BackgroundMany family health innovations that have been shown to be both efficacious and cost-effective fail to scale up for widespread use particularly in low-income and middle-income countries (LMIC). Although individual cases of successful scale-up, in which widespread take up occurs, have been described, we lack an integrated and practical model of scale-up that may be applicable to a wide range of public health innovations in LMIC.ObjectiveTo develop an integrated and practical model of scale-up that synthesises experiences of family health programmes in LMICs.Data sourcesWe conducted a mixed methods study that included in-depth interviews with 33 key informants and a systematic review of peer-reviewed and grey literature from 11 electronic databases and 20 global health agency web sites.Study eligibility criteria, participants and interventionsWe included key informants and studies that reported on the scale up of several family health innovations including Depo-Provera as an example of a product innovation, exclusive breastfeeding as an example of a health behaviour innovation, community health workers (CHWs) as an example of an organisational innovation and social marketing as an example of a business model innovation. Key informants were drawn from non-governmental, government and international organisations using snowball sampling. An article was excluded if the article: did not meet the study's definition of the innovation; did not address dissemination, diffusion, scale up or sustainability of the innovation; did not address low-income or middle-income countries; was superficial in its discussion and/or did not provide empirical evidence about scale-up of the innovation; was not available online in full text; or was not available in English, French, Spanish or Portuguese, resulting in a final sample of 41 peer-reviewed articles and 30 grey literature sources.Study appraisal and synthesis methodsWe used the constant comparative method of qualitative data analysis to extract recurrent themes from the interviews, and we integrated these themes with findings from the literature review to generate the proposed model of scale-up. For the systematic review, screening was conducted independently by two team members to ensure consistent application of the predetermined exclusion criteria. Data extraction from the final sample of peer-reviewed and grey literature was conducted independently by two team members using a pre-established data extraction form to list the enabling factors and barriers to dissemination, diffusion, scale up and sustainability.ResultsThe resulting model—the AIDED model—includes five non-linear, interrelated components: (1) assess the landscape, (2) innovate to fit user receptivity, (3) develop support, (4) engage user groups and (5) devolve efforts for spreading innovation. Our findings suggest that successful scale-up occurs within a complex adaptive system, characterised by interdependent parts, multiple feedback loops and several potential paths to achieve intended outcomes. Failure ...
IMPORTANCE Enhanced recovery pathways (ERPs) have the potential to reduce length of hospital stay, costs, and complications following surgery but can be challenging to implement. OBJECTIVE To examine the body of literature on ERPs to assess how authors describe barriers and facilitators of ERP implementation and identify, in aggregate, the best practices that should be considered utilizing the Consolidated Framework for Implementation Research (CFIR) to extract these elements and summarize common barriers and facilitators according to its 5 major domains: (1) intervention characteristics, (2) inner setting, (3) outer setting, (4) characteristics of the individuals, and (5) the process of implementation.EVIDENCE REVIEW A systematic review was conducted in accordance with the PRISMA statement. An ERP was defined as a bundle of multiple perioperative interventions that involve a multidisciplinary team, had a label different than traditional care, and had a formal way of measuring outcomes. Six databases (PubMed, MEDLINE, Cumulative Index to Nursing and Allied Health Literature Complete, Web of Science, PsychINFO, and Cochrane Central Register of Controlled Trials) of articles published from 1990 to November 30, 2016, were searched. Articles that were included had to address barriers and facilitators of ERP implementation and provide sufficient detail that the CFIR domain could be identified. Data were abstracted by 2 independent researchers using a standardized extraction form.FINDINGS The initial search strategy returned 4563 results; 3883 studies were eliminated by screening titles and abstracts, leaving 680 articles for full-text screening. Of these, 53 studies were included in the review. The key facilitating factors were (1) adapting the program to fit local contexts, (2) achieving and demonstrating early "wins," (3) gaining buy-in from both frontline clinicians and hospital leadership, (4) having a strong ERP team that met regularly, and (5) leveraging supporters and full-time ERP staff. The major barriers identified were (1) meeting with resistance to change from frontline clinicians, (2) not having enough resources for implementation, and (3) external factors, such as patient complexity or rural hospital location. CONCLUSIONS AND RELEVANCEMost ERP literature focuses on the efficacy, safety, or cost-effectiveness of these protocols. To promote the spread of ERP programs, more high-quality studies on the implementation process are needed.
The results of the study primarily highlight the larger issue of information asymmetry within the health care system that, if left unaddressed, will persist as new vulnerable populations of refugees arrive in the United States.
BackgroundDespite the potential for electronic health records (EHRs) to improve patient safety and quality of care, the intended benefits of EHRs are not always realized because of implementation-related challenges. Enlisting clinician super users to provide frontline support to employees has been recommended to foster EHR implementation success. In some instances, their enlistment has been associated with implementation success; in other cases, it has not. Little is known about why some super users are more effective than others. The purpose of this study was to identify super users’ mechanisms of influence and examine their effects on EHR implementation outcomes.MethodsWe conducted a longitudinal (October 2012 – June 2013), comparative case study of super users’ behaviors on two medical units of a large, academic hospital implementing a new EHR system. We assessed super users’ behaviors by observing 29 clinicians and conducting 24 in-depth interviews. The implementation outcome, clinicians’ information systems (IS) proficiency, was assessed using longitudinal survey data collected from 43 clinicians before and after the EHR start-date. We used multivariable linear regression to estimate the relationship between clinicians’ IS proficiency and the clinical unit in which they worked.ResultsSuper users on both units employed behaviors that supported and hindered implementation. Four super user behaviors differed between the two units: proactivity, depth of explanation, framing, and information-sharing. The unit in which super users were more proactive, provided more comprehensive explanations for their actions, used positive framing, and shared information more freely experienced significantly greater improvement in clinicians’ IS proficiency (p =0.03). Use of the four behaviors varied as a function of super users’ role engagement, which was influenced by how the two units’ managers selected super users and shaped the implementation climate.ConclusionsSuper users’ behaviors in implementing EHRs vary substantively and can have important influence on implementation success.
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