Browsing by Subject "Implementation"

Background: Patient safety is critical to prevent medical errors and to improve clinical outcomes. The need to implement programs in patient safety is increasingly recognized as a prime component of healthcare delivery in low- and middle- income countries (LMICs). The goal for our study is to assess the implementation of a patient safety program in Guatemala.

Methods: We used a mixed-methods approach to assess implementation of a patient safety program in the pediatric perioperative unit in Hospital Roosevelt, Guatemala. We collected data from unit staff respondents (n=16) using a qualitative de novo survey, the Evidence-Based Practice Attitude Scale-36 (EBPAS-36) survey, and a semi-structured interview. Interviews and surveys were conducted in Spanish, translated, and analyzed in English using NVivo v12. Quantitative data were analyzed to compare group means across survey domains. Data were triangulated, with final analysis guided by the Consolidated Framework for Implementation Research (CFIR). Data were collected over a 10-day period in July 2018.

Results: Responses underscored several emergent thematic determinants representing the Inner Setting and Characteristics of Individuals CFIR domains, indicating a gap in knowledge of patient safety programs and attitude towards the use of evidence-based patient safety programs. Though respondents expressed an openness and willingness to adopt patient safety practices, few existing practices are in place to prevent medical errors.

Conclusions: The main determinants which affect the implementation of an evidence-based patient safety program in the pediatric perioperative unit in Guatemala are related to the internal structure and culture of the unit, and not to external factors or the intervention itself. Positive attitudes and knowledge of patient safety practices are insufficient to overcome the challenges towards implementation. A framework for future implementation should include education and communication programs, adaptation of existing practices to increase leadership engagement, and use of tools to create a strong culture of safety.

Introduction: Chronic diseases have been increasing globally for decades, while the leading chronic diseases worldwide are cancer, cardiovascular disease (CVD), chronic respiratory disease, and diabetes.1 Behavioral risk factors of chronic diseases that can be modified include physical activity, diet, alcohol consumption and tobacco use.3 4 Several guidelines for screening and prevention recommend that family health history (FHH) is collected by primary care providers for disease risk stratification and management.6 7 MeTree, developed in 2014, is a computerized, patient-facing program that collects information about family health history and generates decision support for providers and patients.6 15 There are several potential barriers to implementation of an online FHH software tool including health literacy, computer skills, and behavioral components. This study collects FHH information through MeTree in a rural population in North Carolina through a unique implementation process using research assistants to manually and verbally assist participants. The aims of this study are to characterize the quality of pedigrees collected and to estimate familial disease aggregation among the families of participants.

Methods: This study enrolled 44 participants from an ongoing study conducted by collaborators from Duke University Health System, Duke Clinical Research Institute,

University of North Carolina Pembroke, and Southeastern Regional Medical Center. To collect FHH information, participants constructed family pedigree in MeTree, one family member at a time with the help of one study research assistant. Once participants created a full family pedigree, an individual risk assessment was generated by MeTree.

Results: More than half of the participants were female (n= 30, 68.2%). The ethnic group that composed the largest part of our study population were Lumbee Indians (n=23, 52.3%) followed by White/Caucasians (n=13, 29.5%) and African Americans (n=7, 15.9%). For quality, the average score across all pedigrees was higher than 65% for all seven components of the criteria. The total number of diseases present among all participants and relatives in the study was 930 (Table 3). Cancer was present in 81.8% of pedigrees and made up 12.2% of all reported diseases. Twenty-five percent of all pedigrees had at least one family member that was diagnosed with lung cancer. Diabetes was also frequently reported and was observed in 75% of all pedigrees. Kidney Disease was reported in at least one or more relatives in 52.3% of pedigrees.

Conclusions: Using a patient-facing online Health Information Technology tool such as MeTree could potentially lead to better health outcomes due to risk assessment and individually-targeted prevention strategies. MeTree may be an important tool to use to address the large burden of chronic diseases in this region.

This dissertation develops a theory of cognition, driven by recent developments in the electrophysiological investigation of the neuronal mechanisms that support adaptive behavior. In the first chapter, I situate the theory in the conceptual landscape of the philosophy of mind, distinguishing componential from systemic dynamical theories of cognition. In the second chapter, I analyze two case studies from electrophysiological cognitive neuroscience, arguing that cognitive neuroscientists are beginning to uncover the dynamical components of cognition. Drawing on the recent literature on mechanisms and scientific explanation, I propose a revised definition of a mechanism that accommodates these dynamical mechanisms, as well as making room for their implementation by physical mechanisms. In the third chapter, I argue that the investigation of a particular class of intelligent behavior begins with the construction of a formal model of the processing problem for that behavior, where this model is distinct from the physical device and the functions performed by the device's components. In the third chapter, I argue that the component dynamical mechanisms of cognitive systems are distinct from though implemented by physical mechanisms. These dynamical mechanisms are described by sets of differential equations, possess a set of organized components and activities that execute the formal models of processing, and are implemented by the physical machinery of the cognitive system, such as the brain. After I argue that these multiple interacting dynamical mechanisms are the components of cognition, defending this componentiality claim against several objections, I define the implementation relation that holds between dynamical and physical mechanisms. I next discuss the grounds for inferring the existence of dynamical mechanisms that are type distinct from physical mechanisms, their implementing substrate. In the fourth chapter, I argue that these dynamical mechanisms are reused: they can execute different formal models and be implemented by different physical substrates. I define this concept of reuse, situating it in the debate on theories of reuse, and illustrate how dynamical mechanisms are reused in cognitive systems.

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