facilitate self-care in 77.1% of studies. While there were clusters of studies that focused on similar conditions (eg, lifestyle/weight loss (12.7%), cancer (11.3%)), there were no patterns in the objectives or tools used. A large proportion of the studies were descriptive (42.3%); however, there were also 48 (16.9%) randomised controlled trials (RCTs). Among the RCTs, 35.4% reported statistically significant results favouring the social media intervention being evaluated; however, 72.9% presented positive conclusions regarding the use of social media. Conclusions There is an extensive body of literature examining the use of social media in patient and caregiver populations. Much of this work is descriptive; however, with such widespread use, evaluations of effectiveness are required. In studies that have examined effectiveness, positive conclusions are often reported, despite non-significant findings.

CALL FOR PAPERS: Bias in Health Data
Autumn Conference of the Section Sociology of Medicine and Health of the German Sociological Association
3-4 October 2013 Florence, Italy
DEADLINE: 31 May 2013

Survey data in health research is often based on answers from respondents who are medical laypeople. Respondents may systematically over- or underestimate the occurrence of a particular disease, i.e. the statistical error (false positive, false negative) is systematically biased by the respondents´ degree of health knowledge and sensitivity to symptoms, which in turn depends on the educational background, gender and so on. Educational background is highly correlated with the degree of health knowledge, which is needed to identify a physical or mental state as “disease”. The more complex the symptoms (as with mental diseases, for example), the more health knowledge is needed in order to classify the symptoms as being connected with a disease or condition. The conference should shed more light on these social mechanisms creating systematic biases in health data. Presentations could focus on the following theoretical, empirical or methodological issues.

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Health Care Administration and Organization
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Using theory and evidence to drive measurement of patient, nurse and organizational outcomes of professional nursing practice.
Non UofA Access
Jeffs L, Sidani S, Rose D, Espin S, Smith O, Martin K, et al.
International journal of nursing practice 2013 Apr;19(2):141-148

An evolving body of literature suggests that the implementation of evidence based clinical and professional guidelines and strategies can improve patient care. However, gaps exist in our understanding of the effect of implementation of guidelines on outcomes, particularly patient outcomes. To address this gap, a measurement framework was developed to assess the impact of an organization-wide implementation of two nursing-centric best-practice guidelines on patient, nurse and organizational level outcomes. From an implementation standpoint, we anticipate that our data will show improvements in the following: (i) patient satisfaction scores and safety outcomes; (ii) nurses ability to value and engage in evidence based practice; and (iii) organizational support for evidence-informed nursing care that results in quality patient outcomes. Our measurement framework and multifaceted methodological approach outlined in this paper might serve as a blueprint for other organizations in their efforts to evaluate the impacts associated with implementation of clinical and professional guidelines and best practices. © 2013 Wiley Publishing Asia Pty Ltd.

Proposing a conceptual framework for integrated local public health policy, applied to childhood obesity – the behavior change ball.
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Hendriks AM, Jansen MW, Gubbels JS, De Vries NK, Paulussen T, Kremers SP.
Implementation science : IS 2013 Apr 18;8:46-5908-8-46

BACKGROUND: Childhood obesity is a ‘wicked’ public health problem that is best tackled by an integrated approach, which is enabled by integrated public health policies. The development and implementation of such policies have in practice proven to be difficult, however, and studying why this is the case requires a tool that may assist local policy-makers and those assisting them. A comprehensive framework that can help to identify options for improvement and to systematically develop solutions may be used to support local policy-makers. DISCUSSION: We propose the ‘Behavior Change Ball’ as a tool to study the development and implementation of integrated public health policies within local government. Based on the tenets of the ‘Behavior Change Wheel’ by Michie and colleagues (2011), the proposed conceptual framework distinguishes organizational behaviors of local policy-makers at the strategic, tactical and operational levels, as well as the determinants (motivation, capability, opportunity) required for these behaviors, and interventions and policy categories that can influence them. To illustrate the difficulty of achieving sustained integrated approaches, we use the metaphor of a ball in our framework: the mountainous landscapes surrounding the ball reflect the system’s resistance to change (by making it difficult for the ball to roll). We apply this framework to the problem of childhood obesity prevention. The added value provided by the framework lies in its comprehensiveness, theoretical basis, diagnostic and heuristic nature and face validity. SUMMARY: Since integrated public health policies have not been widely developed and implemented in practice, organizational behaviors relevant to the development of these policies remain to be investigated. A conceptual framework that can assist in systematically studying the policy process may facilitate this. Our Behavior Change Ball adds significant value to existing public health policy frameworks by incorporating multiple theoretical perspectives, specifying a set of organizational behaviors and linking the analysis of these behaviors to interventions and policies. We would encourage examination by others of our framework as a tool to explain and guide the development of integrated policies for the prevention of wicked public health problems.

Bridges, brokers and boundary spanners in collaborative networks: a systematic review.
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Long JC, Cunningham FC, Braithwaite J.
BMC health services research 2013 Apr 30;13:158-6963-13-158

BACKGROUND: Bridges, brokers and boundary spanners facilitate transactions and the flow of information between people or groups who either have no physical or cognitive access to one another, or alternatively, who have no basis on which to trust each other. The health care sector is a context that is rich in isolated clusters, such as silos and professional “tribes,” in need of connectivity. It is a key challenge in health service management to understand, analyse and exploit the role of key agents who have the capacity to connect disparate groupings in larger systems. METHODS: The empirical, peer reviewed, network theory literature on brokerage roles was reviewed for the years 1994 to 2011 following PRISMA guidelines. RESULTS: The 24 articles that made up the final literature set were from a wide range of settings and contexts not just healthcare. Methods of data collection, analysis, and the ways in which brokers were identified varied greatly. We found four main themes addressed in the literature: identifying brokers and brokerage opportunities, generation and integration of innovation, knowledge brokerage, and trust. The benefits as well as the costs of brokerage roles were examined. CONCLUSIONS: Collaborative networks by definition, seek to bring disparate groups together so that they can work effectively and synergistically together. Brokers can support the controlled transfer of specialised knowledge between groups, increase cooperation by liaising with people from both sides of the gap, and improve efficiency by introducing “good ideas” from one isolated setting into another.There are significant costs to brokerage. Densely linked networks are more efficient at diffusing information to all their members when compared to sparsely linked groups. This means that while a bridge across a structural hole allows information to reach actors that were previously isolated, it is not the most efficient way to transfer information. Brokers who become the holders of, or the gatekeepers to, specialised knowledge or resources can become overwhelmed by the role and so need support in order to function optimally.

What is the impact of a policy brief? Results of an experiment in research dissemination
Non UofA Access
Masset E, Gaarder M, Beynon P, Chapoy C.
Journal of Development Effectiveness 2013;5(1):50-63

Despite the popularity of policy briefs as a tool for disseminating research, there is no evidence of their effectiveness in changing people’s beliefs. We conducted an experiment whereby readers of a policy brief were randomly assigned to different versions of the brief and to a control group. We collected data on opinions and knowledge regarding the impact of agricultural interventions before and after reading a brief disseminating the conclusions of a systematic review. We found that the brief helped some readers to form an opinion, but we found no evidence of a change in prior beliefs. We recommend that more trials and laboratory experiments should be conducted to assess the efficacy of policy briefs and attitudes to evidence-based policy-making. © 2013 Copyright Taylor and Francis Group, LLC.

Clinical credibility and trustworthiness are key characteristics used to identify colleagues from whom to seek information.
Non UofA Access
Marshall AP, West SH, Aitken LM.
Journal of clinical nursing 2013 May;22(9-10):1424-1433

AIMS AND OBJECTIVES: To explore the use of information by nurses making decisions in clinically uncertain situations in one aspect of critical care nursing practice (enteral feeding). In this paper, we report the characteristics, which participants identified as important, of the people from whom they sought information for the purpose of making clinical decisions. BACKGROUND: Registered nurses have a plethora of information sources available to assist them in making clinical decisions. Identifying and selecting the best information to support these decisions can be difficult and is influenced by factors such as accessibility, usefulness and variations in quality of the information. DESIGN: An instrumental case study design using multiple case study analysis. METHOD: Twenty-two critical care nurses from two intensive care units contributed to the data through multiple methods of data collection including concurrent verbal protocols (think aloud), retrospective probing and focus group interviews. RESULTS: Nurses preferentially used colleagues as a source of information when faced with uncertainty about their clinical practice. Most participants placed greater emphasis on evaluating the individual providing the information rather than on evaluating the information itself. Key features used for identifying an individual as a source of information included experience, clinical role, trust and approachability. CONCLUSION: Establishing clearly what clinical credibility means, and to what extent trustworthiness and expertise play a role in the establishment of credibility, is an important debate for nursing. We need to carefully consider what defines the construct of clinical credibility and how this aligns with the concept of clinical currency, to allow clinicians to determine in others the characteristics associated with clinical credibility to access quality information through social interaction. RELEVANCE TO CLINICAL PRACTICE: Processes to focus on determining the quality of information obtained from colleagues should be emphasised. What these processes are and how they could be implemented into clinical practice remains unknown and is highlighted as an area for future research. © 2013 Blackwell Publishing Ltd.

Leading on the frontlines with passion and persistence: a necessary condition for Breastfeeding Best Practice Guideline uptake.
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Matthew-Maich N, Ploeg J, Jack S, Dobbins M.
Journal of clinical nursing 2013 Jun;22(11-12):1759-1770

AIMS AND OBJECTIVES: The research question explored was what are the processes and strategies used by frontline leaders to support the uptake of the Breastfeeding Best Practice Guideline by nurses in maternity care practice settings? BACKGROUND: Best Practice Guidelines have been shown to enhance client care and outcomes. Leadership is known to have a key role in moving Best Practice Guidelines into nursing practice yet how this happens is poorly understood. This insight is needed to consistently and efficiently facilitate Best Practice Guideline uptake into clinical practice. DESIGN: Constructivist grounded theory was used to explore the social processes and strategies involved in facilitating Best Practice Guideline uptake. METHODS: Purposive, criterion-based, theoretical and negative case sampling were used recruiting 58 health professionals and 54 clients. Triangulation and constant comparison of data sources and types (interviews, documents and field notes) were used for analysis and rigour. RESULTS: Passionate, persistent, respected frontline leaders using tailored, multifaceted strategies aimed at three groups of nurse adopters effectively support the uptake of the Breastfeeding Best Practice Guideline in nursing practice. Successful uptake strategies used by frontline leaders that are new or underdeveloped in the previous literature are presented. CONCLUSIONS: The study findings illuminated multidimensional, tailored strategies that frontline leaders use to facilitate the uptake of Best Practice Guidelines. Attention to individual attitudes and beliefs, as well as organisational, interorganisational and interprofessional partnerships are vital to uptake. Organisations that aspire to foster Best Practice Guideline uptake must invest in frontline leaders to ‘make it happen’ and sustain Best Practice Guideline uptake in practice. RELEVANCE TO CLINICAL PRACTICE: Understanding how frontline leaders facilitate Best Practice Guideline uptake is essential to selecting, educating and supporting them to foster desired practice changes. Strategies are explicated that frontline leaders can adopt and tailor to their own practice contexts. © 2012 Blackwell Publishing Ltd.

Advancing knowledge on practice change: linking facilitation to the senses framework.
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Cooper J, Meyer J, Holman C.
Journal of clinical nursing 2013 Jun;22(11-12):1729-1737

AIMS AND OBJECTIVES: To explore the facilitating factors that enabled staff on a rehabilitation ward for older people engage in change activities. BACKGROUND: The importance of facilitation in practice change is widely acknowledged; however, little nursing research has taken place in relation to its nature. Following identification in the early phases of an action research study that learned helplessness states and the use of socially structured defence techniques were preventing staff on a rehabilitation ward for older people from engaging in practice development, some change was achieved. What facilitated this to take place needed to be explored. DESIGN: An action research approach was used. METHODS: Data gained from 13 in-depth interviews with staff and managers together with three years of researcher field notes were analysed using thematic analysis. RESULTS: The continuous presence and neutrality of the researcher who worked together with staff on their issues of concern using a flexible ward-based approach, combined with giving staff the opportunity to explore what it was like for them working in this area, were considered key in helping staff to engage with change. CONCLUSIONS: Analysis of findings suggests that the senses framework presents a theoretical approach to facilitation that can help staff move out of learned helplessness states and reduce the need for the use of socially structured defence techniques. RELEVANCE TO CLINICAL PRACTICE: This study identifies a facilitation approach that enabled staff to engage with practice change. Although carried out in the UK, its findings have wider relevance through the application of a theoretical perspective for practice change facilitation that has not before been considered in this literature, and which is likely to be of interest to those involved in practice change internationally. © 2013 Blackwell Publishing Ltd.

Science and practice aligned within nursing: structure and process for evidence-based practice.
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Boucher J, Roper K, Underhill M, Berry D.
The Journal of nursing administration 2013 Apr;43(4):229-234

Science and Practice Aligned Within Nursing (SPAWN) is an innovative method developed to guide the implementation of evidence-based practice (EBP) by oncology nurses in direct patient care settings. Science and Practice Aligned Within Nursing actualizes and addresses the important and essential practice component of EBP in oncology nursing. This article describes the development of SPAWN infrastructure, phases of the process, implementation, outcome evaluation, key insights, and lessons learned.

Developing a questionnaire to identify perceived barriers for implementing the Dutch physical therapy COPD clinical practice guideline.
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van der Wees PJ, Zagers CA, de Die SE, Hendriks EJ, Nijhuis-van der Sanden MW, de Bie RA.
BMC health services research 2013 May 1;13:159-6963-13-159

BACKGROUND: Clinical practice guidelines have been developed to assist healthcare practitioners in clinical decision making. Publication of clinical practice guidelines does not automatically lead to their uptake and barrier identification has been recognized as an important step in implementation planning. This study aimed at developing a questionnaire to identify perceived barriers for implementing the Dutch COPD guideline for physical therapists and its recommended measurement instruments. METHODS: An overall questionnaire, based on two existing questionnaires, was constructed to identify barriers and facilitators for implementing the COPD guideline. The construct of the questionnaire was assessed in a cross-sectional study among 246 chest physical therapists. Factor analysis was conducted to explore underlying dimensions. Psychometric properties were analyzed using Cronbach’s alpha. Barriers and facilitators were assessed using descriptive statistics. RESULTS: Some 139 physical therapists (57%) responded. Factor analysis revealed 4-factor and 5-factor solutions with an explained variance of 36% and 39% respectively. Cronbach’s alpha of the overall questionnaire was 0.90, and varied from 0.66 to 0.92 for the different factors. Underlying domains of the 5-factor solution were characterized as: attitude towards using measurement instruments, knowledge and skills of the physical therapist, applicability of the COPD guideline, required investment of time & money, and patient characteristics. Physical therapists showed a positive attitude toward using the COPD guideline. Main barriers for implementation were required time investment and financial constraints. CONCLUSIONS: The construct of the questionnaire revealed relevant underlying domains for the identification of barriers and facilitators for implementing the COPD guideline. The questionnaire allowed for tailoring to the target group and may be used across health care professionals as basis for in-depth analysis of barriers to specific recommendations in guidelines. The results of the questionnaire alone do not provide sufficient information to inform the development of an implementation strategy. The infrastructure for developing the guideline can be used for addressing key barriers by the guideline development group, using the questionnaire as well as in-depth analysis such as focus group interviews. Further development of methods for prospective identification of barriers and consequent tailoring of implementation interventions is required.

Promoting continence in nursing homes in four European countries: the use of PACES as a mechanism for improving the uptake of evidence-based recommendations.
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Harvey G, Kitson A, Munn Z.
International journal of evidence-based healthcare 2012 Dec;10(4):388-396

BACKGROUND: Multi-faceted approaches are generally recognised as the most effective way to support the implementation of evidence into practice. Audit and feedback often constitute one element of a multi-faceted implementation package, alongside other strategies, such as interactive education and facilitated support mechanisms. This paper describes a multi-faceted implementation strategy that used the Joanna Briggs Institute Practical Application of Clinical Evidence System (PACES) as an online audit tool to support facilitators working to introduce evidence-based continence recommendations in nursing homes in four different European countries. AIMS/OBJECTIVES: The paper describes the experience of using PACES with an international group of nursing home facilitators. In particular, the objectives of the paper are: to describe the process of introducing PACES to internal facilitators in eight nursing homes; to discuss the progress made during a 12-month period of collecting and analysing audit data using PACES; to summarise the collective experience of using PACES, including reflections on its strengths and limitations. METHODS: Descriptive data were collected during the 12-month period of working with PACES in the eight nursing home sites. These data included digital and written notes taken at an initial 3-day introductory programme, at monthly teleconferences held between the external and internal facilitators and at a final 2-day meeting. Qualitative analysis of the data was undertaken on an ongoing basis throughout the implementation period, which enabled formative evaluation of PACES. A final summative evaluation of the experience of using PACES was undertaken as part of the closing project meeting in June 2011. RESULTS: The nursing home facilitators took longer than anticipated to introduce PACES and it was only after 9-10 months that they became confident and comfortable using the system. This was due to a combination of factors, including a lack of audit knowledge and skills, limited IT access and skills, language difficulties and problems with the PACES system itself. The initial plan of undertaking a full baseline audit followed by focused action cycles had to be revised to allow a more staged, smaller-scale approach to implementation and audit. This involved simplifying the audit process and removing steps such as the calculation of population size estimates. As a result, an accurate baseline measure, prior to introducing changes to continence care, was not achieved. However, by the end of the 12 months, the majority of facilitators had undertaken a full audit and reported value in the process. In particular, they benefited from comparing audit data across sites to share learning and best practice. DISCUSSION/CONCLUSION: Working with PACES as part of a facilitated programme to support the implementation of evidence-based continence recommendations in nursing homes in four European countries has been a valuable learning experience, although not without its challenges. The findings highlight the importance of thorough training and support for first time users of PACES and the need to make the audit process as simple as possible in the initial stages. © 2012 The Authors. International Journal of Evidence-Based Healthcare © 2012 The Joanna Briggs Institute.

Impact of clinical and health services research projects on decision-making: a qualitative study
Solans-Domenech M, Adam P, Guillamon I, Permanyer-Miralda G, Pons J, Escarrabill J.
Health Research Policy and Systems 2013;11(1):15

This article reports on the impact assessment experience of a funding program of non-commercial clinical and health services research. The aim was to assess the level of implementation of results from a subgroup of research projects (on respiratory diseases), and to detect barriers (or facilitators) in the translation of new knowledge to informed decision-making. Methods A qualitative study was performed. The sample consisted of six projects on respiratory diseases funded by the Agency for Health Quality and Assessment of Catalonia between 1996 and 2004. Semi-structured interviews to key informants including researchers and healthcare decision-makers were carried out. Interviews were recorded, transcribed verbatim and analysed on an individual (key informant) and group (project) basis. In addition, the differences between achieved and expected impacts were described. Results Twenty-three semi-structured interviews were conducted. Most participants indicated changes in health services or clinical practice had resulted from research. The channels used to transfer new knowledge were mainly conventional ones, but also in less explicit ways, such as with the involvement of local scientific societies, or via debates and discussions with colleagues and local leaders. The barriers and facilitators identified were mostly organizational (in research management, and clinical and healthcare practice), although there were also some related to the nature of the research as well as personal factors. Both the expected and achieved impacts enabled the identification of the gaps between what is expected and what is truly achieved. Conclusions In this study and according to key informants, the impact of these research projects on decision-making can be direct (the application of a finding or innovation) or indirect, contributing to a more complex change in clinical practice and healthcare organization, both having other contextual factors. The channels used to transfer this new knowledge to clinical practice are complex. Local scientific societies and the relationships between researchers and decision-makers can play a very important role. Specifically, the relationships between managers and research teams and the mutual knowledge of their activity have shown to be effective in applying research funding to practice and decision-making. Finally the facilitating factors and barriers identified by the respondents are closely related to the idiosyncrasy of the human relations between the different stakeholders involved.

Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR)
Damschroder L, Lowery J.
Implementation Science 2013;8(1):51

Background In the United States, as in many other parts of the world, the prevalence of overweight/obesity is at epidemic proportions in the adult population and even higher among Veterans. To address the high prevalence of overweight/obesity among Veterans, the MOVE!(R) weight management program was disseminated nationally to Veteran Affairs (VA) medical centers. The objective of this paper is two-fold: to describe factors that explain the wide variation in implementation of MOVE!; and to illustrate, step-by-step, how to apply a theory-based framework using qualitative data. Methods Five VA facilities were selected to maximize variation in implementation effectiveness and geographic location. Twenty-four key stakeholders were interviewed at each of these facilities about their experiences in implementing MOVE!. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection and analysis of qualitative data. Constructs that most strongly influence implementation effectiveness were identified through a cross-case comparison of ratings. Results Of the 31 CFIR constructs assessed, ten constructs strongly distinguished between facilities with low versus high program implementation effectiveness. The majority (six) were related to the inner setting: networks and communications; tension for change; relative priority; goals and feedback; learning climate; and leadership engagement. One construct each, from intervention characteristics (relative advantage) and outer setting (patient needs and resources), plus two from process (executing and reflecting) also strongly distinguished between high and low implementation. Two additional constructs weakly distinguished, 16 were mixed, three constructs had insufficient data to assess, and one was not applicable. Detailed descriptions of how each distinguishing construct manifested in study facilities and a table of recommendations is provided. Conclusions This paper presents an approach for using the CFIR to code and rate qualitative data in a way that will facilitate comparisons across studies. An online Wiki resource (www.wiki.cfirwiki.net) is available, in addition to the information presented here, that contains much of the published information about the CFIR and its constructs and sub-constructs. We hope that the described approach and open access to the CFIR will generate wide use and encourage dialogue and continued refinement of both the framework and approaches for applying it.

Testing use of payers to facilitate evidence-based practice adoption: protocol for a cluster-randomized trial
Molfenter T, Kim J, Quanbeck A, Patel-Porter T, Starr S, McCarty D.
Implementation Science 2013;8(1):50

Background More effective methods are needed to implement evidence-based findings into practice. The Advancing Recovery Framework offers a multi-level approach to evidence-based practice implementation by aligning purchasing and regulatory policies at the payer level with organizational change strategies at the organizational level. Methods The Advancing Recovery Buprenorphine Implementation Study is a cluster-randomized controlled trial designed to increase use of the evidence-based practice buprenorphine medication to treat opiate addiction. Ohio Alcohol, Drug Addiction, and Mental Health Services Boards (ADAMHS), who are payers, and their addiction tre atment organizations were recruited for a trial to assess the effects of payer and treatment organization changes (using the Advancing Recovery Framework) versus treatment organization changes alone on the use of buprenorphine. A matched-pair randomization, based on county charac teristics, was applied, resulting in seven county ADAMHS boards and twenty-five treatment organizations in each arm. Opioid dependent patients are nested within cluster (treatment organization), and treatment organization clusters are nested within ADAMHS county board. The primary outcome is the percentage of individuals with an opioid depende nce diagnosis who use buprenorphine during the 24-month intervention period and the 12-month sustainability period. The trial is currently in the baseline data collection stage. Discussion Although addiction treatment providers are under increasing pressure to implement evidence-based practices that have been proven to improve patient outcomes, adoption of these practices lags, compared to other areas of healthcare. Reasons frequently cited for the slow adoption of EBPs in addiction treatment include, regulatory issues, staff, or client resistance and lack of resources. Yet the way addiction treatment is funded, the payer’s role–has not received a lot of attention in research on EBP adoption. This research is unique because it investigates the role of payers in evidence-based practice implementation using a randomized controlled design instead of case examples. The testing of the Advancing Recovery Framework is designed to broaden the understanding of the impact payers have on evidence-based practice (EBP) adoption. Trial registration NCT01702142 (ClinicalTrials.gov registry, USA)

Brookings Institute: Building on Recent Advances in Evidence-Based Policymaking (US)
April 2013

The current fiscal environment makes it imperative that we produce more value with each dollar that government spends. Doing so will require better use of evidence in policymaking. The good news is that over the past decade new government strategies have begun to emerge—at the federal, state, and local levels—that simultaneously offer the potential to make better use of taxpayer dollars and speed up progress in addressing serious social problems. These strategies: subsidize learning and experimentation so that new solutions are developed, increase the amount of evidence on the effectiveness of existing and potential new programs, make greater use of evidence in budget and management decisions, make purposeful efforts to target improved outcomes for particular populations, and spur innovation and align incentives through cross-sector and community-based collaborations.

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Health Care Administration and Organization

The mediating effects of structural empowerment on job satisfaction for nurses in long-term care facilities
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Li IC, Kuo HT, Huang HC, Lo HL, Wang HC.
Journal of nursing management 2013 Apr;21(3):440-448

Aims  The purpose of this study was to explore the mediating effects of work empowerment on job satisfaction for nurses in long-term care facilities in Taiwan. Background  Previous research has noted that job satisfaction is an important factor that reflects upon the work environment and the characteristics of the job itself. It is important to link work empowerment to job satisfaction among nurses. Methods  This research study used a cross-sectional design. A total of 65 nurses participated in the study. Regression models and Sobel tests were fitted to evaluate the relationship between work empowerment and job satisfaction. Results  Structural empowerment mediated the effects of psychological empowerment on job satisfaction (standardized β = 0.46, Sobel test: z = 2.69, P = 0.007). Conclusions  Both psychological and structural empowerment positively correlated with job satisfaction among nurses in long-term care facilities. The structural empowerment had a mediating effect on job satisfaction. Implications for nursing management  The managers of long-term care facilities should create an empowering work environment for nurses by providing them with available resources and by involving them in the developmental goals of the facilities. The critical structural components of an empowered workplace can contribute to the psychological empowerment of nurses and increase their job satisfaction. © 2012 Blackwell Publishing Ltd.

Attributes of nursing work environment as predictors of registered nurses’ job satisfaction and intention to leave
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Choi SP, Cheung K, Pang SM.
Journal of nursing management 2013 Apr;21(3):429-439

Aim  To examine how front-line registered nurses’ perception of their work environment associates with and predicts nurse outcomes in terms of job satisfaction and turnover intention. Background  Mounting evidence has pointed to an inseparable link between attributes of the nursing work environment and nurse outcomes. However, there is a paucity of research examining nurses’ perception of their work environment beyond the Western context. Methods  This cross-sectional survey involved 1271 registered nurses working in 135 inpatient units in 10 public hospitals in Hong Kong. The instrument comprised items developed from in-depth interviews with front-line nurses that explored nurses’ perception of their work environment. Results  Factor analysis identified five dimensions (professionalism, co-worker relationship, management, staffing and resources, and ward practice) of the nursing work environment. Logistic regression analysis further identified professionalism, management and ward practice as significant factors in predicting nurses’ turnover intention, and staffing and resources as an additional factor in predicting their job satisfaction. Conclusions  Attributes of the nursing work environment have a significant bearing on nurses’ job satisfaction and intention to leave. Implications for nursing management  Managerial effort should focus on improving nurses’ work conditions through detailed resource planning, effective management and removal of work constraints that affect nursing practice. © 2012 Blackwell Publishing Ltd.

Interprofessional education: effects on professional practice and healthcare outcomes (update).
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Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M.
Cochrane database of systematic reviews (Online) 2013 Mar 28;3:CD002213

BACKGROUND: The delivery of effective, high-quality patient care is a complex activity. It demands health and social care professionals collaborate in an effective manner. Research continues to suggest that collaboration between these professionals can be problematic. Interprofessional education (IPE) offers a possible way to improve interprofessional collaboration and patient care. OBJECTIVES: To assess the effectiveness of IPE interventions compared to separate, profession-specific education interventions; and to assess the effectiveness of IPE interventions compared to no education intervention. SEARCH METHODS: For this update we searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE and CINAHL, for the years 2006 to 2011. We also handsearched the Journal of Interprofessional Care (2006 to 2011), reference lists of all included studies, the proceedings of leading IPE conferences, and websites of IPE organisations. SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled before and after (CBA) studies and interrupted time series (ITS) studies of IPE interventions that reported objectively measured or self reported (validated instrument) patient/client or healthcare process outcomes. DATA COLLECTION AND ANALYSIS: At least two review authors independently assessed the eligibility of potentially relevant studies. For included studies, at least two review authors extracted data and assessed study quality. A meta-analysis of study outcomes was not possible due to heterogeneity in study designs and outcome measures. Consequently, the results are presented in a narrative format. MAIN RESULTS: This update located nine new studies, which were added to the six studies from our last update in 2008. This review now includes 15 studies (eight RCTs, five CBA and two ITS studies). All of these studies measured the effectiveness of IPE interventions compared to no educational intervention. Seven studies indicated that IPE produced positive outcomes in the following areas: diabetes care, emergency department culture and patient satisfaction; collaborative team behaviour and reduction of clinical error rates for emergency department teams; collaborative team behaviour in operating rooms; management of care delivered in cases of domestic violence; and mental health practitioner competencies related to the delivery of patient care. In addition, four of the studies reported mixed outcomes (positive and neutral) and four studies reported that the IPE interventions had no impact on either professional practice or patient care. AUTHORS’ CONCLUSIONS: This updated review reports on 15 studies that met the inclusion criteria (nine studies from this update and six studies from the 2008 update). Although these studies reported some positive outcomes, due to the small number of studies and the heterogeneity of interventions and outcome measures, it is not possible to draw generalisable inferences about the key elements of IPE and its effectiveness. To improve the quality of evidence relating to IPE and patient outcomes or healthcare process outcomes, the following three gaps will need to be filled: first, studies that assess the effectiveness of IPE interventions compared to separate, profession-specific interventions; second, RCT, CBA or ITS studies with qualitative strands examining processes relating to the IPE and practice changes; third, cost-benefit analyses.

Guideline adaptation and implementation planning: a prospective observational study.
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Harrison MB, Graham ID, van den Hoek J, Dogherty EJ, Carley ME, Angus V.
Implementation science 2013 May 8;8(1):49

BACKGROUND: Adaptation of high-quality practice guidelines for local use has been advanced as an efficient means to improve acceptability and applicability of evidence-informed care. In a pan-Canadian study, we examined how cancer care groups adapted pre-existing guidelines to their unique context and began implementation planning. METHODS: Using a mixed-methods, case-study design, five cases were purposefully sampled from self-identified groups and followed as they used a structured method and resources for guideline adaptation. Cases received the ADAPTE Collaboration toolkit, facilitation, methodological and logistical support, resources and assistance as required. Documentary and primary data collection methods captured individual case experience, including monthly summaries of meeting and field notes, email/telephone correspondence, and project records. Site visits, process audits, interviews and a final evaluation forum with all cases contributed to a comprehensive account of participant experience. RESULTS: Study cases took 12 to >24 months to complete guideline adaptation. Although participants appreciated the structure, most found the ADAPTE method complex and lacking practical aspects. They needed assistance establishing individual guideline mandate and infrastructure, articulating health questions, executing search strategies, appraising evidence, and achieving consensus. Facilitation was described as a multi-faceted process, a team effort, and an essential ingredient for guideline adaptation. While front-line care providers implicitly identified implementation issues during adaptation, they identified a need to add an explicit implementation planning component. CONCLUSIONS: Guideline adaptation is a positive initial step toward evidence-informed care, but adaptation (vs. ‘de novo’ development) did not meet expectations for reducing time or resource commitments. Undertaking adaptation is as much about the process (engagement and capacity building) as it is about the product (adapted guideline). To adequately address local concerns, cases found it necessary to also search and appraise primary studies, resulting in hybrid (adaptation plus de novo) guideline development strategies that required advanced methodological skills.Adaptation was found to be an action element in the knowledge translation continuum that required integration of an implementation perspective. Accordingly, the adaptation methodology and resources were reformulated and substantially augmented to provide practical assistance to groups not supported by a dedicated guideline panel and to provide more implementation planning support. The resulting framework is called CAN-IMPLEMENT.

HRSA: The U.S. Nursing Workforce: Trends in Supply and Education
April 2013

Understanding the supply, distribution, and educational pipeline of nurses is key to designing programs and policies that will ensure access to care and an effective health care system. The U.S. Nursing Workforce: Trends in Supply and Education analyzes data from a variety of sources to present recent trends and the current status of the registered nurse (RN) and licensed practical nurse (LPN) workforces.

CFHI: Moving to Action: Evidence-Based Retention and Recruitment Policy Initiatives for Nursing
March 2013

The studies in this program of research were conducted using primary data collected from 4,295 Canadian-educated registered nurses living and working in the US, as well as 2,675 registered nurses (RNs) and licensed practical nurses (LPNs) who had moved across Canada to work. The studies involved survey questionnaires, focus groups, and geographic mapping data. The surveys contained substantial additional information in the form of comments from participants that provided the opportunity for a more in-depth qualitative understanding of nurses’ perceptions of migration and mobility issues in Canada.

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Health Care Innovation and Quality Assurance

Quality improvement initiative to reduce serious safety events and improve patient safety culture.
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Muething SE, Goudie A, Schoettker PJ, Donnelly LF, Goodfriend MA, Bracke TM, et al.
Pediatrics 2012 Aug;130(2):e423-31

BACKGROUND AND OBJECTIVE: Many thousands of patients die every year in the United States as a result of serious and largely preventable safety events or medical errors. Safety events are common in hospitalized children. We conducted a quality improvement initiative to implement cultural and system changes with the goal of reducing serious safety events (SSEs) by 80% within 4 years at our large, urban pediatric hospital. METHODS: A multidisciplinary SSE reduction team reviewed the safety literature, examined recent SSEs, interviewed internal leaders, and visited other leading organizations. Senior hospital leaders provided oversight, monitored progress, and helped to overcome barriers. Interventions focused on: (1) error prevention; (2) restructuring patient safety governance; (3) a new root cause analysis process and a common cause database; (4) a highly visible lessons learned program; and (5) specific tactical interventions for high-risk areas. Our outcome measures were the rate of SSEs and the change in patient safety culture. RESULTS: SSEs per 10000 adjusted patient-days decreased from a mean of 0.9 at baseline to 0.3 (P < .0001). The days between SSEs increased from a mean of 19.4 at baseline to 55.2 (P < .0001). After a worsening of patient safety culture outcomes in the first year of intervention, significant improvements were observed between 2007 and 2009. CONCLUSIONS: Our multifaceted approach was associated with a significant and sustained reduction of SSEs and improvements in patient safety culture. Multisite studies are needed to better understand contextual factors and the significance of specific interventions.

A quality improvement evaluation case study: impact on public health outcomes and agency culture.
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Livingood WC, Sabbagh R, Spitzfaden S, Hicks A, Wells L, Puigdomenech S, et al.
American Journal of Preventive Medicine 2013 May;44(5):445-452

BACKGROUND: Quality improvement (QI) is increasingly recognized as an important strategy to improve healthcare services and health outcomes, including reducing health disparities. However, there is a paucity of evidence documenting the value of QI to public health agencies and services. PURPOSE: The purpose of this project was to support and assess the impact on the outcomes and organizational culture of a QI project to increase immunization rates among children aged 2 years (4:3:1:3:3:1 series) within a large public health agency with a major pediatric health mission. METHODS: The intervention consisted of the use of a model-for-improvement approach to QI for the delivery of immunization services in public health clinics, utilizing plan-do-study-act cycles and multiple QI techniques. A mixed-method (qualitative and quantitative) model of evaluation was used to collect and analyze data from June 2009 to July 2011 to support both summative and developmental evaluation. The Florida Immunization Registry (Florida SHOTS [State Health Online Tracking System]) was used to monitor and analyze changes in immunization rates from January 2009 to July 2012. An interrupted time-series application of covariance was used to assess significance of the change in immunization rates, and paired comparison using parametric and nonparametric statistics were used to assess significance of pre- and post-QI culture items. RESULTS: Up-to-date immunization rates increased from 75% to more than 90% for individual primary care clinics and the overall county health department. In addition, QI stakeholder scores on ten key items related to organizational culture increased from pre- to post-QI intervention. Statistical analysis confirmed significance of the changes. CONCLUSIONS: The application of QI combined with a summative and developmental evaluation supported refinement of the QI approach and documented the potential for QI to improve population health outcomes and improve public health agency culture. Copyright © 2013 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Achieving and sustaining profound institutional change in healthcare: case study using neo-institutional theory.
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Macfarlane F, Barton-Sweeney C, Woodard F, Greenhalgh T.
Social science & medicine (1982) 2013 Mar;80:10-18

Change efforts in healthcare sometimes have an ambitious, whole-system remit and seek to achieve fundamental changes in norms and organisational culture rather than (or as well as) restructuring the service. Long-term evaluation of such initiatives is rarely undertaken. We report a secondary analysis of data from an evaluation of a profound institutional change effort in London, England, using a mixed-method longitudinal case study design. The service had received £15 million modernisation funding in 2004, covering multiple organisations and sectors and overseen by a bespoke management and governance infrastructure that was dismantled in 2008. In 2010-11, we gathered data (activity statistics, documents, interviews, questionnaires, site visits) and compared these with data from 2003 to 2008. Data analysis was informed by neo-institutional theory, which considers organisational change as resulting from the material-resource environment and three ‘institutional pillars’ (regulative, normative and cultural-cognitive), enacted and reproduced via the identities, values and activities of human actors. Explaining the long-term fortunes of the different components of the original programme and their continuing adaptation to a changing context required attention to all three of Scott’s pillars and to the interplay between macro institutional structures and embedded human agency. The paper illustrates how neo-institutional theory (which is typically used by academics to theorise macro-level changes in institutional structures over time) can also be applied at a more meso level to inform an empirical analysis of how healthcare organisations achieve change and what helps or hinders efforts to sustain those changes. Copyright © 2013 Elsevier Ltd. All rights reserved.

A Phased Cluster-randomized Trial of Rural Hospitals Testing a Quality Collaborative to Improve Heart Failure Care: Organizational Context Matters.
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Newhouse RP, Dennison Himmelfarb C, Morlock L, Frick KD, Pronovost P, Liang Y.
Medical care 2013 May;51(5):396-403

BACKGROUND: : Use of evidence-based practices for heart failure (HF) patients has the potential to improve outcomes and reduce variations in care delivery. OBJECTIVES: : To evaluate the effect of a rural hospital quality collaborative and organizational context (nurse staffing and practice environment) on 4 HF core measures. RESEARCH DESIGN: : Phased cluster-randomized trial with delayed intervention control group. The intervention included a HF toolkit, 2 onsite meetings, and a monthly phone call. SUBJECTS: : Twenty-three rural eastern US hospitals, registered nurses who care for HF patients (N=591). MEASURES: : Seven quarters of 4 HF core measures, nurse staffing (nursing skill mix, registered nurse hours per patient day, nurse-turnover), and a survey of practice environment. RESULTS: : Using regression models with generalized estimating equation autoregressive methods, no statistically significant changes were found during the intervention period on all 4 core measures for either group. Higher nurse-turnover was related to all 4 core measures: lower compliance with discharge instructions [β=-1.042; 95% confidence interval (CI): -1.777, -0.307], smoking cessation (β=-1.148; 95% CI: -2.180, -0.117), left ventricular ejection fraction (β=-0.893; 95% CI: -1.784, -0.002), and prescribing angiotensin converting enzyme inhibitors on discharge (β=-1.044; 95% CI: -1.820, -0.269). Better practice environment was related to higher left ventricular ejection fraction (β=0.217; 95% CI: 0.054, 0.379). CONCLUSIONS: : Significant improvements in 4 core measures were realized in stable environments (less nurse-turnover). Assuring appropriate nurse staffing and stability is essential to increase organizational preparation for quality initiatives and adoption of best practices in HF care in rural hospitals.

Improving diabetes care and patient outcomes in skilled-care communities: successes and lessons from a quality improvement initiative.
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Boyle PJ, O’Neil KW, Berry CA, Stowell SA, Miller SC.
Journal of the American Medical Directors Association 2013 May;14(5):340-344

OBJECTIVE: To improve the quality of care for residents of long term care (LTC) facilities who have diabetes by (1) improving glycemic control, (2) increasing comprehensive diabetes management, (3) reducing fragmented care, and (4) empowering patient-care teams to educate patients and families regarding this disease. DESIGN: Based on the Plan-Do-Study-Act principles of effective change, a baseline evaluation of contemporary care for residents with diabetes was conducted through focus-group interviews, a confidence survey, and chart review. Three live educational workshops provided guideline-recommended information addressing educational desires and needs of clinical staff, a tool for improving performance in key areas of need, and an opportunity for care teams to engage in dialogue about advances in diabetes with a national diabetes expert. Reassessment was performed via chart review twice at 3 and 5 months post education. Key lessons and tools for improvements were disseminated to other LTC communities through a CME-certified publication activity and follow-up teleconferences. SETTING: Two skilled-nursing LTC communities. PARTICIPANTS: Physicians, administrators, nurses, certified nursing assistants, and nutrition staff. INTERVENTION: Three live continuing education/continuing medical education-certified workshops attended by 83 health care professionals. MEASUREMENTS: Twenty-five comprehensive clinical indicators of diabetes care and overall health were assessed for all residents with a diabetes diagnosis at baseline (n = 35), 3 months (n = 40), and 5 months (n = 27) post education. RESULTS: The primary objective of improving glycemic control we reached through a statistically significant 18% reduction in the percentage of residents experiencing hypoglycemia from baseline to 3 months post education (31% at baseline, 13% at 3 months, P = .046). Low levels of hypoglycemia (11%) were maintained at 5 months post education. Positive changes in an additional 3 measures of patient health include improved daily blood glucose levels, reduced ranges of HbA1c, and improved low-density lipoprotein cholesterol concentrations. Improvements in 4 measures of clinician performance were also observed, namely comprehensive foot evaluations, referrals to specialists for foot care and eye exams, and improved use of physical activity. CONCLUSION: Diabetes care, particularly in elder adults, is complex and requires a multidisciplinary approach. Focused quality improvement activities within LTC communities offer care providers the information and tools required to make effective changes that have the ability to promote improved patient care. These efforts must be multidisciplinary and effectively engage all stakeholders. Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

Trends and Predictors of Quality of Care in VA Nursing Homes Related to Serious Mental Illness.
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Kim HM, Banaszak-Holl J, Kales H, Mach J, Blow F, McCarthy JF.
Medical care 2013 Apr 29

OBJECTIVE: Within Veterans Affairs (VA) nursing homes (NHs), quality issues have a tremendous impact on the population with serious mental illness (SMI), who are more likely than their non-SMI Veteran counterparts to use NH services. We examined recent trends in quality indicators (QIs) measuring poor performance of VA NHs and whether the facility-level QIs vary with SMI concentration within the facility. METHODS: From VA administrative records including Minimum Data Set assessments, we identified all residents in the 135 VA NHs between fiscal years 2005 (FY05) through FY07. We used a zero-inflated Poisson regression to assess trends in and facility-level predictors of 3 process-related QIs: depression without antidepressant therapy; bladder/bowel incontinence without a toileting plan; and physical restraint use. Facility-level predictors included collocated special care units, rurality, staffing, physical plant characteristics, SMI prevalence, and SMI admission volume. RESULTS:: During FY05-FY07, restraint use declined from 1.2% to 1.1% and incontinence without a toileting plan from 25.8% to 22.1%, but untreated depression increased from 5.1% to 5.5%. Despite overall gains in quality, higher SMI prevalence was associated with higher odds of physical restraint use and lack of toileting plan. Higher SMI prevalence was also associated with higher frequency of untreated depression. Other characteristics such as complex building structure were predictive of variation in quality, but the relationships were not consistent across QI types. CONCLUSION: VA NHs had significant improvements in these examined QIs during the study period. Nonetheless, overall poorer quality was observed at sites with higher SMI concentrations.

IOM: From Pilots to Practice: Speeding the Movement of Successful Pilots to Effective Practice (US)
April 2013

In this discussion paper, authors identify practical strategies for improving health care and reducing costs with the knowledge gained from pilot projects. Developed by individual participants from the IOM’s Value Incentives Learning Collaborative, the paper outlines several reasons for the slow pace of adoption for the many effective pilots conducted across the U.S. health care system. Citing common lessons learned from real pilots across the country, from North Carolina to Indiana to Oregon, the authors identify several approaches to improve the planning, evaluation, scale-up, and spread of effective pilot projects, including broader incorporation of scale-up tactics at the onset of a project, and continuous pilot modification throughout the project’s duration.

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Organizational Change

Emerging innovation niches: An agent based model
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Lopolito A, Morone P, Taylor R.
Research Policy 2013

The creation of an innovation niche depends on the interaction of three mechanisms involving: converging expectations, networking among the innovation actors, and learning about the novelty through efficient knowledge creation and diffusion. Such mechanisms define the key characteristics of a network of firms (i.e. the innovation niche), and the interaction among them guides the development and diffusion of a new technology. In this paper, we propose an agent-based model to investigate the dynamics characterising such interactions and the role that policy intervention can have in governing the niche development process. Specifically, we consider and assess the impact of two policy actions: (1) increasing actors’ expectations towards the new technology by means of information spreading and (2) providing subsidies aimed at stimulating technological switch. Our results confirm the importance of policy intervention and show the dominance of information spreading activities over subsidies. The former policy action, in fact, preserves a broad consensus around the new technology, a fact which turned out to be fundamental in order to promote efficient knowledge diffusion and the effective use of individual and network resources. © 2013 Elsevier B.V. All rights reserved.

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Research Methodology

A protocol for a systematic review on the impact of unpublished studies and studies published in the gray literature in meta-analyses.
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Schmucker C, Bluemle A, Briel M, Portalupi S, Lang B, Motschall E, et al.
Systematic reviews 2013 May 2;2(1):24

BACKGROUND: Meta-analyses are particularly vulnerable to the effects of publication bias. Despite methodologists’ best efforts to locate all evidence for a given topic the most comprehensive searches are likely to miss unpublished studies and studies that are published in the gray literature only. If the results of the missing studies differ systematically from the published ones, a meta-analysis will be biased with an inaccurate assessment of the intervention’s effects.As part of the OPEN project (www.open-project.eu) we will conduct a systematic review with the following objectives:[black small square] To assess the impact of studies that are not published or published in the gray literature on pooled effect estimates in meta-analyses (quantitative measure)[black small square] To assess whether the inclusion of unpublished studies or studies published in the gray literature leads to different conclusions in meta-analyses (qualitative measure) METHODS: Inclusion criteria: Methodological research projects of a cohort of meta-analyses (, which compare the effect of the inclusion or exclusion of unpublished studies or studies published in the gray literature.Literature search: To identify relevant research projects we will conduct electronic searches in Medline, Embase and The Cochrane Library; check reference lists; and contact experts.Outcomes: 1) The extent to which the effect estimate in a meta-analyses changes with the inclusion or exclusion of studies that were not published or published in the gray literature; and 2) the extent to which the inclusion of unpublished studies impacts the meta-analyses’ conclusions.Data collection: Information will be collected on the area of health care; the number of meta-analyses included in the methodological research project; the number of studies included in the meta-analyses; the number of study participants; the number and type of unpublished studies; studies published in the gray literature and published studies; the sources used to retrieve studies that are unpublished, published in the gray literature, or commercially published; and the validity of the methodological research project.Data synthesis: Data synthesis will involve descriptive and statistical summaries of the findings of the included methodological research projects. DISCUSSION: Results are expected to be publicly available in the middle of 2013.

University of York: Expected health benefits of additional evidence: Principles, methods and applications (UK)

The purpose of this research is to illustrate: i) the principles of what assessments are required when considering the need for additional evidence and the priority of proposed research; and ii) how these assessments might be informed by quantitative analysis based on standard methods of systematic review and meta-analysis.

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Aging

Effects of an Acute Care for Elders Unit on Costs and 30-Day Readmissions.
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Flood KL, Maclennan PA, McGrew D, Green D, Dodd C, Brown CJ.
JAMA internal medicine 2013 Apr 22:1-7

IMPORTANCE Providing high-quality care while containing cost is essential for the economic stability of our health care system. The United States is experiencing a rapidly growing elderly population. The Acute Care for Elders (ACE) unit interdisciplinary team model of care has been shown to improve outcomes in hospitalized older adults. The University of Alabama at Birmingham ACE unit incorporates evidence-based care processes. We hypothesized that the ACE model would also reduce costs. OBJECTIVE To examine variable direct costs from an interdisciplinary ACE compared with a multidisciplinary usual care (UC) unit. DESIGN Retrospective cohort study. SETTING Tertiary care academic medical center. PARTICIPANTS Hospitalists’ patients aged 70 years or older spending the entirety of their hospitalization in either the ACE or UC unit in fiscal year 2010. MAIN OUTCOME MEASURES Using administrative data, we analyzed variable direct costs for ACE and UC patients. We also conducted a subset analysis restricted to the 25 most common diagnosis related groups (DRGs) shared by ACE and UC patients. Generalized linear regression was used to estimate cost ratios and 95% confidence intervals adjusted for age, sex, comorbidity score, and case mix index (CMI). RESULTS A total of 818 hospitalists’ patients met inclusion criteria: 428 from the ACE and 390 from the UC unit. For this study group (all DRGs), the mean (SD) variable direct cost per patient was $2109 ($1870) for ACE and $2480 ($2113) for UC (P = .009). Adjusted cost ratios revealed significant cost savings for patients with low (0.82; 95% CI, 0.72-0.94) or moderate (0.74; 95% CI, 0.62-0.89) CMI scores; care was cost neutral for patients with high CMI scores (1.13; 95% CI, 0.93-1.37). Significantly fewer ACE patients than UC patients were readmitted within 30 days of discharge (7.9% vs 12.8%; P = .02). Subset analysis of the 25 most common DRGs revealed a significantly reduced mean (SD) variable direct cost per patient for ACE compared with UC patients ($1693 [$1063] vs $2138 [$1431]; P < .001); cost ratios for total (0.78; 95% CI, 0.70-0.87) and daily (0.89; 95% CI, 0.85-0.94) variable direct costs remained significant after adjustment. CONCLUSIONS AND RELEVANCE The ACE unit team model reduces costs and 30-day readmissions. In an era when improving care processes while reducing costs is a vital objective for the Medicare program and our nation as a whole, the ACE model meets these goals.

Evaluation of the Mobile Acute Care of the Elderly (MACE) Service.
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Hung WW, Ross JS, Farber J, Siu AL.
JAMA internal medicine 2013 Apr 22:1-7

IMPORTANCE Older adults are particularly vulnerable to adverse events during hospitalization for acute medical problems. The Mobile Acute Care of the Elderly (MACE) service is a novel model of care delivered by an interdisciplinary team, designed to deliver specialized care to hospitalized older adults to improve patient outcomes. OBJECTIVE To evaluate the impact of the MACE service when compared with general medical service (usual care). DESIGN Prospective, matched cohort study. SETTING The Mount Sinai Hospital, an urban tertiary acute care hospital. PARTICIPANTS Patients aged 75 years or older admitted because of an acute illness to either the MACE service or usual care. Patients were matched for age, diagnosis, and ability to ambulate independently. EXPOSURES Admission to the MACE service when compared with admission to usual care. MAIN OUTCOME MEASURES Patient outcomes included incidence of adverse events, including falls, pressure ulcers, restraint use, and catheter-associated urinary tract infections, along with length of stay, rehospitalization within 30 days, functional status at 30 days, and patient satisfaction during care transitions, measured with the 3-item Care Transition Measure. RESULTS A total of 173 matched pairs of patients were recruited. The mean (SD) age was 85.2 (5.3) and 84.7 (5.4) years in the MACE and usual-care groups, respectively. After adjustment for confounders, patients in the MACE group were less likely to experience adverse events (9.5% vs 17.0%; adjusted odds ratio, 0.11; 95% CI, 0.01-0.88; P = .04) and had shorter hospital stays (0.8 days, 95% CI, 0.7-0.9; P = .001) than patients receiving usual care. Patients in the MACE group were not less likely to have a lower rate of rehospitalization within 30 days than those in the usual-care group (odds ratio, 0.91; 95% CI, 0.39-2.10; P = .83). Functional status did not differ between the 2 groups. Care Transition Measure scores were 7.4 points (95% CI, 2.9-11.9; P = .001) higher in the MACE group. CONCLUSIONS AND RELEVANCE Admission to the MACE service was associated with lower rates of adverse events, shorter hospital stays, and better satisfaction. This model has the potential to improve care outcomes among hospitalized older adults. TRIAL REGISTRATION clinicaltrials.gov Identifier:NCT00927160.

Impact on seniors of the patient-centered medical home: evidence from a pilot study.
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Fishman PA, Johnson EA, Coleman K, Larson EB, Hsu C, Ross TR, et al.
The Gerontologist 2012 Oct;52(5):703-711

PURPOSE: To assess the impact on health care cost and quality among seniors of a patient-centered medical home (PCMH) pilot at Group Health Cooperative, an integrated health care system in Washington State. DESIGN AND METHODS: A prospective before-and-after evaluation of the experience of seniors receiving primary care services at 1 pilot clinic compared with seniors enrolled at the remaining 19 primary care clinics owned and operated by Group Health. Analyses of secondary data on quality and cost were conducted for 1,947 seniors in the PCMH clinic and 39,396 seniors in the 19 control clinics. Patient experience with care was based on survey data collected from 487 seniors in the PCMH clinic and of 668 in 2 specific control clinics that were selected for their similarities in organization and patient composition to the pilot clinic. RESULTS: After adjusting for baseline, seniors in the PCMH clinic reported higher ratings than controls on 3 of 7 patient experience scales. Seniors in the PCMH clinic had significantly greater quality outcomes over time, but this difference was not significant relative to control. PCMH patients used more e-mail, phone, and specialist visits but fewer emergency services and inpatient admissions for ambulatory care sensitive conditions. At 1 and 2 years, the PCMH and control clinics did not differ significantly in overall costs. IMPLICATIONS: A PCMH redesign can be associated with improvements in patient experience and quality without increasing overall cost.

The fiscal impact of informal caregiving to home care recipients in Canada: how the intensity of care influences costs and benefits to government.
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Jacobs JC, Lilly MB, Ng C, Coyte PC.
Social science & medicine (1982) 2013 Mar;81:102-109

The objective of this study was to estimate the annual costs and consequences of unpaid caregiving by Canadians from a government perspective. We estimated these costs both at the individual and population levels for caregivers aged 45 and older. We conducted a cost-benefit analysis where we considered the costs of unpaid caregiving to be potential losses in income tax revenues and changes in social assistance payments and the potential benefit of reduced paid care expenditures. Our costing methods were based on multivariate analyses using the 2007 General Social Survey, a cross-sectional survey of 23,404 individuals. We determined the differential probability of employment, wages, and hours worked by caregivers of varying intensity versus non-caregivers. We also used multivariate analysis to determine how receiving different intensities of unpaid care impacted both the probability of receiving paid care and the weekly hours of paid care received. At the lowest intensities of caregiving, there was a net benefit to government from caregiving, at both the individual and population levels. At the population level, the net benefit to government was estimated to be $4.4 billion for caregivers providing less than five hours of weekly care. At the highest intensity of caregiving, there was a net cost to government of $641 million. Our overall findings were robust to a number of changes applied in our sensitivity analysis. We found that the factor with the greatest impact on cost was the probability of labour force participation. As the biggest cost driver appears to be the higher likelihood of intense caregivers dropping out of the labour force, government policies that enable intense caregivers to balance caregiving with employment may help to mitigate these losses. Copyright © 2013 Elsevier Ltd. All rights reserved.

An exploration of nursing home managers’ knowledge of and attitudes towards the management of pain in residents with dementia.
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Barry HE, Parsons C, Peter Passmore A, Hughes CM.
International journal of geriatric psychiatry 2012 Dec;27(12):1258-1266

BACKGROUND: The aims of this study were to explore the knowledge, attitudes and beliefs that nursing home managers hold with regard to the assessment and management of pain in residents with dementia and to determine how these may be affected by the demographic characteristics of the respondents. METHODS: A questionnaire comprising six sections was mailed, on two occasions during March and April 2010, to 244 nursing home managers in Northern Ireland (representing 96% of the nursing homes in Northern Ireland). RESULTS: The response rate was 39%. Nearly all respondents (96%) provided care to residents with dementia, yet only 60% of managers claimed to use pain treatment guidelines within their nursing home. Respondents demonstrated good knowledge about pain in residents with dementia and acknowledged the difficulties surrounding accurate pain assessment. Nursing home managers were uncertain about how to manage pain in residents with dementia, demonstrating similar concerns about the use of opioid analgesics to those reported in previous studies about pain in older people. Managers who had received recent training (p = 0.044) were less likely to have concerns about the use of opioid analgesia than those who had not received training. Respondents’ beliefs about painkillers were largely ambivalent and were influenced by the country in which they had received their nursing education. CONCLUSIONS: The study has revealed that accurate pain assessment, training of nursing staff and a standardised approach to pain management (the use of pain management guidelines) within nursing homes all have a significant part to play in the successful management of pain in residents with dementia. Copyright © 2012 John Wiley & Sons, Ltd.

Appreciating the ‘person’ in long-term care.
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McCormack B, Roberts T, Meyer J, Morgan D, Boscart V.
International journal of older people nursing 2012 Dec;7(4):284-294

BACKGROUND: Internationally, approaches to the long-term care of older people are changing. New models are being developed that aim to de-institutionalise care settings, maximise opportunities for older people to participate in decision-making and move from a predominant medical model of care to one that is community orientated. AIMS: The aim of this study is to highlight similarities and differences between the different models that exist and explore the implications of these for the role of the registered nurse in long-term care. METHODS: We chose three models for review as these represent a range of views of person centredness, each having distinct roots and focus. The models chosen were as follows: (i) culture change, (ii) person-centred practice and (iii) relationship-centred care. RESULTS: The review highlights two key issues – (i) the distinctiveness of different models and frameworks and (ii) different interpretations of ‘person’. Firstly, we identify a disconnection between espoused differences between models and frameworks and the reality of these differences. The evidence also identifies how some models and frameworks adopt a more inclusive conceptualisation of person and personhood and do not define personhood in relation to role (resident, nurse and family member). CONCLUSIONS: There is merit in the development of models and frameworks that try to make explicit the different dimensions of person centredness in long-term care. However, the focus on the development of these, without sufficient attention being paid to evidence of best practices grounded in the concept of personhood, person-centred care is in danger of losing its original humanistic emphasis. Further, models and frameworks need to take account of the personhood of all persons. IMPLICATIONS FOR PRACTICE: Registered nurses need to have an understanding of the concept of personhood to make sense of the various person-centred practice frameworks that exist. Without this understanding, there is a danger that the essence of personhood may be lost in the zeal to implement particular models and frameworks. © 2012 Blackwell Publishing Ltd.

Identifying the gaps in infection prevention and control resources for long-term care facilities in British Columbia.
Non UofA Access
Gamage B, Schall V, Grant J, PICNet Long-term Care Needs Assessment Working Group.
American Journal of Infection Control 2012 Mar;40(2):150-154

BACKGROUND: Infection prevention and control (IPC) is a critical, although often neglected, part of long-term care (LTC) management. Little is known about what IPC resources are available for LTC and how that impacts patient care and safety. METHODS: One hundred eighty-eight LTC facilities were randomly selected out of all British Columbia facilities and surveyed using a validated survey tool. The tool was used to collect data regarding IPC resources grouped within 6 indices: (1) leadership, (2) infection control professionals (ICP) coverage, (3) policies and procedures, (4) support through partnerships, (5) surveillance, and (6) control activities. All components measured have been identified as key for an effective IPC program. Survey responses were used to calculate scores for IPC programs as a whole and for each of the 6 indices. RESULTS: Of 188 randomly selected facilities, 86 institutions participated. Facilities were compared by region, funding source, and ICP coverage. Overall, LTC facilities lacked IPC leadership, especially physician support. Having no dedicated ICP was associated with poorer scores on all indices. Only 41% of practicing ICPs had more than 2 years experience, and only 14% were professionally certified. Twenty-two percent of ICPs had additional roles within the institution, and 44% had additional roles outside of the institution. Thirty-five percent of institutions had no IPC dedicated budget. DISCUSSION: LTC institutions-with bed numbers exceeding those in acute care-represent an important aspect of health services. These data show that many LTC facilities lack the necessary resources to provide quality infection control programs. Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

AARP: Home Alone-Family Caregivers Providing Complex Chronic Care (US)
October 2012

This study challenges the common perception of family caregiving as a set of personal care and household chores that most adults already do or can easily master. Family caregivers have traditionally provided assistance with bathing, dressing, eating, and household tasks such as shopping and managing finances. While these remain critically important to the well-being of care recipients, the role of family caregivers has dramatically expanded to include performing medical/nursing tasks of the kind and complexity once only provided in hospitals.

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Events

UofA

Data Analysis with Nested Data
Presenter: Dr. Don Schopflocher, UofA School of Public Health
ECHA 5-140
May 23, 2013 12:00-13:00

Sponsored by Health Systems AoE.

KUSP Brown Bag Seminar: An Introduction to Propensity Scoring Methods
Presenter: Sunghyun Kang, Senior Analyst KUSP
ECHA 5-140
May 22, 2013 12:00-13:00

Concerned about balancing non-equivalent groups?

Outside the Pale: Addressing the synchronicity of mental health and palliative care
Friday May 24th, 2013 Dvorkin Centre 2G2.07(WMC) 16:00‐17:00pm
Presenter: Dr.Philip Larkin

Through a case study presentation of Martin, a man with bi‐polardisorder and metastatic colon cancer,the issues of exclusion (‘outside the pale’) will be debated anda case offered for a more equitable model of palliative care formentalhealth service users, proffered.

CIHR’s New Open Suite of Programs and Associated Peer Review Town Hall
Thursday May 16, 2013 08:30-10:20 ECHA 2-190

In December 2012, CIHR initiated a process to design a new Open Suite of Programs and associate peer review system. Dr. Jane Aubin (Chief Scientific Officer and Vice-President of Research and Knowledge Translation, CIHR) will visit to the University of Alberta on Thursday, May 16, 2013 to answer questions about the proposed changes.

Developing a Knowledge Translation Plan for CIHR Operating Grant Applications
Wednesday May 15, 2013 12:00-13:00 2-430 ECHA
Presenter: Dr. Shannon Scott

Completing rigorous inquiry is challenging and recently additional expectations, typically from funding agencies, have been placed on researchers to put their research findings to work. Putting research findings of all types, quantitative, qualitative, systematic review, to work comes under the guise of several overlapping, often disciplinary and geographically influenced monikers. In this workshop participants will learn about the different terms in this field of putting research into action (e.g., knowledge translation, research implementation, research utilization, etc.) and what these terms mean for researchers. The differences between end-of-grant knowledge translation and integrated knowledge translation will also be discussed. This workshop will cover the important components in developing an effective knowledge translation plan for qualitative and quantitative research studies in the context of the CIHR Open Operating Grant Program (OOGP) application.

SSHRC or CIHR?
Wednesday May 22 10:00-11:30 Education South 122
Facilitator: Dr. John Spence, Associate Dean Research, Faculty of Physical Education

Are you uncertain whether you should submit a grant proposal to SSHRC or CIHR? Do you want to learn strategies for positioning your resesarch for success in a CIHR funding competition? This session is designed for social science/humanities researchers who are crossing from SSHRC TO CIHR.

Family Centered Care: Ethical Implications? Part 2
Thursday 16 May 2013 12:00-13:00 1J2.13 WMC
Presenter: Dr. Brendan Leier

Non UofA

Scholarly Writing Retreat Fall 2013
November 8-10 Atlanta, GA Cost $800 US

The National League for Nursing is sponsoring another Scholarly Writing Retreat. These retreats (three per year) are supported by Pocket Nurse and are designed for nurse faculty who have completed research or a recent innovation but have problems writing for publication.

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News

For the elderly, a dose of ‘senior friendly’ hospital care

Ontario hospitals implement strategies for hospitalized elderly.

U of Saskatchewan research chair examines “biggest experiment world-wide” in improving health-care quality

Thomas Rotter is watching closely as health regions across Saskatchewan strive to adapt the principles of Lean – a system originally developed to build cars – to help cut health-care costs, decrease wait times and move innovations more quickly from the lab to the bedside.

Alberta Health Services set to formalize 100-km policy for seniors’ continuing care

To help clear acute-care beds, Alberta seniors awaiting a continuing care placement who can’t get into the facility of their choice are subject to a “first available bed” strategy that allows them to be placed in an open spot in another facility — a rule Health Minister Fred Horne calls “a necessary response to a very temporary situation.

Alberta Health Services streamlines care for hip fractures

Alberta Health Services is standardizing the way it takes care of patients who have suffered a hip fracture in an effort to get them back on their feet sooner.

Alberta announces new cancer-care plan

Reduced wait times, more effective treatments and improved rates of prevention are among the major benefits Alberta patients can expect from a new provincial cancer strategy, the Alberta government announced at the end of April.

BioMed Central’s Biology and Medical Editors launch new editorial policies.

Existing policies have been updated and expanded.

Ontario budget will see more hospital downsizing and community upsizing, health minister says

Funding for community and health services is expected to jump by $260 million to $4.56 billion when the Ontario budget comes down Thursday afternoon.

In nursing, specializing is ‘the new normal’

The role of nurses is evolving across Canada as the industry attempts to meet the challenges of an increasingly complex health care system. Many colleges, educational institutes and nursing organizations are rolling out specialized training programs to help nurses provide better care in such areas as oncology, neonatal, mental health, geriatric, perioperative and palliative care. This trend is “the new normal” in nursing, says Barb Mildon, president of the Canadian Nurses Association.

Research Participants Needed

Are you a member of a healthcare team? Your experiences and stories add to further our understanding of healthcare team processes. Interviews and a full-day workshop in art-based research will take place. Contact Susan Sommerfeldt 780-492-9509

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Resources

Managing for Impact

This portal is the portal for Managing for Impact (M4I), with particular focus on Participatory Planning, Monitoring and Evaluation (PPME). The portal is managed by Centre for Development Innovation (CDI), Wageningen University and Research centre. It provides access to key publications and internet resources on planning, monitoring and evaluation.

NCCMT: Understanding Research Evidence Video Series

Understanding and interpreting research evidence is an important part of practicing evidence-informed public health. You need to understand some basic concepts. That’s why the National Collaborating Centre for Methods and Tools has developed a series of short videos to explain some important terms that you are likely to encounter when looking at research evidence.

NRC’s makeover leaves Canadian industry setting the agenda

The overhaul, quietly begun two years ago and formally unveiled Tuesday, means the 97-year-old NRC will focus on a clutch of large-scale, business-driven research projects at the expense of the basic science that was once at its core.

ARHQ: Systematic Review Data Repository

The Systematic Review Data Repository (SRDR) is a powerful and easy-to-use tool for the extraction and management of data for systematic review or meta-analysis. It is also an open and searchable archive of systematic reviews and their data.

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Opportunities

Deputy Director, Knowledge Translation
FHI 360, North Carolina
DEADLINE: 31 May 2013

The Deputy Director, Knowledge Translation, will provide leadership in the translation of research results into policy and programs, and in the replication and scale-up of evidence-based practices. The deputy director should be a senior manager with an advanced degree in public health, social science, or a related field with at least 10 years of experience translating evidence to inform FP/RH programs and policy and at least 5 years leading complex FP/RH service delivery and/or Implementation Science projects in developing countries. This full-time position will report to the Project Director and will be based in North Carolina.

Research Fellows (2 positions)
Royal College of Physicians, London UK
DEADLINE: 20 May 2013

If you have related experience and a desire to make a difference in improving healthcare delivery and the quality of patient care, we would be delighted to hear from you. The NCGC produces evidence-based clinical practice guidelines on behalf of NICE specialising in guidance for acute and chronic conditions across a wide and varied range of clinical topics.

Consultant: Systematic Reviews
York Health Economics Constortium, York UK
DEADLINE May 31, 2013

The primary purpose of the role is to undertake systematic reviews and other review activity on a wide range of project types (scoping reviews, rapid reviews, systematic reviews, qualitative reviews). The candidate will be expected to work in project teams alongside other research staff and Project Directors. YHEC staff include information specialists, health economists, qualitative researchers and support staff experienced in supporting reviews. YHEC also frequently collaborates with Quantics, a leading UK Biostatistical Consultancy.

Senior Consultant: Systematic Reviews
York Health Economics Constortium, York UK
DEADLINE May 31, 2013

The primary purpose of the role is to undertake systematic reviews and other review activity on a wide range of project types (scoping reviews, rapid reviews, systematic reviews, qualitative reviews). The candidate will be expected to work in project teams alongside other research staff and Project Directors. YHEC staff include information specialists, health economists, qualitative researchers and support staff experienced in supporting reviews. YHEC also frequently collaborates with Quantics, a leading UK Biostatistical Consultancy.

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