The major disadvantages of contracting a large portion of the water security research portfolio include the following:. If the EPA were to build its staff knowledge and skills by conducting more research in-house, these skills could also provide a long-term asset to the EPA, because this knowledge could be applied to other research problems and could enhance the information resources immediately available during emergency events and natural disasters.
Excessive dependence on contracting may hinder the development of the precise skills and knowledge required for EPA staff to prepare and manage external research contracts effectively. Adequate contract oversight necessitates that one or more persons at the NHSRC be capable of writing an effective scope of work, monitoring the progress of the contract, and interpreting the results in the context of a water security application.
This usually entails identifying, in advance, research obstacles and other technical problems that may arise. The research skills that are needed to prepare and monitor the progress of contracts are likely to erode with time as individuals become engaged as full-time project officers rather than continuing to conduct research themselves. Offsite research usually does not allow for frequent face-to-face meetings and direct review of laboratory work.
When research is conducted in-house, problems can be identified and protocols modified immediately without lengthy delays, negotiations, or cost overruns. Contracting mechanisms limit the degree of flexibility in setting or changing research priorities in response to new information, emergencies, or shifting agency priorities.
There are also clear advantages of contracting to complement the expertise of EPA staff and to select the best and most knowledgeable researchers to conduct advanced research projects.
In the following specific circumstances, contracting may offer notable advantages to the EPA:. When the EPA lacks major equipment or specialized facilities that may be needed only for a limited number of experiments. When NHSRC staff lack skills, and researchers at another facility are highly skilled in the type of research and equipment required.
Even in this situation, however, the NHSRC needs to have a project officer with sufficient subject matter expertise to develop and monitor the contract and interpret and integrate the results. When fast results are required and well-established protocols exist. Contractors can supply additional personnel to carry out required tasks, perhaps using NHSRC equipment and facilities, to supplement EPA staffing capabilities.
Thus, contracting can be used to achieve staffing flexibility. When two or more new methods with slightly different analytical approaches need to be developed and evaluated for comparison purposes. Components of a large study can be completed by multiple contractors, and the best method can be either adopted by the NHSRC or used as the starting point for further development by NHSRC researchers.
In summary, advantages and disadvantages exist to using contracts and other external funding mechanisms for conducting water security research. Based on the advantages, extramural funding should be used to support specific research in the EPA water security research program. Careful attention, however, should be given to achieving the right balance. The EPA should develop greater in-house research capability, or at least subject matter expertise, in disciplines that have been historically weak and where long-term water security concerns are projected.
Such areas include physical security and behavioral sciences see Chapter 4. The NHSRC should make a conscious decision about the necessary balance of skills among its personnel and rebalance its permanent staff lines in accordance with that decision.
As noted above, even if research is to be conducted via contracts, the EPA needs adequate in-house expertise to evaluate and manage such contracts. Many other EPA programs have evolved in a similar manner. For example, the startup of the EPA hazardous waste program occurred via the transfer of individuals from solid waste, water, and other programs.
As the permanence of the endeavor became clear, the skill set of permanent staff changed to address the technical needs of the program e.
Three comprehensive management initiatives, designated strategic goals, are slated to be completed within the next three years, and one of the goals is to attract, develop, and retain a talented and diverse workforce.
Activities which support this goal include 1 creating the next generation of scientists through efforts such as the STAR Fellowship Program, the AAAS Environmental and Risk Policy Fellows Programs, the Association of Schools of Public Health Fellows Program, the ORD post-doctoral employee program, support for minority academic institutions, and support for state and national science fairs; and 2 implementing initiatives to strengthen the ORD in attracting and retaining a well-qualified workforce, as outlined in EPA e.
The EPA could also employ a number of possible underutilized mechanisms to enhance its onsite expertise without adding permanent staffing. This approach could also foster cross-training with EPA staff and provide further long-term benefits. One key part of strengthening the EPA water security research program involves building alliances with relevant experts.
The EPA is currently working to expand its network of experts while also improving coordination among federal agencies and nongovernment organizations through the Distribution System Research Consortium. The Distribution System Research Consortium is an umbrella organization made up of 14 partnering federal and nonfederal organizations to advance science, technology, and research to protect water distribution systems from terrorist attack.
EPA, c , to receive input from and foster alliances with water utilities, trade organizations, local and state governments, public health organizations, and emergency responders. The EPA should also work to foster alliances with professional engineering and technical societies and to build new alliances with experts in other related fields, such as earthquake impact mitigation, disaster response, or social science related to terrorism.
Continually improving collaboration with outside experts will keep the EPA abreast of new developments in the field and minimize duplication of effort. Effective independent peer review is an important mechanism for avoiding research errors, program problems, and inefficiencies.
Peer review applies to both project-level evaluations including reviews of proposals and final products and program-level reviews. The EPA has long used peer review for evaluating research proposals in its competitive grants program. A major challenge is providing independent peer review of NHSRC activities that contain classified, or sensitive but unclassified, material. Currently, sensitive and classified peer-review mechanisms may not be sufficient.
Sensitive and classified peer-review activities, while new to the EPA, are not new to the federal government. The EPA should examine available mechanisms to provide effective independent peer review of sensitive or classified work. The NHSRC should carefully review areas where independent peer review involving sensitive and classified material is helpful or necessary and explore some of the following options:.
The EPA could work with other governmental agencies e. If specific deficiencies in the roster of. The NHSRC could establish an advisory committee of outside experts to provide independent peer review, with the expectation that the experts could receive security clearance at appropriate levels.
By defining a sufficiently broad mix of individuals on this committee, a pool of individuals qualified to provide an appropriate peer review would be available. Other organizations have developed peer review committees in this manner e. One of the most difficult challenges faced by the EPA and many other organizations is communicating research results and products effectively to those who need them at the time they need them.
This kind of planning involves identifying 1 key audiences; 2 the interests, needs, and concerns of those audiences; and 3 communication methods e. In other words, the communications plan should be client-centered. These recommendations include approaches for identifying the needs of water security stakeholders, improving research synthesis, identifying effective mechanisms for dissemination, evaluating communication strategies, and emphasizing training and technology transfer.
The NHSRC should increase its use of formal and informal methods of soliciting early input and involvement from its priority audiences to. Some examples include getting input from audiences prior to developing a communication effort, pretesting materials on an intended audience, and soliciting feedback on communication efforts during early phases of implementation.
Based on the results of this so-called formative evaluation , changes can be made to increase the usefulness and effectiveness of the communication products. The comprehensiveness and rigor of formative evaluation can be adjusted based on the importance, scope, and resources expended on the communication program itself.
In the long run, formative evaluation can save resources by ensuring that communication reaches those who most need or want it in ways these audiences find useful Rossi et al.
The CDC conducted a formative evaluation to identify priority audiences and to develop its communication strategy, messages, and materials.
Based on follow-up research, additional ways to further improve communication for subsequent reports were identified. Seven general categories of potential users of published research and technical support information are identified in the Action Plan EPA, a : water industry representatives, response organizations, public health organizations, federal agencies, laboratories, academia, and the general public.
Potential users of the information vary from DHS, which may require highly classified information, to the media and general public. Not all potential users can be identified a priori ; some potential users may only realize their need for the information at the time of an incident or suspected incident. The EPA should take into account the wide range of audiences for the water security research findings to identify the most effective approaches to disseminate the information.
As discussed in Chapter 2 , the recent fast pace of security-specific research has led to a flood of focused publications in the scientific literature, and it is a challenge for end users to keep up with the latest findings. Information synthesis is an important element of research translation that can summarize the state of knowledge, highlight the relevance of research findings to end users, and generalize the results, where applicable, to other dual-use applications.
Many Action Plan projects seem to be directed at some level of information synthesis, although it is too early to judge the effectiveness of these products. The value of research findings can only be realized when people who have the ability to affect change are aware of the information and can access and use the results. Through these Web sites, nonclassified documents are available to individuals who seek them.
Through Web searches or frequent visits to the Web sites, the water-sector specialist can stay current with newly released scientific reports. However, there are other sector specialists who do not regularly seek out the online documents. Multiple mechanisms exist for making end users aware that new water security research and technical support information is available, including homeland security-specific mechanisms and broadly applicable information portal technology, which are described below.
The EPA faces an additional challenge of information overload when communicating the results of EPA water security research. As noted in. York: University of York; [cited Mar 25, ]. The effectiveness of clinical guideline implementation strategies-a synthesis of systematic review findings.
J Eval Clin Pract [Internet]. Achieving change in primary care-causes of the evidence to practice gap: systematic reviews of reviews. Implement Sci [Internet]. In addition, the set of identified implementation strategies can also be stratified according to the interventions target, including:.
Any proposal for changes in clinical practice through implementing of evidence-informed guidelines needs to consider the process as an exercise in organizational, political, and even social arrangements. It must be endowed with adaptive capacity in different contexts and, especially, strict monitoring.
It seems to be an additional challenge that the inclusion of these aspects occurs from the stage of formulating clinical practice guidelines so that they can be explicitly included in the documents to allow adjustment and adaptation to the local level of implementation.
Thus, platforms that support the implementation of evidence-informed clinical practice guidelines need to structure a complete Knowledge Translation process involving mechanisms at different levels to address each step. The formulation and implementation of guidelines represent a process to be improved and explored as an indispensable resource for the improvement of health systems performance.
Abrir menu Brasil. Revista Brasileira de Epidemiologia. Abrir menu. About the author. Overviews of systematic reviews that investigated factors contributing to un successful implementation have pointed out several factors related to: clinical practice guidelines, such as document format and accessibility, ease of application, divergent recommendations among guidelines, and lack of compliance at local settings; health workers to whom the recommendations are addressed, such as lack of medical knowledge or disagreement with recommendations, conservative attitude, prior professional experience and legal concerns; patients, such as attitudes or behaviour ; organizational setting, such as lack of institutional support from colleagues or supervisors, lack of staff and time 3 3.
Publication Dates Publication in this collection 22 Oct Date of issue To date, there has not been a systematic analysis of guideline features that may improve their use. The purpose of this study was to create a taxonomy of these attributes, and assess whether current guidelines contain these features, thereby identifying ways in which guidelines could be modified to potentially improve their use. This implementability framework could inform the development of modified guidelines or adjunct products, and evaluation of how various attributes influence perceptions about, and use of guidelines, prior to more definitive testing of whether their inclusion indeed improves use.
This study involved two key phases. The first phase was to develop an implementability framework of guideline format and content apart from clinical recommendations that are desired by users, or influence use of guidelines.
The second phase was to use the framework assembled in phase one to examine the content of current practice guidelines, and refine or extend the framework. Given the lack of controlled and observational studies on this topic, the methods were based on a modified meta-narrative approach [ 43 ].
The meta-narrative approach is more suitable than a systematic review for conceptually examining literature that may be limited in quantity and quality, and vary in disciplinary focus and study design. It involves periodic input from a multidisciplinary research team to define the objectives and interpret the findings from a variety of conceptual perspectives. In this case, we used a modified approach that focused on healthcare literature rather than other disciplines, but were inclusive of a variety of study designs.
We purposely used a broad search strategy based on few terms practice guidelines as topic AND guideline adherence AND attitude of health personnel or decision making, organizational or policy making knowing that sensitivity and specificity would be limited.
Two individuals independently selected eligible items. Studies were ineligible if they focused on guideline-informed tools such as clinical pathways; guidelines for non-medical interventions; clinical effectiveness of medical interventions; involved students, trainees, or patients as participants; investigated guideline use without examining views about guideline features that influenced use; evaluated interventions to promote guideline use; concluded that guideline features could be improved to promote their use without evaluating those features; or were in the form of abstracts, letters, commentaries, or editorials.
All items selected by at least one individual were retrieved, and one individual extracted data. Quality assessment of studies was not undertaken to be inclusive of all relevant implementability elements. Desirable or influential features potentially associated with guideline use were annotated in eligible studies, then tabulated. This tabulated list included the features of guidelines identified in each study as desirable or influencing guideline use.
From this list, common items were categorized and defined. The research team met in person and by teleconference to review and refine the draft framework. This largely involved minor edits to domain definitions. The draft framework was used to guide content analysis of guidelines, which expanded the number of elements in framework domains.
This extended framework was reviewed and refined by the research team in person and by teleconference. Manifest content analysis was used to examine guidelines for the presence of implementability elements.
We selected a directed approach, which seeks to validate and extend elements in a framework [ 45 ]. This means data are coded using elements in the draft framework, and data that cannot be coded are analyzed to assess if they represent a new element.
Individual guidelines were chosen as the unit of analysis. Eligible guidelines included all those identified by GAC using a comprehensive search strategy and judged by trained experts using the Appraisal of Guidelines Research and Evaluation AGREE instrument to be high quality that covered comprehensive management of these conditions and were publicly available [ 46 ]. Full versions of selected guidelines and adjunct products were retrieved from sponsor web sites. A form was developed to extract content from each guideline according to the implementability framework.
Round one extraction was performed by ARG. This produced an expanded, revised framework, used by ARG to again extract data from each guideline. A research assistant independently reviewed the features in all guidelines, and a physician VAP independently reviewed coding of the elements for two guidelines on each clinical topic. ARG met with both independent reviewers to compare findings and resolve differences through discussion. Extracted data was tabulated.
The presence of implementability elements within sampled guidelines was described using summary statistics including number, proportion, and mean or median. Detailed content was analyzed using Mays' narrative review method, based on verbatim reporting, rather than statistical summary or conceptual analysis of information [ 47 ].
Data were examined to discuss the number of guidelines addressing each element overall and by topic, thereby identifying opportunities for modifying guideline format or content to enhance implementability. Findings were reviewed by the research team in person and by teleconference.
The vast majority of literature search results were ineligible because they evaluated the clinical effectiveness of medical interventions or interventions to promote guideline use. Eligible studies included one RCT, one observational study, four systematic reviews, three surveys, two modified Delphi studies, and six qualitative studies involving either focus groups or interviews.
Based on features desired by, or influencing guideline use among primarily physicians, a preliminary taxonomy of eight implementability domains emerged, including adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation Table 2.
The final framework derived through content analysis of guidelines included 22 elements organized within eight domains Table 4. Format elements that may facilitate guideline use are summarized in Table 5. One-half of the guidelines were published in journals or available in a summary version, and one-quarter were available as downloadable digital or patient versions.
Many were very large documents with median pages of Most featured a table of contents Nearly all guidelines used an evidence grading system Few summarized the evidence in tabular format Content elements that may facilitate guideline use are summarized in Table 6. Clinical considerations by which to individualize recommendations were available in most guidelines For many guidelines this largely consisted of tables that summarized diagnostic or risk criteria, pharmacologic dosing, indications for treatment or referral, and management options All four hypertension guidelines included specific skill-based instructions for measuring blood pressure.
Some guidelines featured sections explicitly labelled considerations for either special populations two diabetes guidelines or by health system capacity one diabetes guideline. Two heart failure guidelines graphically highlighted considerations within text boxes or balloons labelled practice points or tips.
Less than one-half of the guidelines included information to educate or engage patients Of these, five provided information to help clinicians discuss relevant issues with patients, two included information sheets for patients, and seven provided contact information phone number or web site where information for patients could be obtained.
No guidelines identified stakeholder needs or values, or costs or impact associated with use. Few included technical When included, this content was generally limited in detail.
For example, technical guidance included: 'organization of care to deliver the above recommendations is largely concerned with putting registration, recall and record systems in place to ensure care delivery occurs for all people with diabetes, and having the healthcare professionals trained and available D12 ' or 'multidisciplinary care programs improve patients' quality of life, satisfaction with care, and the risk of unplanned hospitalization for heart failure HF One-half of the guidelines included performance measures that could be used to monitor recommended clinical care.
While For example: 'implementation may be supported by a variety of activities including continuing education and training, and clinical audit LU07 ' or 'implementation programs are needed because it has been shown that the outcome of a disease may be favourably influenced by thorough application of clinical recommendations HF Relatively few studies published over the last 15 years specifically examined guideline features desired by, or associated with use among health professionals, most of these focused on physicians, and it does not appear that studies were informed by preceding research to build a cumulative body of knowledge.
Considerable research has examined other factors influencing guideline use such as physician and organizational characteristics, but these studies were not eligible for this review, nor were numerous studies that examined general attitudes to guidelines on specific clinical topics.
Review of 18 eligible studies revealed several features related to format or content that may positively influence guideline use, and this was expanded by reviewing the content of high quality international guidelines on various clinical topics. Most guidelines we examined contained a large volume of graded evidence and numerous tables featuring complementary clinical information to the point of being cumbersome, despite the presence of navigational features such as tables of contents.
Few contained additional features specified by users or suggested by research to improve guideline use. Guideline use could potentially be improved by developing alternate versions for different purposes, incorporating summaries of evidence and recommendations, including information to facilitate interaction with and involvement of patients, outlining resource implications, and describing how to locally plan, promote, and monitor guideline use.
Our findings simply suggest that more guidelines could be modified to include implementability content, but it remains unclear how various implementability features might influence guideline use. A recent analysis recommended that the reliability, relevance, and readability of knowledge resources be improved to support evidence-based decision making [ 48 ]. Evidence is just one of several factors that inform decisions about guideline use [ 49 ].
In reality, clinicians must often draw upon expertise and experience to consider what is best for and desired by those receiving care, but have expressed uncertainty about how to balance evidence with professional judgment and patient preferences, and the need for guidance to support these decisions [ 50 , 51 ]. Furthermore, clinical decisions about guideline use are influenced by the availability and mobilization of organizational or system level resources, which are governed by managers and policy makers who must reconcile the competing interests of multiple stakeholders [ 34 ].
Further insight could be gained by drawing upon decision science to examine the cognitive processes underlying guideline use. Considerable research has established that humans are not rational decision makers who identify alternative options, compare them on the same set of evaluative dimensions, and generate probability and utility estimates for different courses of action [ 52 ]. Instead, it appears that a combination of intuitive based on experience and analytic based on mental simulation mechanisms are employed [ 53 ].
This is particularly true in 'naturalistic' situations where decisions are complex; the quantity of information may be large or its implications ambiguous; goals may be shifting, poorly defined, or competing; and decisions have high stakes and are made within a dynamic environment under time constraints, as is true of the healthcare sector [ 54 ]. It has been suggested that guidelines include content that mediates decisions among different stakeholders in a manner consistent with these cognitive processes [ 55 ].
This may influence attitudes about guideline relevance and confidence in choosing a course of action, which may be associated with use [ 56 ]. While the concept of implementability is not new, the proposed framework is unique because it includes features that may be relevant not only to individuals, but to the managers and policy makers that govern the environment within which individuals function, and because it offers a novel way to improve guideline use by considering how to support different types and processes of decision making [ 28 , 57 , 58 ].
Interpretation of the findings may be limited in several ways. We studied guidelines relevant to primary and institutional care. Other guidelines relevant to specialty care may differ in their implementability characteristics.
However, while we reviewed few guidelines, they were specifically selected to represent different topics, countries, and types of developer.
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