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1.  Developing a checklist for guideline implementation planning: review and synthesis of guideline development and implementation advice 
Background
Developers, users and others have requested or advocated for guidance on how to plan for, and implement guidelines concurrent to their development given that existing resources are lacking such information. The purpose of this research was to develop a guideline implementation planning checklist.
Methods
Documents that described or evaluated the processes of planning or undertaking implementation were identified in several publications that had systematically identified such resources, and by searching medical literature databases (MEDLINE, EMBASE). Data that described implementation planning; how to develop guideline versions or tools that would support user implementation; and options and mechanisms for disseminating or implementing guidelines were independently extracted from eligible documents by the principal investigator and a trained research assistant. Data were integrated to create a unique list of guideline implementation planning processes and considerations.
Results
Thirty-five documents were eligible. Of these, 16 (45.7%) provided sparse information on implementation planning, 25 (71.4%) mentioned different versions or tools for implementation, and 30 (85.7%) listed options for dissemination or implementation. None provided instructions for operationalizing implementation strategies. Data were integrated into a multi-item Guideline Implementation Planning Checklist including considerations for implementation planning (12), development of implementation tools (8), types of implementation tools (12), and options for dissemination (11) and implementation (12).
Conclusions
Developers or users can apply the Guideline Implementation Planning Checklist to prepare for and/or undertake guideline implementation. Further development of the checklist is warranted to elaborate on all components. In ongoing research, we will consult with the international guideline community to do so. At the same time, guideline implementation is complex, so developers and users would benefit from training, and by including knowledge translation experts and brokers on implementation planning committees.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-015-0205-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s13012-015-0205-5
PMCID: PMC4329197
Guidelines; Implementation
2.  How does context influence collaborative decision-making for health services planning, delivery and evaluation? 
Background
Collaboration among researchers (clinician, non-clinician) and decision makers (managers, policy-makers, clinicians), referred to as integrated knowledge translation (IKT), enhances the relevance and use of research, leading to improved decision-making, policies, practice, and health care outcomes. However IKT is not widely practiced due to numerous challenges. This research explored how context influenced IKT as a means of identifying how IKT could be strengthened.
Methods
This research investigated IKT in three health services programs for colon cancer screening, prostate cancer diagnosis, and the treatment of pancreatic cancer. Qualitative methods were used to explore contextual factors that influenced how IKT occurred, and its impact. Data were collected between September 1, 2012 and May 15, 2013 from relevant documents, observation of meetings, and interviews with researchers and decision-makers, analyzed using qualitative methods, and integrated.
Results
Data were analyzed from 39 documents, observation of 6 meetings, and 36 interviews. IKT included interaction at meetings, joint undertaking of research, and development of guidelines. IKT was most prevalent in one program with leadership, clear goals, dedicated funding and other infrastructural resources, and an embedded researcher responsible for, and actively engaged in IKT. This program achieved a variety of social, research and health service outcomes despite mixed individual views about the value of IKT and the absence of a programmatic culture of IKT. Participants noted numerous challenges including lack of time and incentives, and recommendations to support IKT. A conceptual framework of factors that influence IKT and associated outcomes was generated, and can be used by others to plan or evaluate IKT.
Conclusions
The findings can be applied by researchers, clinicians, managers or policy-makers to plan or improve collaborative decision-making for health services planning, delivery, evaluation or quality improvement. Further research is needed to explore whether these findings are widespread, and further understand how IKT can be optimized.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-014-0545-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-014-0545-x
PMCID: PMC4239386  PMID: 25407487
Integrated knowledge translation; Health services research; Collaboration; Qualitative methods
3.  Multiple Interacting Factors Influence Adherence, and Outcomes Associated with Surgical Safety Checklists: A Qualitative Study 
PLoS ONE  2014;9(9):e108585.
Objectives
The surgical safety checklist (SSC) is meant to enhance patient safety but studies of its impact conflict. This study explored factors that influenced SSC adherence to suggest how its impact could be optimized.
Methods
Participants were recruited purposively by profession, region, hospital type and time using the SSC. They were asked to describe how the SSC was adopted, associated challenges, perceived impact, and suggestions for improving its use. Grounded theory and thematic analysis were used to collect and analyse data. Findings were interpreted using an implementation fidelity conceptual framework.
Results
Fifty-one participants were interviewed (29 nurses, 13 surgeons, 9 anaesthetists; 18 small, 14 large and 19 teaching hospitals; 8 regions; 31 had used the SC for ≤12 months, 20 for 13+ months). The SSC was inconsistently reviewed, and often inaccurately documented as complete. Adherence was influenced by multiple issues. Extensive modification to accommodate existing practice patterns eliminated essential interaction at key time points to discuss patient management. Staff were often absent or not paying attention. They did not feel it was relevant to their work given limited evidence of its effectiveness, and because they were not engaged in its implementation. Organizations provided little support for implementation, training, monitoring and feedback, which are needed to overcome these, and other individual and team factors that challenged SSC adherence. Responses were similar across participants with different characteristics.
Conclusions
Multiple processes and factors influenced SSC adherence. This may explain why, in studies evaluating SSC impact, outcomes were variable. Recommendations included continuing education, time for pilot-testing, and engaging all staff in SSC review. Others may use the implementation fidelity framework to plan SSC implementation or evaluate SSC adherence. Further research is needed to establish which SSC components can be modified without compromising its effectiveness.
doi:10.1371/journal.pone.0108585
PMCID: PMC4178177  PMID: 25260030
4.  Exploring mentorship as a strategy to build capacity for knowledge translation research and practice: a scoping systematic review 
Background
Knowledge translation (KT) supports use of evidence in healthcare decision making but is not widely practiced. Mentoring is a promising means of developing KT capacity. The purpose of this scoping systematic review was to identify essential components of mentoring that could be adapted for KT mentorship.
Methods
Key social sciences and management databases were searched from January 2002 to December 2011 inclusive. Empirical research in non-healthcare settings that examined mentorship design and impact for improving job-specific knowledge and skill were eligible. Members of the study team independently selected eligible studies, and extracted and summarized data.
Results
Of 2,101 search results, 293 were retrieved and 13 studies were eligible for review. All but one reported improvements in knowledge, skill, or behavior. Mentoring program components included combining preliminary workshop-based training with individual mentoring provided either in person or remotely; training of mentors; and periodic mentoring for at least an hour over a minimum period of six months. Barriers included the need for infrastructure for recruitment, matching, and training; lack of clarity in mentoring goals; and limited satisfaction with mentors and their availability. Findings were analyzed against a conceptual framework of factors that influence mentoring design and impact to identify issues warranting further research.
Conclusion
This study identified key mentoring components that could be adapted for KT mentorship. Overall, few studies were identified. Thus further research should explore whether and how mentoring should be tailored to baseline knowledge or skill and individual KT needs; evaluate newly developed or existing KT mentorship programs based on the factors identified here; and examine whether and how KT mentorship develops KT capacity. The conceptual framework could be used to develop or evaluate KT mentoring programs.
doi:10.1186/s13012-014-0122-z
PMCID: PMC4182766  PMID: 25252966
Knowledge translation; Mentorship
5.  A framework of the desirable features of guideline implementation tools (GItools): Delphi survey and assessment of GItools 
Background
Guidelines are the foundation for healthcare planning, delivery and quality improvement but are not consistently implemented. Few guidelines are accompanied by guideline implementation tools (GItools). Users have requested GItools, and developers have requested guidance on how to develop GItools. First it is necessary to characterize GItools. The purpose of this research was to generate a framework of desirable features of GItools.
Methods
Items representing desirable GItool features were generated by a cross-sectional survey of the international guideline community. Items were confirmed by 31 guideline developers, implementers and researchers in a two-round Delphi survey administered on the Internet. The resulting GItool framework was applied with a sample of GItools accompanying guidelines identified in the National Guideline Clearinghouse.
Results
The cross-sectional survey was completed by 96 respondents from Australia, Canada, the United Kingdom, the United States, The Netherlands, and various other countries. Seven of nine items were rated by the majority as desirable. A total of 31 panelists from 10 countries including Australia, Canada, Germany, New Zealand, Peru, Saudi Arabia, Spain, the United Kingdom, and the United States took part in a two-round Delphi survey. Ten items achieved consensus as desirable GItool features in round #1, and two additional items in round #2. A total of 13 GItools for Resource Planning, Implementation and Evaluation were identified among 149 guidelines on a variety of clinical topics (8.7%). Many GItools did not possess features considered desirable.
Conclusions
Inclusion of higher quality GItools in guidelines is needed to support user adoption of guidelines. The GItool framework can serve as the basis for evaluating and adapting existing GItools, or developing new GItools. Further research is needed to validate the framework, develop and implement instruments by which developers can apply the framework, and specify which guidelines should be accompanied by GItools.
doi:10.1186/s13012-014-0098-8
PMCID: PMC4244063  PMID: 25091091
Guidelines; Implementation
7.  How can diagnostic assessment programs be implemented to enhance inter-professional collaborative care for cancer? 
Background
Inter-professional collaborative care (ICC) for cancer leads to multiple system, organizational, professional, and patient benefits, but is limited by numerous challenges. Empirical research on interventions that promote or enable ICC is sparse so guidance on how to achieve ICC is lacking. Research shows that ICC for diagnosis could be improved. Diagnostic assessment programs (DAPs) appear to be a promising model for enabling ICC. The purpose of this study was to explore how DAP structure and function enable ICC, and whether that may be associated with organizational and clinical outcomes.
Methods
A case study approach will be used to explore ICC among eight DAPs that vary by type of cancer (lung, breast), academic status, and geographic region. To describe DAP function and outcomes, and gather information that will enable costing, recommendations expressed in DAP standards and clinical guidelines will be assessed through retrospective observational study. Data will be acquired from databases maintained by participating DAPs and the provincial cancer agency, and confirmed by and supplemented with review of medical records. We will conduct a pilot study to explore the feasibility of estimating the incremental cost-effectiveness ratio using person-level data from medical records and other sources. Interviews will be conducted with health professionals, staff, and referring physicians from each DAP to learn about barriers and facilitators of ICC. Qualitative methods based on a grounded approach will be used to guide sampling, data collection and analysis.
Discussion
Findings may reveal opportunities for unique structures, interventions or tools that enable ICC that could be developed, implemented, and evaluated through future research. This information will serve as a formative needs assessment to identify the nature of ongoing or required improvements, which can be directly used by our decision maker collaborators, and as a framework by policy makers, cancer system managers, and DAP managers elsewhere to strategically plan for and implement diagnostic cancer services.
doi:10.1186/1748-5908-9-4
PMCID: PMC3884012  PMID: 24383742
Inter-professional collaborative care; Multidisciplinary care team; Inter-professional relations; Communication; Cooperative behavior; Diagnostic assessment program; Breast cancer; Lung cancer
8.  Quality of narrative operative reports in pancreatic surgery 
Canadian Journal of Surgery  2013;56(5):E121-E127.
Background
Quality in health care can be evaluated using quality indicators (QIs). Elements contained in the surgical operative report are potential sources for QI data, but little is known about the completeness of the narrative operative report (NR). We evaluated the completeness of the NR for patients undergoing a pancreaticoduodenectomy.
Methods
We reviewed NRs for patients undergoing a pancreaticoduodenectomy over a 1-year period. We extracted 79 variables related to patient and narrator characteristics, process of care measures, surgical technique and oncology-related outcomes by document analysis. Data were coded and evaluated for completeness.
Results
We analyzed 74 NRs. The median number of variables reported was 43.5 (range 13–54). Variables related to surgical technique were most complete. Process of care and oncology-related variables were often omitted. Completeness of the NR was associated with longer operative duration.
Conclusion
The NRs were often incomplete and of poor quality. Important elements, including process of care and oncology-related data, were frequently missing. Thus, the NR is an inadequate data source for QI. Development and use of alternative reporting methods, including standardized synoptic operative reports, should be encouraged to improve documentation of care and serve as a measure of quality of surgical care.
doi:10.1503/cjs.028611
PMCID: PMC3788021  PMID: 24067527
9.  Predictors of Multivisceral Resection in Patients with Locally Advanced Colorectal Cancer 
Annals of surgical oncology  2008;15(7):1923-1930.
Background
Practice guidelines recommend en bloc multivisceral resection (MVR) for all involved organs in patients with locally advanced adherent colorectal cancer (LAACRC) to reduce local recurrence and improve survival. We found that MVR was performed in one-third of eligible American patients in the Surveillance, Epidemiology and End Results cancer registry but that study could not identify factors amenable to quality improvement. This study was conducted to examine rates, and predictors of MVR among Canadian patients with LAACRC.
Methods
Rates of MVR were examined by observational study. Eligible patients were aged 20–74 years who had surgery for nonmetastatic LAACRC from July 1997 to December 2000. Patient, tumor, surgeon, and hospital characteristics were extracted from medical records. Summary statistics were compared by type of surgery (MVR, partial MVR, standard resection). To identify factors associated with MVR we analyzed operative notes and transcripts from interviews with general surgeons using standard qualitative methods.
Results
Factors associated with MVR included fewer years in practice, preoperative treatment planning, involvement of surgical consultants, and access to diagnostic imaging and systems to enable preoperative multidisciplinary planning. Judgments regarding the nature of peritumoral adhesions, resectability, and personal technical skill may mediate decision-making. Many surgeons would prefer to refer patients than undertake complicated, lengthy cases.
Conclusion
Further research is required to validate these findings in larger studies and among patients undergoing surgery for conditions other than LAACRC, and evaluate strategies to improve rates of MVR through enhanced individual awareness and system capacity.
doi:10.1245/s10434-008-9930-1
PMCID: PMC2770244  PMID: 18473145
Colorectal neoplasms; Multivisceral resection; Decision-making; Practice guideline adherence; Continuing education; Quality improvement
10.  Developing a patient and family-centred approach for measuring the quality of injury care: a study protocol 
Background
Quality indicators (QI) are used in health care to measure quality of service and performance improvement. Health care professionals and organizations caring for patients with injuries need information regarding the quality of care provided and the outcomes experienced in order to target improvement efforts. However, very little is known about the quality of injury care provided to individual patients and populations and even less about patients’ perspectives on quality of care. The absence of QIs that incorporate patient or family preferences, needs or values has been identified as an important gap in the science and practice of injury quality improvement. The primary objective of this research protocol is to develop and evaluate the first set of patient and family-centred QIs of injury care for critically injured patients
Methods/design
This mixed methods study is comprised of three Sub-Studies. Sub-Study A will utilize focus group methodology to describe the preferences, needs and values of critically injured patients and their family members regarding the quality of health care delivered. Qualitative content analysis of the transcripts will begin after the first completed focus group and will draw on grounded theory using a process of open, axial and selective coding. A panel of stakeholders will be assembled during Sub-Study B to review the themes identified from the focus groups and develop a catalogue of potential patient and family-centred QIs of injury care using the RAND/UCLA Appropriateness Method (RAM). The QIs developed by the stakeholder panel will be pilot tested in Sub-Study C using surveys of patients and their family members to determine construct validity, intra-rater reliability and clinical sensibility.
Discussion
Measuring the quality of injury care is but a first step towards improving patient outcomes. This research will develop the first set of patient and family-centred QIs of injury care. To improve patient care, we need accessible, reliable indicators of quality that are important to patients, and that can then be used to establish quality of care benchmarks, to flag potential problems or successes, follow trends over time and identify disparities across organizations, communities, populations and regions.
doi:10.1186/1472-6963-13-31
PMCID: PMC3570378  PMID: 23351430
Injury; Patient-centred care; Quality improvement; Quality indicators; Trauma; Focus group; Consensus panel; Survey
11.  “More bang for the buck”: exploring optimal approaches for guideline implementation through interviews with international developers 
Background
Population based studies show that guidelines are underused. Surveys of international guideline developers found that many do not implement their guidelines. The purpose of this research was to interview guideline developers about implementation approaches and resources.
Methods
Semi-structured telephone interviews were conducted with representatives of guideline development agencies identified in the National Guideline Clearinghouse and sampled by country, type of developer, and guideline clinical indication. Participants were asked to comment on the benefits and resource implications of three approaches for guideline implementation that varied by responsibility: developers, intermediaries, or users.
Results
Thirty individuals from seven countries were interviewed, representing government (n = 12) and professional (n = 18) organizations that produced guidelines for a variety of clinical indications. Organizations with an implementation mandate featured widely inconsistent funding and staffing models, variable approaches for choosing promotional strategies, and an array of dissemination activities. When asked to choose a preferred approach, most participants selected the option of including information within guidelines that would help users to implement them. Given variable mandate and resources for implementation, it was considered the most feasible approach, and therefore most likely to have impact due to potentially broad use.
Conclusions
While implementation approaches and strategies need not be standardized across organizations, the findings may be used by health care policy makers and managers, and guideline developers to generate strategic and operational plans that optimize implementation capacity. Further research is needed to examine how to optimize implementation capacity by guideline developers, intermediaries and users.
doi:10.1186/1472-6963-12-404
PMCID: PMC3561165  PMID: 23153052
Guideline development; Guideline implementation; Qualitative research
12.  Surgical site infection prevention: a survey to identify the gap between evidence and practice in University of Toronto teaching hospitals 
Canadian Journal of Surgery  2012;55(4):233-238.
Background
A gap exists between the best evidence and practice with regards to surgical site infection (SSI) prevention. Awareness of evidence is the first step in knowledge translation.
Methods
A web-based survey was distributed to 59 general surgeons and 68 residents at University of Toronto teaching hospitals. Five domains pertaining to SSI prevention with questions addressing knowledge of prevention strategies, efficacy of antibiotics, strategies for changing practice and barriers to implementation of SSI prevention strategies were investigated.
Results
Seventy-six individuals (60%) responded. More than 90% of respondents stated there was evidence for antibiotic prophylaxis and perioperative normothermia and reported use of these strategies. There was a discrepancy in the perceived evidence for and the self-reported use of perioperative hyperoxia, omission of hair removal and bowel preparation. Eighty-three percent of respondents felt that consulting published guidelines is important in making decisions regarding antibiotics. There was also a discrepancy between what respondents felt were important strategies to ensure timely administration of antibiotics and what strategies were in place. Checklists, standardized orders, protocols and formal surveillance programs were rated most highly by 75%–90% of respondents, but less than 50% stated that these strategies were in place at their institutions.
Conclusion
Broad-reaching initiatives that increase surgeon and trainee awareness and implementation of multifaceted hospital strategies that engage residents and attending surgeons are needed to change practice.
doi:10.1503/cjs.036810
PMCID: PMC3404142  PMID: 22617541
13.  Integrating guideline development and implementation: analysis of guideline development manual instructions for generating implementation advice 
Background
Guidelines are important tools that inform healthcare delivery based on best available research evidence. Guideline use is in part based on quality of the guidelines, which includes advice for implementation and has been shown to vary. Others hypothesized this is due to limited instructions in guideline development manuals. The purpose of this study was to examine manual instructions for implementation advice.
Methods
We used a directed and summative content analysis approach based on an established framework of guideline implementability. Six manuals identified by another research group were examined to enumerate implementability domains and elements.
Results
Manuals were similar in content but lacked sufficient detail in particular domains. Most frequently this was Accomodation, which includes information that would help guideline users anticipate and/or overcome organizational and system level barriers. In more than one manual, information was also lacking for Communicability, information that would educate patients or facilitate their involvement in shared decision making, and Applicability, or clinical parameters to help clinicians tailor recommendations for individual patients.
Discussion
Most manuals that direct guideline development lack complete information about incorporating implementation advice. These findings can be used by those who developed the manuals to consider expanding their content in these domains. It can also be used by guideline developers as they plan the content and implementation of their guidelines so that the two are integrated. New approaches for guideline development and implementation may need to be developed. Use of guidelines might be improved if they included implementation advice, but this must be evaluated through ongoing research.
doi:10.1186/1748-5908-7-67
PMCID: PMC3457906  PMID: 22824094
Guideline development; Guideline implementation; Implementability
14.  The guideline implementability research and application network (GIRAnet): an international collaborative to support knowledge exchange: study protocol 
Background
Modifying the format and content of guidelines may facilitate their use and lead to improved quality of care. We reviewed the medical literature to identify features desired by different users and associated with guideline use to develop a framework of implementability and found that most guidelines do not contain these elements. Further research is needed to develop and evaluate implementability tools.
Methods
We are launching the Guideline Implementability Research and Application Network (GIRAnet) to enable the development and testing of implementability tools in three domains: Resource Implications, Implementation, and Evaluation. Partners include the Guidelines International Network (G-I-N) and its member guideline developers, implementers, and researchers. In phase one, international guidelines will be examined to identify and describe exemplar tools. Indication-specific and generic tools will populate a searchable repository. In phase two, qualitative analysis of cognitive interviews will be used to understand how developers can best integrate implementability tools in guidelines and how health professionals use them for interpreting and applying guidelines. In phase three, a small-scale pilot test will assess the impact of implementability tools based on quantitative analysis of chart-based behavioural outcomes and qualitative analysis of interviews with participants. The findings will be used to plan a more comprehensive future evaluation of implementability tools.
Discussion
Infrastructure funding to establish GIRAnet will be leveraged with the in-kind contributions of collaborating national and international guideline developers to advance our knowledge of implementation practice and science. Needs assessment and evaluation of GIRAnet will provide a greater understanding of how to develop and sustain such knowledge-exchange networks. Ultimately, by facilitating use of guidelines, this research may lead to improved delivery and outcomes of patient care.
doi:10.1186/1748-5908-7-26
PMCID: PMC3338081  PMID: 22471937
Guidelines; Guideline development; Guideline implementation; Research networks; Knowledge exchange
15.  Paucity of qualitative research in general medical and health services and policy research journals: analysis of publication rates 
Background
Qualitative research has the potential to inform and improve health care decisions but a study based on one year of publications suggests that it is not published in prominent health care journals. A more detailed, longitudinal analysis of its availability is needed. The purpose of this study was to identify, count and compare the number of qualitative and non-qualitative research studies published in high impact health care journals, and explore trends in these data over the last decade.
Methods
A bibliometric approach was used to identify and quantify qualitative articles published in 20 top general medical and health services and policy research journals from 1999 to 2008. Eligible journals were selected based on performance in four different ranking systems reported in the 2008 ISI Journal Citation Reports. Qualitative and non-qualitative research published in these journals were identified by searching MEDLINE, and validated by hand-searching tables of contents for four journals.
Results
The total number of qualitative research articles published during 1999 to 2008 in ten general medical journals ranged from 0 to 41, and in ten health services and policy research journals from 0 to 39. Over this period the percentage of empirical research articles that were qualitative ranged from 0% to 0.6% for the general medical journals, and 0% to 6.4% for the health services and policy research journals.
Conclusions
This analysis suggests that qualitative research it is rarely published in high impact general medical and health services and policy research journals. The factors that contribute to this persistent marginalization need to be better understood.
doi:10.1186/1472-6963-11-268
PMCID: PMC3214160  PMID: 21992238
16.  How can we improve guideline use? A conceptual framework of implementability 
Background
Guidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines.
Methods
A guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team.
Results
The final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic.
Conclusions
Numerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.
doi:10.1186/1748-5908-6-26
PMCID: PMC3072935  PMID: 21426574
17.  Protocol: developing a conceptual framework of patient mediated knowledge translation, systematic review using a realist approach 
Background
Patient involvement in healthcare represents the means by which to achieve a healthcare system that is responsive to patient needs and values. Characterization and evaluation of strategies for involving patients in their healthcare may benefit from a knowledge translation (KT) approach. The purpose of this knowledge synthesis is to develop a conceptual framework for patient-mediated KT interventions.
Methods
A preliminary conceptual framework for patient-mediated KT interventions was compiled to describe intended purpose, recipients, delivery context, intervention, and outcomes. A realist review will be conducted in consultation with stakeholders from the arthritis and cancer fields to explore how these interventions work, for whom, and in what contexts. To identify patient-mediated KT interventions in these fields, we will search MEDLINE, the Cochrane Library, and EMBASE from 1995 to 2010; scan references of all eligible studies; and examine five years of tables of contents for journals likely to publish quantitative or qualitative studies that focus on developing, implementing, or evaluating patient-mediated KT interventions. Screening and data collection will be performed independently by two individuals.
Conclusions
The conceptual framework of patient-mediated KT options and outcomes could be used by healthcare providers, managers, educationalists, patient advocates, and policy makers to guide program planning, service delivery, and quality improvement and by us and other researchers to evaluate existing interventions or develop new interventions. By raising awareness of options for involving patients in improving their own care, outcomes based on using a KT approach may lead to greater patient-centred care delivery and improved healthcare outcomes.
doi:10.1186/1748-5908-6-25
PMCID: PMC3076239  PMID: 21426573
18.  Multidisciplinary Cancer Conferences: Exploring Obstacles and Facilitators to Their Implementation 
Journal of Oncology Practice  2010;6(2):61-68.
A study of the implementation in Canada of multidisciplinary cancer conferences—which can facilitate diagnosis and treatment discussions and optimize patient management—using grounded theory methodology.
Purpose:
Multidisciplinary cancer conferences (MCCs) provide an opportunity for health professionals to discuss diagnosis and treatment options to optimize patient management. The purpose of this study was to explore the barriers and facilitators in implementing MCCs in Canada.
Methods:
This exploratory study used qualitative interviews and observation to explore the experiences of implementing MCCs in four hospitals in Ontario, Canada. Interviews were transcribed verbatim and analyzed using standard qualitative research methodology guided by grounded theory principles.
Results:
Thirty-seven MCCs for gastrointestinal cancer were observed across three hospital sites, and 48 interviews were conducted among a range of clinical specialists and administrators. The dominant theme suggested that MCCs can most effectively be implemented if administrators and health professionals see value in MCCs, despite the time and effort required. A number of factors (eg, provincial policy, hospital administrative and clinician support, and an efficient MCC process) influenced whether MCCs were valued.
Conclusion:
Variation exists in the enthusiasm of health professionals and the administrative capacity of institutions regarding routine implementation of MCCs. A systematic implementation plan for MCCs is needed involving both cancer care providers and administrators.
doi:10.1200/JOP.091085
PMCID: PMC2835483  PMID: 20592777
19.  Development of a synoptic MRI report for primary rectal cancer 
Background
Although magnetic resonance imaging (MRI) is an important imaging modality for pre-operative staging and surgical planning of rectal cancer, to date there has been little investigation on the completeness and overall quality of MRI reports. This is important because optimal patient care depends on the quality of the MRI report and clear communication of these reports to treating physicians. Previous work has shown that the use of synoptic pathology reports improves the quality of pathology reports and communication between physicians.
Methods
The aims of this project are to develop a synoptic MRI report for rectal cancer and determine the enablers and barriers toward the implementation of a synoptic MRI report for rectal cancer in the clinical setting. A three-step Delphi process with an expert panel will extract the key criteria for the MRI report to guide pre-operative chemoradiation and surgical planning following a review of the literature, and a synoptic template will be developed. Furthermore, standardized qualitative research methods will be used to conduct interviews with radiologists to determine the enablers and barriers to the implementation and sustainability of the synoptic MRI report in the clinic setting.
Conclusion
Synoptic MRI reports for rectal cancer are currently not used in North America and may improve the overall quality of MRI report and communication between physicians. This may, in turn, lead to improved patient care and outcomes for rectal cancer patients.
doi:10.1186/1748-5908-4-79
PMCID: PMC3224933  PMID: 19954526
20.  Factors influencing antibiotic prophylaxis for surgical site infection prevention in general surgery: a review of the literature 
Canadian Journal of Surgery  2009;52(6):481-489.
Background
Surgical site infections (SSIs) are common surgical complications that can be prevented with antibiotic prophylaxis. Research shows poor adherence to guidelines for this practice. We conducted a scoping review to identify factors or interventions that influence antibiotic prophylaxis administration.
Methods
An investigator with informatics training searched indexed (MEDLINE, Cochrane Library) and nonindexed (Internet) sources from January 1996 to February 2007. Selected studies were English-language, peer-reviewed, quantitative or qualitative studies describing factors or interventions influencing adherence to SSI-prevention guidelines or SSI rates in general surgery. Two investigators independently reviewed citations and full-text articles and extracted data, and met to compare selections or data and resolve differences through discussion. We extracted data on type of surgery, study design, intervention or factors examined and key findings. We then examined the quantity and type of studies and their findings.
Results
Nineteen of 192 studies met the eligibility criteria. Seven studies investigated predictors of appropriate antibiotic use through descriptive or exploratory means. Twelve evaluated adherence to antibiotic prophylaxis recommendations by comparing patient cohorts before and after the introduction of quality-improvement strategies. Individual knowledge, attitudes, beliefs and practice; team communication and allocation of responsibilities; and institutional support for promoting and monitoring practice appear to influence practice.
Conclusion
Larger and multisite studies included in our review favour implementation of multidisciplinary pathways, individualized performance data and written or computerized order sets as quality-improvement strategies, but further research is warranted to more rigorously evaluate the effectiveness of these strategies on antibiotic prophylaxis practice.
PMCID: PMC2792388  PMID: 20011184
21.  Exploring mentorship as a strategy to build capacity for knowledge translation research and practice: protocol for a qualitative study 
Background
Research funders, educators, investigators and decision makers worldwide have identified the need to improve the quality of health care by building capacity for knowledge translation (KT) research and practice. Peer-based mentorship represents a vehicle to foster KT capacity. The purpose of this exploratory study is to identify mentoring models that could be used to build KT capacity, consult with putative mentee stakeholders to understand their KT mentorship needs and preferences, and generate recommendations for the content and format of KT mentorship strategies or programs, and how they could be tested through future research.
Methods
A conceptual framework was derived based on mentoring goals, processes and outcomes identified in the management and social sciences literature, and our research on barriers and facilitators of academic mentorship. These concepts will inform data collection and analysis. To identify useful models by which to design, implement and evaluate KT mentorship, we will review the social sciences, management, and nursing literature from 1990 to current, browse tables of contents of relevant journals, and scan the references of all eligible studies. Eligibility screening and data extraction will be performed independently by two investigators. Semi-structured interviews will be used to collect information about KT needs, views on mentorship as a knowledge sharing strategy, preferred KT mentoring program elements, and perceived barriers from clinician health services researchers representing different disciplines. Qualitative analysis of transcripts will be performed independently by two investigators, who will meet to compare findings and resolve differences through discussion. Data will be shared and discussed with the research team, and their feedback incorporated into final reports.
Discussion
These findings could be used by universities, research institutes, funding agencies, and professional organizations in Canada and elsewhere to develop, implement, and evaluate mentorship for KT research and practice. This research will establish a theoretical basis upon which we and others can compare the cost-effectiveness of interventions that enhance KT mentorship. If successful, this program of research may increase knowledge about, confidence in, and greater utilization of KT processes, and the quality and quantity of KT research, perhaps ultimately leading to better implementation and adoption of recommended health care services.
doi:10.1186/1748-5908-4-55
PMCID: PMC2738649  PMID: 19691833
22.  An exploration of how guideline developer capacity and guideline implementability influence implementation and adoption: study protocol 
Background
Practice guidelines can improve health care delivery and outcomes but several issues challenge guideline adoption, including their intrinsic attributes, and whether and how they are implemented. It appears that guideline format may influence accessibility and ease of use, which may overcome attitudinal barriers of guideline adoption, and appear to be important to all stakeholders. Guideline content may facilitate various forms of decision making about guideline adoption relevant to different stakeholders. Knowledge and attitudes about, and incentives and capacity for implementation on the part of guideline sponsors may influence whether and how they develop guidelines containing these features, and undertake implementation. Examination of these issues may yield opportunities to improve guideline adoption.
Methods
The attributes hypothesized to facilitate adoption will be expanded by thematic analysis, and quantitative and qualitative summary of the content of international guidelines for two primary care (diabetes, hypertension) and institutional care (chronic ulcer, chronic heart failure) topics. Factors that influence whether and how guidelines are implemented will be explored by qualitative analysis of interviews with individuals affiliated with guideline sponsoring agencies.
Discussion
Previous research examined guideline implementation by measuring rates of compliance with recommendations or associated outcomes, but this produced little insight on how the products themselves, or their implementation, could be improved. This research will establish a theoretical basis upon which to conduct experimental studies to compare the cost-effectiveness of interventions that enhance guideline development and implementation capacity. Such studies could first examine short-term outcomes predictive of guideline utilization, such as recall, attitude toward, confidence in, and adoption intention. If successful, then long-term objective outcomes reflecting the adoption of processes and associated patient care outcomes could be evaluated.
doi:10.1186/1748-5908-4-36
PMCID: PMC3224968  PMID: 19573246
23.  Challenges in multidisciplinary cancer care among general surgeons in Canada 
Background
While many factors can influence the way that cancer care is delivered, including the way that evidence is packaged and disseminated, little research has evaluated how health care professionals who manage cancer patients seek and use this information to identify whether and how this could be supported. Through interviews we identified that general surgeons experience challenges in coordinating care for complex cancer patients whose management is not easily addressed by guidelines, and conducted a population-based survey of general surgeon information needs and information seeking practices to extend these findings.
Methods
General surgeons with privileges at acute care hospitals in Ontario, Canada were mailed a questionnaire to solicit information needs (task, importance), information seeking (source, frequency of and reasons for use), key challenges and suggested solutions. Non-responders received up to three reminder packages. Significant differences among sub-groups (age, setting) were examined statistically (Kruskal Wallis, Mann Whitney, Chi Square). Standard qualitative methods were used to thematically analyze open-ended responses.
Results
The response rate was 44.2% (170/385) representing all 14 health regions. System resource constraints (60.4%), comorbidities (56.4%) and physiologic factors (51.8%) were top-ranked issues creating information needs. Local surgical colleagues (84.6%), other local colleagues (82.2%) and the Internet (81.1%) were top-ranked sources of information, primarily due to familiarity and speed of access. No resources were considered to be highly applicable to patient care. Challenges were related to limitations in diagnostics and staging, operative resources, and systems to support multidisciplinary care, together accounting for 76.0% of all reported issues. Findings did not differ significantly by surgeon age or setting of care.
Conclusion
General surgeons appear to use a wide range of information resources but they may not address the complex needs of many cancer patients. Decision-making is challenged by informational and logistical issues related to the coordination of multidisciplinary care. This suggests that limitations in system capacity may, in part, contribute to variable guideline compliance. Further research is required to evaluate the appropriateness of information seeking, and both concurrent and consecutive mechanisms by which to achieve multidisciplinary care.
doi:10.1186/1472-6947-8-59
PMCID: PMC2631026  PMID: 19102761
24.  Multiple factors influence compliance with colorectal cancer staging recommendations: an exploratory study 
Background
For patients with colorectal cancer (CRC) retrieval by surgeons, and assessment by pathologists of at least 12 lymph nodes (LNs) predicts the need for adjuvant treatment and improved survival. Different interventions (educational presentation, engaging clinical opinion leaders, performance data sent to hospital executives) to improve compliance with this practice had variable results. This exploratory study examined factors hypothesized to have influenced the outcome of those interventions.
Methods
Semi-structured interviews were conducted with 26 surgeons and pathologists at eleven hospitals. Clinicians were identified by intervention organizers, public licensing body database, and referral from interviewees. An interview guide incorporating open-ended questions was pilot-tested on one surgeon and pathologist. A single investigator conducted all interviews by phone. Transcripts were analyzed independently by two investigators using a grounded approach,ho then compared findings to resolve differences.
Results
Improvements in LN staging practice may have occurred largely due to educational presentations that created awareness, and self-initiated changes undertaken by pathologists. Executives that received performance data may not have shared this with staff, and opinion leaders engaged to promote compliance may not have fulfilled their roles. Barriers to change that are potentially amenable to quality improvement included perceptions about the practice (perceived lack of evidence for the need to examine at least 12 LNs) and associated responsibilities (blaming other profession), technical issues (need for pathology assistants, better clearing solutions and laboratory facilities), and a lack of organizational support for multidisciplinary interaction (little communication between surgeons and pathologists) or quality improvement (no change leaders or capacity for monitoring).
Conclusion
Use of an exploratory approach provided an in-depth view of the way that numerous factors amenable to quality improvement influenced the adoption of new CRC LN staging recommendations. Continued interventions targeting physicians and executives, in the absence of a receptive organizational infrastructure, may be fruitless. Individualized rather than regional or punitive performance data, coupled with increased organizational capacity for change may stimulate greater surgical and organizational response to quality improvement. Descriptive or experimental studies are needed to test these hypotheses.
doi:10.1186/1472-6963-8-34
PMCID: PMC2270818  PMID: 18254944
25.  Development of quality indicators for colorectal cancer surgery, using a 3-step modified Delphi approach 
Canadian Journal of Surgery  2005;48(6):441-452.
Background
Little performance measurement has been undertaken in the area of oncology, particularly for surgery, which is a pivotal event in the continuum of cancer care. This work was conducted to develop indicators of quality for colorectal cancer surgery, using a 3-step modified Delphi approach.
Methods
A multidisciplinary panel, comprising surgical and methodological co-chairs, 9 surgeons, a medical oncologist, a radiation oncologist, a nurse and a pathologist, reviewed potential indicators extracted from the medical literature through 2 consecutive rounds of rating followed by consensus discussion. The panel then prioritized the indicators selected in the previous 2 rounds.
Results
Of 45 possible indicators that emerged from 30 selected articles, 15 were prioritized by the panel as benchmarks for assessing the quality of surgical care. The 15 indicators represent 3 levels of measurement (provincial/regional, hospital, individual provider) across several phases of care (diagnosis, surgery, adjuvant therapy, pathology and follow-up), as well as broad measures of access and outcome. The indicators selected by the panel were more often supported by evidence than those that were discarded.
Conclusions
This project represents a unique initiative, and the results may be applicable to colorectal cancer surgery in any jurisdiction.
PMCID: PMC3211732  PMID: 16417050

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