Facilitating future implementation and translation to clinical practice: The Implementation Planning Assessment Tool for clinical trials.

Implementation assessment plans are crucial for clinical trials to achieve their full potential. Without a proactive plan to implement trial results, it can take decades for one-fifth of effective interventions to be adopted into routine care settings. The Veterans Health Administration Office of Research and Development is undergoing a systematic transformation to embed implementation planning in research protocols through the Cooperative Studies Program, its flagship clinical research program.

Formative evaluation and adaptation of pre-and early implementation of diabetes shared medical appointments to maximize sustainability and adoption.

Background: Understanding the many factors that influence implementation of new programs, in addition to their success or failure, is extraordinarily complex. This qualitative study examines the implementation and adaptation process of two linked clinical programs within Primary Care, diabetes shared medical appointments (SMAs) and a reciprocal Peer-to-Peer (P2P) support program for patients with poorly controlled diabetes, through the lens of the Consolidated Framework for Implementation Research (CFIR). We illustrate the role and importance of pre-implementation interviews for guiding ongoing adaptations to improve implementation of a clinical program, achieve optimal change, and avoid type III errors.

'The Hand on the Doorknob': Visit Agenda Setting by Complex Patients and Their Primary Care Physicians.

Background: Choosing which issues to discuss in the limited time available during primary care visits is an important task for complex patients with chronic conditions.

Design, Setting, And Participants: We conducted sequential interviews with complex patients (n = 40) and their primary care physicians (n = 17) from 3 different health systems to investigate how patients and physicians prepare for visits, how visit agendas are determined, and how discussion priorities are established during time-limited visits.

Key Results: Visit flow and alignment were enhanced when both patients and physicians were effectively prepared before the visit, when the patient brought up highest-priority items first, the physician and patient worked together at the beginning of the visit to establish the visit agenda, and other team members contributed to agenda setting.

User-Centered Design of a Tablet Waiting Room Tool for Complex Patients to Prioritize Discussion Topics for Primary Care Visits.

Background: Complex patients with multiple chronic conditions often face significant challenges communicating and coordinating with their primary care physicians. These challenges are exacerbated by the limited time allotted to primary care visits.

Objective: Our aim was to employ a user-centered design process to create a tablet tool for use by patients for visit discussion prioritization.

Unique factors rural Veterans' Affairs hospitals face when implementing health care-associated infection prevention initiatives.

Purpose: Health care-associated infection (HAI) is costly to hospitals and potentially life-threatening to patients. Numerous infection prevention programs have been implemented in hospitals across the United States. Yet, little is known about infection prevention practices and implementation in rural hospitals.

Variations in risk perceptions: a qualitative study of why unnecessary urinary catheter use continues to be problematic.

Background: Catheter associated urinary tract infection (CAUTI) is one of the most commonly acquired health care associated infections within the United States. We examined the implementation of an initiative to prevent CAUTI, to better understand how health care providers' perceptions of risk influenced their use of prevention practices and the potential impact these risk perceptions have on patient care decisions. Understanding such perceptions are critical for developing more effective approaches to ensure the successful uptake of key patient safety practices and thus safer care for hospitalized patients.

Barriers to reducing urinary catheter use: a qualitative assessment of a statewide initiative.

Importance: Preventing catheter-associated urinary tract infection (CAUTI), a common health care-associated infection, is important for improving the care of hospitalized patients and in meeting the goals for reduction of health care-associated infections set by the US Department of Health and Human Services.

Objective: To identify ways to enhance CAUTI prevention efforts based on the experiences of hospitals participating in the Michigan Health and Hospital Association Keystone Center for Patient Safety statewide program to reduce unnecessary use of urinary catheters (the Bladder Bundle).

Design: Qualitative assessment of data collected through semistructured telephone interviews with key informants at 12 hospitals and in-person interviews and site visits at 3 of the 12 hospitals.

Preventing catheter-associated urinary tract infection in the United States: a national comparative study.

Importance: Despite the national goal to reduce catheter-associated urinary tract infection (CAUTI) by 25% by 2013, limited data exist describing prevention practices for CAUTI in US hospitals and none associate national practice use to CAUTI-specific standardized infection ratios (SIRs).

Objectives: To identify practices currently used to prevent CAUTI and to compare use and SIRs for a national sample of US hospitals with hospitals in the state of Michigan, which launched a CAUTI prevention initiative in 2007 ("Keystone Bladder Bundle Initiative").

Design And Setting: In 2009, we surveyed infection preventionists at a sample of US hospitals and all Michigan hospitals.

Preventing hospital-acquired infections: a national survey of practices reported by U.S. hospitals in 2005 and 2009.

Background: Hospital-acquired infection (HAI) is common, costly, and potentially lethal. Whether initiatives to reduce HAI--such as the Centers for Medicare and Medicaid Services (CMS) no payment rule--have increased the use of preventive practices is not known.

Objective: To examine the use of infection prevention practices by U.

Introducing the patient safety professional: why, what, who, how, and where?

Background: Hospital-acquired complications, such as nosocomial infection, falls, and venous thromboembolism, are well known to be frequent and morbid. Unfortunately, prevention remains challenging. Two widely touted prevention strategies-checklists and reminders-have inherent barriers that limit their use as general solutions to these endemic problems.

The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study.

Patient safety is a healthcare priority worldwide, with most hospitals engaging in activities to improve care quality, safety and outcomes. Despite these efforts, we have limited understanding of why quality improvement efforts are successful in some hospitals and not others. Using data collected as part of a multi-center study, we closely examined quality improvement efforts and the implementation of recommended practices to prevent central line-associated bloodstream infections (CLABSI) in U.

The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study.

Objective: Healthcare-associated infection (HAI) is costly and causes substantial morbidity. We sought to understand why some hospitals were engaged in HAI prevention activities while others were not. Because preliminary data indicated that hospital leadership played an important role, we sought better to understand which behaviors are exhibited by leaders who are successful at implementing HAI prevention practices in US hospitals.

Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle.

Background: Catheter-associated urinary tract infection (CAUTI), a frequent health care-associated infection (HAI), is a costly and common condition resulting in patient discomfort, activity restriction, and hospital discharge delays. The Centers for Medicare & Medicaid Services (CMS) no longer reimburses hospitals for the extra cost of caring for patients who develop CAUTI. The Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety & Quality has initiated a statewide initiative, MHA Keystone HAI, to help ameliorate the burden of disease associated with indwelling catheterization.

Catheter-associated urinary tract infection and the Medicare rule changes.

Catheter-associated urinary tract infection, a common and potentially preventable complication of hospitalization, is 1 of the hospital-acquired complications chosen by the Centers for Medicare & Medicaid Services (CMS) for which hospitals no longer receive additional payment. To help readers understand the potential consequences of the recent CMS rule changes, the authors examine the preventability of catheter-associated infection, review the CMS rule changes regarding catheter-associated urinary tract infection, offer an assessment of the possible consequences of these changes, and provide guidance for hospital-based administrators and clinicians. Although the CMS rule changes related to catheter-associated urinary tract infection are controversial, they may do more good than harm, because hospitals are likely to redouble their efforts to prevent catheter-associated urinary tract infection, which may minimize unnecessary placement of indwelling catheters and facilitate prompt removal.

How active resisters and organizational constipators affect health care-acquired infection prevention efforts.

Background: As of October 2008, hospitals in the United States no longer receive Medicare reimbursement for certain types of health care-associated infection (HAI), thereby heightening the need for effective prevention efforts. The mere existence of evidence-based practices, however, does not always result in the use of such practices because of the complexities inherent in translating evidence into practice. A qualitative study was conducted to determine the barriers to implementing evidence-based practices to prevent HAI, with a specific focus on the role played by hospital personnel.

Adoption of alcohol-based handrub by United States hospitals: a national survey.

The extent to which the use of alcohol-based handrub for hand hygiene has been adopted by US hospitals is unknown. A survey of infection control coordinators (response rate, 516 [72%] of 719) revealed that most hospitals (436 [84%] of 516) have adopted alcohol-based handrub. Leadership support and staff receptivity play a significant role in its adoption.

Qualitative research methods: key features and insights gained from use in infection prevention research.

Infection control professionals and hospital epidemiologists are accustomed to using quantitative research. Although quantitative studies are extremely important in the field of infection control and prevention, often they cannot help us explain why certain factors affect the use of infection control practices and identify the underlying mechanisms through which they do so. Qualitative research methods, which use open-ended techniques, such as interviews, to collect data and nonstatistical techniques to analyze it, provide detailed, diverse insights of individuals, useful quotes that bring a realism to applied research, and information about how different health care settings operate.

Preventing ventilator-associated pneumonia in the United States: a multicenter mixed-methods study.

Objective: To determine what practices are used by hospitals to prevent ventilator-associated pneumonia (VAP) and, through qualitative methods, to understand more fully why hospitals use certain practices and not others.

Design: Mixed-methods, sequential explanatory study.

Methods: We mailed a survey to the lead infection control professionals at 719 US hospitals (119 Department of Veterans Affairs [VA] hospitals and 600 non-VA hospitals), to determine what practices are used to prevent VAP.

A multicenter qualitative study on preventing hospital-acquired urinary tract infection in US hospitals.

Objective: Although urinary tract infection (UTI) is the most common hospital-acquired infection, there is little information about why hospitals use or do not use a range of available preventive practices. We thus conducted a multicenter study to understand better how US hospitals approach the prevention of hospital-acquired UTI.

Methods: This research is part of a larger study employing both quantitative and qualitative methods.

Preventing hospital-acquired urinary tract infection in the United States: a national study.

Background: Although urinary tract infection (UTI) is the most common hospital-acquired infection in the United States, to our knowledge, no national data exist describing what hospitals in the United States are doing to prevent this patient safety problem. We conducted a national study to examine the current practices used by hospitals to prevent hospital-acquired UTI.

Methods: We mailed written surveys to infection control coordinators at a national random sample of nonfederal US hospitals with an intensive care unit and >or=50 hospital beds (n=600) and to all Veterans Affairs (VA) hospitals (n=119).

An observational study of the effectiveness of practice guideline implementation strategies examined according to physicians' cognitive styles.

Background: Reviews of guideline implementation recommend matching strategies to the specific setting, but provide little specific guidance about how to do so. We hypothesized that the highest level of guideline-concordant care would be achieved where implementation strategies fit well with physicians' cognitive styles.

Methods: We conducted an observational study of the implementation of guidelines for hypertension management among patients with diabetes at 43 Veterans' Health Administration medical center primary care clinics.

Use of central venous catheter-related bloodstream infection prevention practices by US hospitals.

Objective: To examine the extent to which US acute care hospitals have adopted recommended practices to prevent central venous catheter-related bloodstream infections (CR-BSIs).

Participants And Methods: Between March 16, 2005, and August 1, 2005, a survey of infection control coordinators was conducted at a national random sample of nonfederal hospitals with an intensive care unit and more than 50 hospital beds (n=600) and at all Department of Veterans Affairs (VA) medical centers (n=119). Primary outcomes were regular use of 5 specific practices and a composite approach for preventing CR-BSIs.

Does implementation of evidence-based guidelines follow the available evidence? Implementation of hypertension guidelines at Veterans Affairs medical centers.

Background: We sought to determine whether the proportion of strategies adopted in the implementation of evidence-based clinical guidelines by Department of Veterans Affairs medical centers (VAMCs) reflects an evidence-based assessment of the implementation strategies' relative effectiveness that was widely disseminated among VAMCs.

Methods: We used data from a multisite observational study we conducted to test a model of changing clinical behaviors. For that study, we had compiled information from key informants at 43 VAMCs about strategies for implementing the VA's new hypertension management guidelines.