A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework

Background

The Promoting Action on Research Implementation in Health Services framework, or PARIHS, is a conceptual framework that posits key, interacting elements that influence successful implementation of evidence-based practices. It has been widely cited and used as the basis for empirical work; however, there has not yet been a literature review to examine how the framework has been used in implementation projects and research. The purpose of the present article was to critically review and synthesize the literature on PARIHS to understand how it has been used and operationalized, and to highlight its strengths and limitations.

Methods

We conducted a qualitative, critical synthesis of peer-reviewed PARIHS literature published through March 2009. We synthesized findings through a three-step process using semi-structured data abstraction tools and group consensus.

Results

Twenty-four articles met our inclusion criteria: six core concept articles from original PARIHS authors, and eighteen empirical articles ranging from case reports to quantitative studies. Empirical articles generally used PARIHS as an organizing framework for analyses. No studies used PARIHS prospectively to design implementation strategies, and there was generally a lack of detail about how variables were measured or mapped, or how conclusions were derived. Several studies used findings to comment on the framework in ways that could help refine or validate it. The primary issue identified with the framework was a need for greater conceptual clarity regarding the definition of sub-elements and the nature of dynamic relationships. Strengths identified included its flexibility, intuitive appeal, explicit acknowledgement of the outcome of 'successful implementation,' and a more expansive view of what can and should constitute 'evidence.'

Conclusions

While we found studies reporting empirical support for PARIHS, the single greatest need for this and other implementation models is rigorous, prospective use of the framework to guide implementation projects. There is also need to better explain derived findings and how interventions or measures are mapped to specific PARIHS elements; greater conceptual discrimination among sub-elements may be necessary first. In general, it may be time for the implementation science community to develop consensus guidelines for reporting the use and usefulness of theoretical frameworks within implementation studies.     

Social aspects for sustainability assessment of technologies—challenges for social life cycle assessment (SLCA)

Purpose

Technologies can contribute to sustainable development (e.g., improving living conditions) and at the same time cause sustainability problems (e.g., emissions). Decisions on alternative technologies should thus ideally be based on the principle to minimize the latter. Analyzing environmental, economic, and social aspects related to technologies supports decisions by identifying the “more sustainable” technology. This paper focuses on social issues. First, it discusses the applicability of the social life cycle assessment (SLCA) guidelines for a comparative technology analysis, taking the example of two case studies in developing countries. Indicating technologies as “sustainable” also means that they are indeed operated over the expected lifetime, which, in development projects, is often not guaranteed. Consequently, social aspects related to implementation conditions should be considered in an SLCA study as well. Thus, a second focus is laid on identifying appropriate indicators to address these aspects.

Methods

First, the SLCA guidelines were examined with regard to applying this product-related approach to two real case studies (analysis of technologies/plants for water supply and for decentralized fuel production) for a comparative technology analysis. Suitable indicators are proposed. To address the second focus, a literature research on technology assessment and implementation in developing countries was conducted. Moreover, socioeconomic studies in the investigation areas of the case studies were consulted. Based on this, indicators addressing implementation conditions were identified from the SLCA guidelines and additional literature.

Results and discussion

The study shows social issues and indicators found in the SLCA guidelines and considered suitable for a comparative technology analysis in the case studies. However, for a sustainability assessment of technologies, especially in developing countries, further indicators are required to address technology implementation conditions. A set of additional social indicators like reported trust in institutions or fluctuation of personnel is proposed. Though these indicators were derived based on specific case studies, they can also be suggested to other technologies and are not necessarily limited to developing countries.

Conclusions

The study pointed out that an application of the SLCA guidelines considering the whole life cycle was not (yet) feasible for the case studies considered. This is mainly due to the lack of data. Regarding technology implementation, it was examined which indicators are available in this SLCA approach and which could additionally be integrated and applied. This is relevant as a potential contribution of technologies to sustainable development can only be achieved when the technologies are successfully implemented.     

A PCA-based method for construction of composite sustainability indicators

Purpose

Sustainable manufacturing is practiced globally as a comprehensive strategy for improving the sustainability performance of the manufacturing industry. While sustainability is characterized into such three dimensions as economic, environmental, and social, currently, there is no quantitative method yet to measure the so-called ??sustainability?? in the manufacturing industry. The objective of this research is to develop a comprehensive and effective quantitative method to measure the overall sustainability performance of manufacturing companies.

Methods

In this paper, an integrated methodology is presented for the development of composite sustainability indicators based on principal component analysis (PCA). In developing this integrated approach, both industry and academia surveys are conducted to identify what sustainability indicators are favored by the sustainable manufacturing community. A unique index is then generated to measure the overall sustainability performance of industrial practices. The methodology can be used for benchmarking the overall sustainability performance of various manufacturing companies.

Results

A case study is conducted on a total of 11 global electronic manufacturing companies. The overall sustainability performance of these companies are measured, benchmarked, and ranked. The results showed that PCA is an effective approach for constructing composite sustainability indicators across environmental, economic, and social dimensions.

Conclusions

From this research, it is found that industry and academia have different views on the sustainability measurement, evidenced by different weights put on the same indicator in industry and academia. The case study demonstrated that the methodology presented in this paper is an effective tool for comprehensive measurement of sustainability performance of manufacturing companies. Strengths and weaknesses of each company can be identified. Then, the recommended improvements can be suggested based on the study of each of the individual indicators.     

Determinants of preventable readmissions in the United States: a systematic review

Background

Hospital readmissions are a leading topic of healthcare policy and practice reform because they are common, costly, and potentially avoidable events. Hospitals face the prospect of reduced or eliminated reimbursement for an increasing number of preventable readmissions under nationwide cost savings and quality improvement efforts. To meet the current changes and future expectations, organizations are looking for potential strategies to reduce readmissions. We undertook a systematic review of the literature to determine what factors are associated with preventable readmissions.

Methods

We conducted a review of the English language medicine, health, and health services research literature (2000 to 2009) for research studies dealing with unplanned, avoidable, preventable, or early readmissions. Each of these modifying terms was included in keyword searches of readmissions or rehospitalizations in Medline, ISI, CINAHL, The Cochrane Library, ProQuest Health Management, and PAIS International. Results were limited to US adult populations.

Results

The review included 37 studies with significant variation in index conditions, readmitting conditions, timeframe, and terminology. Studies of cardiovascular-related readmissions were most common, followed by all cause readmissions, other surgical procedures, and other specific-conditions. Patient-level indicators of general ill health or complexity were the commonly identified risk factors. While more than one study demonstrated preventable readmissions vary by hospital, identification of many specific organizational level characteristics was lacking.

Conclusions

The current literature on preventable readmissions in the US contains evidence from a variety of patient populations, geographical locations, healthcare settings, study designs, clinical and theoretical perspectives, and conditions. However, definitional variations, clear gaps, and methodological challenges limit translation of this literature into guidance for the operation and management of healthcare organizations. We recommend that those organizations that propose to reward reductions in preventable readmissions invest in additional research across multiple hospitals in order to fill this serious gap in knowledge of great potential value to payers, providers, and patients.     

Training community resource center and clinic personnel to prompt patients in listing questions for doctors: Follow-up interviews about barriers and facilitators to the implementation of consultation planning

Background

Behavioral health services for children and adolescents in the U.S. are lacking in accessibility, availability and quality. Evidence-based interventions for emotional and behavioral disorders can improve quality, yet few studies have systematically examined their implementation in routine care settings.

Methods

Using quantitative and qualitative data, we evaluated a multi-faceted implementation strategy to implement cognitive-behavioral therapy (CBT) for depressed adolescents into two publicly-funded mental healthcare centers. Extent of implementation during the study's duration and variables influencing implementation were explored.

Results

Of the 35 clinicians eligible to participate, 25 (71%) were randomized into intervention (n = 11) or usual care (n = 14). Nine intervention clinicians completed the CBT training. Sixteen adolescents were enrolled in CBT with six of the intervention clinicians; half of these received at least six CBT manually-based sessions. Multiple barriers to CBT adoption and sustained use were identified by clinicians in qualitative interviews.

Conclusion

Strategies to implement evidence-based interventions into routine clinical settings should include multi-method, pre-implementation assessments of the clinical environment and address multiple barriers to initial uptake as well as long-term sustainability.     

Recruiting medical groups for research: relationships, reputation, requirements, rewards, reciprocity, resolution, and respect

Background

In order to conduct good implementation science research, it will be necessary to recruit and obtain good cooperation and comprehensive information from complete medical practice organizations. The goal of this paper is to report an effective example of such a recruitment effort for a study of the organizational aspects of depression care quality.

Methods

There were 41 medical groups in the Minnesota region that were eligible for participation in the study because they had sufficient numbers of patients with depression. We documented the steps required to both recruit their participation in this study and obtain their completion of two questionnaire surveys and two telephone interviews.

Results

All 41 medical groups agreed to participate and consented to our use of confidential data about their care quality. In addition, all 82 medical directors and quality improvement coordinators completed the necessary questionnaires and interviews. The key factors explaining this success can be summarized as the seven R's: Relationships, Reputation, Requirements, Rewards, Reciprocity, Resolution, and Respect.

Conclusion

While all studies will not have all of these factors in such good alignment, attention to them may be important to other efforts to add to our knowledge of implementation science.     

Effective continuing professional development for translating shared decision making in primary care: A study protocol

Background

There is growing interest in the use of cognitive, behavioural, and organisational theories in implementation research. However, the extent of use of theory in implementation research is uncertain.

Methods

We conducted a systematic review of use of theory in 235 rigorous evaluations of guideline dissemination and implementation studies published between 1966 and 1998. Use of theory was classified according to type of use (explicitly theory based, some conceptual basis, and theoretical construct used) and stage of use (choice/design of intervention, process/mediators/moderators, and post hoc/explanation).

Results

Fifty-three of 235 studies (22.5%) were judged to have employed theories, including 14 studies that explicitly used theory. The majority of studies (n = 42) used only one theory; the maximum number of theories employed by any study was three. Twenty-five different theories were used. A small number of theories accounted for the majority of theory use including PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation), diffusion of innovations, information overload and social marketing (academic detailing).

Conclusions

There was poor justification of choice of intervention and use of theory in implementation research in the identified studies until at least 1998. Future research should explicitly identify the justification for the interventions. Greater use of explicit theory to understand barriers, design interventions, and explore mediating pathways and moderators is needed to advance the science of implementation research.     

Methods for the guideline-based development of quality indicators--a systematic review

Background

Quality indicators (QIs) are used in many healthcare settings to measure, compare, and improve quality of care. For the efficient development of high-quality QIs, rigorous, approved, and evidence-based development methods are needed. Clinical practice guidelines are a suitable source to derive QIs from, but no gold standard for guideline-based QI development exists. This review aims to identify, describe, and compare methodological approaches to guideline-based QI development.

Methods

We systematically searched medical literature databases (Medline, EMBASE, and CINAHL) and grey literature. Two researchers selected publications reporting methodological approaches to guideline-based QI development. In order to describe and compare methodological approaches used in these publications, we extracted detailed information on common steps of guideline-based QI development (topic selection, guideline selection, extraction of recommendations, QI selection, practice test, and implementation) to predesigned extraction tables.

Results

From 8,697 hits in the database search and several grey literature documents, we selected 48 relevant references. The studies were of heterogeneous type and quality. We found no randomized controlled trial or other studies comparing the ability of different methodological approaches to guideline-based development to generate high-quality QIs. The relevant publications featured a wide variety of methodological approaches to guideline-based QI development, especially regarding guideline selection and extraction of recommendations. Only a few studies reported patient involvement.

Conclusions

Further research is needed to determine which elements of the methodological approaches identified, described, and compared in this review are best suited to constitute a gold standard for guideline-based QI development. For this research, we provide a comprehensive groundwork.     

Multiple Interacting Factors Influence Adherence,and Outcomes Associated with Surgical Safety Checklists: A Qualitative Study

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.     

Difficulties implementing a mental health guideline: an exploratory investigation using psychological theory

Background

Monitoring and Messaging Devices (MMDs) are telehealth systems used by patients in their homes, and are designed to promote patient self-management, patient education, and clinical monitoring and follow-up activities. Although these systems have been widely promoted by health care systems, including the Veterans Health Administration, very little information is available on factors that facilitate use of the MMD system, or on barriers to use.

Methods

We conducted in-depth qualitative interviews with clinicians using MMD-based telehealth programs at two Veterans Affairs Medical Centers in the Midwestern United States.

Results

Findings suggest that MMD program enrollment is limited by both clinical and non-clinical factors, and that patients have varying levels of program participation and system use. Telehealth providers see MMDs as a useful tool for monitoring patients who are interested in working on management of their disease, but are concerned with technical challenges and the time commitment required to use MMDs.

Conclusion

Telehealth includes a rapidly evolving and potentially promising range of technologies for meeting the growing number of patients and clinicians who face the challenges of diabetes care, and future research should explore the most effective means of ensuring successful program implementation.     

Analysis of the link between a definition of sustainability and the life cycle methodologies

Purpose

It has been claimed that in order to assess the sustainability of products, a combination of the results from a life cycle assessment (LCA), social life cycle assessment (SLCA) and life cycle costing (LCC) is needed. Despite the frequent reference to this claim in the literature, very little explicit analysis of the claim has been made. The purpose of this article is to analyse this claim.

Methods

An interpretation of the goals of sustainability, as outlined in the report Our Common Future (WCED 1987), which is the basis for most literature on sustainability assessment in the LCA community, is presented and detailed to a level enabling an analysis of the relation to the impact categories at midpoint level considered in life cycle (LC) methodologies.

Results

The interpretation of the definition of sustainability as outlined in Our Common Future (WCED 1987) suggests that the assessment of a product's sustainability is about addressing the extent to which product life cycles affect poverty levels among the current generation, as well as changes in the level of natural, human and produced and social capital available for the future population. It is shown that the extent to which product life cycles affect poverty to some extent is covered by impact categories included in existing SLCA approaches. It is also found that the extent to which product life cycles affect natural capital is well covered by LCA, and human capital is covered by both LCA and SLCA but in different ways. Produced capital is not to any large extent considered in any of the LC methodologies. Furthermore, because of the present level of knowledge about what creates and destroys social capital, it is difficult to assess how it relates to the LC methodologies. It is also found that the LCC is only relevant in the context of a life cycle sustainability assessment (LCSA) if focusing on the monetary gains or losses for the poor. Yet, this is an aspect which is already considered in several SLCA approaches.

Conclusions

The current consensus that LCSA can be performed through combining the results from an SLCA, LCA and LCC is only partially supported in this article: The LCSA should include both an LCA and an SLCA, which should be expanded to better cover how product life cycles affect poverty and produced capital. The LCC may be included if it has as a focus to asses income gains for the poor.     

Adjuncts or adversaries to shared decision-making? Applying the Integrative Model of behavior to the role and design of decision support interventions in healthcare interactions

Background

Clinical practice guidelines have been a popular tool for the improvement of health care through the implementation of evidence from systematic research. Yet, it is increasingly clear that knowledge alone is insufficient to change practice. The social, cultural, and material contexts within which practice occurs may invite or reject innovation, complement or inhibit the activities required for success, and sustain or alter adherence to entrenched practices. However, knowledge translation (KT) models are limited in providing insight about how and why contextual contingencies interact, the causal mechanisms linking structural aspects of context and individual agency, and how these mechanisms influence KT. Another limitation of KT models is the neglect of methods to engage potential adopters of the innovation in critical reflection about aspects of context that influence practice, the relevance and meaning of innovation in the context of practice, and the identification of strategies for bringing about meaningful change.

Discussion

This paper presents a KT model, the Critical Realism and the Arts Research Utilization Model (CRARUM), that combines critical realism and arts-based methodologies. Critical realism facilitates understanding of clinical settings by providing insight into the interrelationship between its structures and potentials, and individual action. The arts nurture empathy, and can foster reflection on the ways in which contextual factors influence and shape clinical practice, and how they may facilitate or impede change. The combination of critical realism and the arts within the CRARUM model promotes the successful embedding of interventions, and greater impact and sustainability.

Conclusion

CRARUM has the potential to strengthen the science of implementation research by addressing the complexities of practice settings, and engaging potential adopters to critically reflect on existing and proposed practices and strategies for sustaining change.     

Towards a triple bottom-line sustainability assessment of the U.S. construction industry

Purpose

The construction industry has considerable impacts on the environment, economy, and society. Although quantifying and analyzing the sustainability implications of the built environment is of great importance, it has not been studied sufficiently. Therefore, the overarching goal of this study is to quantify the overall environmental, economic, and social impacts of the U.S. construction sectors using an economic input–output-based sustainability assessment framework.

Methods

In this research, the commodity-by-industry supply and use tables published by the U.S. Bureau of Economic Analysis, as part of the International System of National Accounts, are merged with a range of environmental, economic, and social metrics to develop a comprehensive sustainability assessment framework for the U.S. construction industry. After determining these sustainability assessment metrics, the direct and indirect sustainability impacts of U.S construction sectors have been analyzed from a triple bottom-line perspective.

Results

When analyzing the total sustainability impacts by each construction sector, “Residential Permanent Single and Multi-Family Structures" and "Other Non-residential Structures" are found to have the highest environmental, economic, and social impacts in comparison with other construction sectors. The analysis results also show that indirect suppliers of construction sectors have the largest sustainability impacts compared with on-site activities. For example, for all U.S. construction sectors, on-site construction processes are found to be responsible for less than 5 % of total water consumption, whereas about 95 % of total water use can be attributed to indirect suppliers. In addition, Scope 3 emissions are responsible for the highest carbon emissions compared with Scopes 1 and 2. Therefore, using narrowly defined system boundaries by ignoring supply chain-related impacts can result in underestimation of triple bottom-line sustainability impacts of the U.S. construction industry.

Conclusions

Life cycle assessment (LCA) studies that consider all dimensions of sustainability impacts of civil infrastructures are still limited, and the current research is an important attempt to analyze the triple bottom-line sustainability impacts of the U.S. construction sectors in a holistic way. We believe that this comprehensive sustainability assessment model will complement previous LCA studies on resource consumption of U.S. construction sectors by evaluating them not only from environmental standpoint, but also from economic and social perspectives.     

A systematic review of the psychometric properties of self-report research utilization measures used in healthcare

Background

In healthcare, a gap exists between what is known from research and what is practiced. Understanding this gap depends upon our ability to robustly measure research utilization.

Objectives

The objectives of this systematic review were: to identify self-report measures of research utilization used in healthcare, and to assess the psychometric properties (acceptability, reliability, and validity) of these measures.

Methods

We conducted a systematic review of literature reporting use or development of self-report research utilization measures. Our search included: multiple databases, ancestry searches, and a hand search. Acceptability was assessed by examining time to complete the measure and missing data rates. Our approach to reliability and validity assessment followed that outlined in the Standards for Educational and Psychological Testing.

Results

Of 42,770 titles screened, 97 original studies (108 articles) were included in this review. The 97 studies reported on the use or development of 60 unique self-report research utilization measures. Seven of the measures were assessed in more than one study. Study samples consisted of healthcare providers (92 studies) and healthcare decision makers (5 studies). No studies reported data on acceptability of the measures. Reliability was reported in 32 (33%) of the studies, representing 13 of the 60 measures. Internal consistency (Cronbach's Alpha) reliability was reported in 31 studies; values exceeded 0.70 in 29 studies. Test-retest reliability was reported in 3 studies with Pearson's r coefficients > 0.80. No validity information was reported for 12 of the 60 measures. The remaining 48 measures were classified into a three-level validity hierarchy according to the number of validity sources reported in 50% or more of the studies using the measure. Level one measures (n = 6) reported evidence from any three (out of four possible) Standards validity sources (which, in the case of single item measures, was all applicable validity sources). Level two measures (n = 16) had evidence from any two validity sources, and level three measures (n = 26) from only one validity source.

Conclusions

This review reveals significant underdevelopment in the measurement of research utilization. Substantial methodological advances with respect to construct clarity, use of research utilization and related theory, use of measurement theory, and psychometric assessment are required. Also needed are improved reporting practices and the adoption of a more contemporary view of validity (i.e., the Standards) in future research utilization measurement studies.     

Implementation fidelity trajectories of a health promotion program in multidisciplinary settings: managing tensions in rehabilitation care

Background

Although the importance of evaluating implementation fidelity is acknowledged, little is known about heterogeneity in fidelity over time. This study aims to generate insight into the heterogeneity in implementation fidelity trajectories of a health promotion program in multidisciplinary settings and the relationship with changes in patients’ health behavior.

Methods

This study used longitudinal data from the nationwide implementation of an evidence-informed physical activity promotion program in Dutch rehabilitation care. Fidelity scores were calculated based on annual surveys filled in by involved professionals (n?=?±?70). Higher fidelity scores indicate a more complete implementation of the program’s core components. A hierarchical cluster analysis was conducted on the implementation fidelity scores of 17 organizations at three different time points. Quantitative and qualitative data were used to explore organizational and professional differences between identified trajectories. Regression analyses were conducted to determine differences in patient outcomes.

Results

Three trajectories were identified as the following: ‘stable high fidelity’ (n?=?9), ‘moderate and improving fidelity’ (n?=?6), and ‘unstable fidelity’ (n?=?2). The stable high fidelity organizations were generally smaller, started earlier, and implemented the program in a more structured way compared to moderate and improving fidelity organizations. At the implementation period’s start and end, support from physicians and physiotherapists, professionals’ appreciation, and program compatibility were rated more positively by professionals working in stable high fidelity organizations as compared to the moderate and improving fidelity organizations (p?<?.05). Qualitative data showed that the stable high fidelity organizations had often an explicit vision and strategy about the implementation of the program. Intriguingly, the trajectories were not associated with patients’ self-reported physical activity outcomes (adjusted model β?=???651.6, t(613)?=???1032, p?=?.303).

Conclusions

Differences in organizational-level implementation fidelity trajectories did not result in outcome differences at patient-level. This suggests that an effective implementation fidelity trajectory is contingent on the local organization’s conditions. More specifically, achieving stable high implementation fidelity required the management of tensions: realizing a localized change vision, while safeguarding the program’s standardized core components and engaging the scarce physicians throughout the process. When scaling up evidence-informed health promotion programs, we propose to tailor the management of implementation tensions to local organizations’ starting position, size, and circumstances.

Trial registration

The Netherlands National Trial Register NTR3961. Registered 18 April 2013.

     

A UNEP/SETAC approach towards a life cycle sustainability assessment—our contribution to Rio+20

Purpose

To contribute to the upcoming United Nations Conference on Sustainable Development (Rio+20) in 2012 by introducing a life cycle sustainability assessment (LCSA) and showing how it can play a crucial role in moving towards sustainable consumption and production. The publication, titled Towards a Life Cycle Sustainability Assessment, and published by the UNEP/SETAC Life Cycle Initiative aims to show how three life cycle techniques—(environmental) LCA, S-LCA and LCC—can be combined as part of an over-arching LCSA.

Methods

The method was demonstrated by evaluating the characteristics of each phase for each life cycle technique. In defining the goal and scope of an LCSA, for example, different aspects should be taken into account to establish the aim of the study as well as the functional unit, system boundaries, impact category and allocation. Then, the data to be collected for the life cycle sustainability inventory can be either in a unit process or on an organisational level. They can also be quantitative or qualitative. Life cycle sustainability impact assessment should consider the relevance of the impacts as well as the perspective of stakeholders. The interpretation should not add up the results, but rather evaluate them jointly. In order to clarify the approach, a case study is presented to evaluate three types of marble according to the proposed method.

Results and discussion

The authors have identified that while LCSA is feasible, following areas need more development: data production and acquisition, methodological development, discussion about LCSA criteria (e.g. cutoff rules), definitions and formats of communication and dissemination of LCSA results and the expansion of research and applications combining (environmental) LCA, LCC and S-LCA. The authors also indicate that it is necessary to develop more examples and cases to improve user capacity to analyse the larger picture and therefore address the three dimensions or pillars of sustainability in a systematic way. Software and database providers are called for in order to facilitate user-friendly and accessible tools to promote LCSAs.

Conclusions

The application demonstrated that, although methodological improvements are still needed, important steps towards an overarching sustainability assessment have been accomplished. LCSA is possible and should be pursued; however, more efforts should be made to improve the technique and facilitate the studies in order to contribute to a greener economy.     

Sustainability governance service providers: the role of third-party product certification in facilitating corporate life cycle management

Purpose

This article aims to analyze the role that third-party product sustainability certifications play in supply chain sustainability governance and hence the impact that they may have on facilitating corporate life cycle management (LCM). Particular emphasis is given to exploring the extent to which such schemes allow firms to outsource the work of communication, motivation, enablement, and control of sustainability-related information and performance upstream in the supply chain.

Methods

The research design is based on a comparative case study methodology. The corporate practices of sourcing the sustainability certified products in the food retailing and textile sectors are compared, to explain when third-party product sustainability certification reduces the corporate need to engage in collaborative relationships with suppliers, thereby reducing efforts associated with implementation of corporate life cycle management.

Results and discussion

In our study, we found evidence that affirms the role of third-party product sustainability certification in reducing corporate necessity to actively engage with coordination of sustainability issues upstream in the supply chain. However, we also identified a range of factors—the intention of the buying company, the supply chain context, and the design of the certification scheme—that influence the extent, to which third-party product sustainability certification replaces the corporate need for additional work to facilitate supplier compliance. Some of these factors, e.g., the design of the certification scheme, are new and have been underexplored in the supply chain management and value chain governance literature yet.

Conclusions

Our findings suggest that corporate LCM practitioners should consider third-party sustainability certification as an instrument for the transfer of significant life cycle information along the supply chain and as a tool to facilitate corporate life cycle management. The extent to which third-party product sustainability certification would be able to facilitate corporate life cycle management depends not only on whether certification requirements are based on the LCA studies but also on the market scope of the certification schemes, the scope of the certification requirements, and the architecture of the certification management services. If these parameters are aligned with corporate ambitions and allow buyers to fully outsource the work associated with communication, motivation, enablement, and control of sustainability-related information and supplier performance, the life cycle management can be exercised by companies by simply choosing to procure sustainability certified products.

     

Exploring scale-up,spread, and sustainability: an instrumental case study tracing an innovation to enhance dysphagia care

Background

Adoption, adaptation, scale-up, spread, and sustainability are ill-defined, undertheorised, and little-researched implementation science concepts. An instrumental case study will track the adoption and adaptation, or not, of a locally developed innovation about dysphagia as a patient safety issue. The case study will examine a conceptual framework with a continuum of spread comprising hierarchical control or ‘making it happen’, participatory adaptation or ‘help it happen’, and facilitated evolution or ‘let it happen’.

Methods

This case study is a prospective, longitudinal design using mixed methods. The fifteen-month (October 2012 to December 2013) instrumental case study is set in large, healthcare organisation in England. The innovation refers to introducing a nationally recognised, inter-disciplinary dysphagia competency framework to guide workforce development about fundamental aspects of care. Adoption and adaptation will be examined at an organisational level and along two, contrasting care pathways: stroke and fractured neck of femur. A number of educational interventions will be deployed, including training a cadre of trainers to cascade the essentials of dysphagia management and developing a Dysphagia Toolkit as a learning resource. Mixed methods will be used to investigate scale-up, spread, and sustainability in acute and community settings. A purposive sample of senior managers and clinical leaders will be interviewed to identify path dependency or the context specific particularities of implementation. A pre- and post-evaluation, using mealtime observations and a survey, will investigate the learning effect on staff adherence to patient specific dysphagia recommendations and attitudes towards dysphagia, respectively. Official documents and an ethnographic field journal allow critical junctures, temporal aspects and confounding factors to be explored.

Discussion

Researching spread and sustainability presents methodological and practical challenges. These include fidelity, adaptation latitude, time, and organisational changes. An instrumental case study will allow these confounding factors to be tracked over time and in place. The case study is underpinned by, and will test a conceptual framework about spread, to explore theoretical generalizability.

     

Trends in publications regarding evidence-practice gaps: A literature review

Background

Well-designed trials of strategies to improve adherence to clinical practice guidelines are needed to close persistent evidence-practice gaps. We studied how the number of these trials is changing with time, and to what extent physicians are participating in such trials.

Methods

This is a literature-based study of trends in evidence-practice gap publications over 10 years and participation of clinicians in intervention trials to narrow evidence-practice gaps. We chose nine evidence-based guidelines and identified relevant publications in the PubMed database from January 1998 to December 2007. We coded these publications by study type (intervention versus non-intervention studies). We further subdivided intervention studies into those for clinicians and those for patients. Data were analyzed to determine if observed trends were statistically significant.

Results

We identified 1,151 publications that discussed evidence-practice gaps in nine topic areas. There were 169 intervention studies that were designed to improve adherence to well-established clinical guidelines, averaging 1.9 studies per year per topic area. Twenty-eight publications (34%; 95% CI: 24% - 45%) reported interventions intended for clinicians or health systems that met Effective Practice and Organization of Care (EPOC) criteria for adequate design. The median consent rate of physicians asked to participate in these well-designed studies was 60% (95% CI, 25% to 69%).

Conclusions

We evaluated research publications for nine evidence-practice gaps, and identified small numbers of well-designed intervention trials and low rates of physician participation in these trials.