***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective To explore the causes of failure to activate the rapid response system ( RRS ) . The organisation has a recognised incidence of staff failing to act when confronted with a deteriorating patient and leading to adverse outcomes . Design A multi- method study using the following : a point prevalence survey to determine the incidence of abnormal simple bedside observations and activation of the rapid response team by clinical staff ; a prospect i ve audit of all patients experiencing a cardiac arrest , unplanned intensive care unit admission or death over an 8-week period ; structured interviews of staff to explore cognitive and sociocultural barriers to activating the RRS . Setting Southern Health is a comprehensive healthcare network with 570 adult in-patient beds across four metropolitan teaching hospitals in the south-eastern sector of Melbourne . Measurements Frequency of physiological instability and outcomes within the in-patient hospital population . Qualitative data from staff interviews were thematically coded . Results The incidence of physiological instability in the acute adult population was 4.04 % . Nearly half of these patients ( 42 % ) did not receive an appropriate clinical response from the staff , despite most ( 69.2 % ) recognising their patient met physiological criteria for activating the RRS , and being ‘ quite ’ , or ‘ very ’ concerned about their patient ( 75.8 % ) . Structured interviews with 91 staff members identified predominantly sociocultural reasons for failure to activate the RRS . Conclusions Despite an organisational commitment to the RRS , clinical staff act on local cultural rules within the clinical environment that are usually not explicit . Better underst and ing of these informal rules may lead to more appropriate activation of the RRS Background Increasing dem and s on general practice to manage chronic disease may warrant organisational change at the practice level . Staff 's readiness for organisational change can act as a facilitator or barrier to implementing interventions aim ed at organisational change . Objectives To explore general practice staff readiness for organisational change and its association with staff and practice s characteristics . Methods This is a cross-sectional study of practice s in three Australian states involved in a r and omised control trial on the effectiveness of an intervention to enhance the role of non-general practitioner staff in chronic disease management . Readiness for organisational change , job satisfaction and practice characteristics were assessed using question naires . Results 502 staff from 58 practice s completed question naires . Practice characteristics were not associated with staff readiness for change . A multilevel regression analysis showed statistically significant associations between staff readiness for organisational change ( range 1 to 5 ) and having a non- clinical staff role ( vs general practitioner ; B=−0.315 ; 95 % CI −0.47 to −0.16 ; p<0.001 ) , full-time employment ( vs part-time ; B=0.175 , 95 % CI 0.06 to 0.29 ; p<0.01 ) and lower job satisfaction ( B=−0.277 , 95 % CI −0.40 to −0.15 ; p<0.001 ) . Conclusions The results suggest that different approaches are needed to facilitate change which addresses the mix of practice staff . Moderately low job satisfaction may be an opportunity for organisational change BACKGROUND Surgery has become an integral part of global health care , with an estimated 234 million operations performed yearly . Surgical complications are common and often preventable . We hypothesized that a program to implement a 19-item surgical safety checklist design ed to improve team communication and consistency of care would reduce complications and deaths associated with surgery . METHODS Between October 2007 and September 2008 , eight hospitals in eight cities ( Toronto , Canada ; New Delhi , India ; Amman , Jordan ; Auckl and , New Zeal and ; Manila , Philippines ; Ifakara , Tanzania ; London , Engl and ; and Seattle , WA ) representing a variety of economic circumstances and diverse population s of patients participated in the World Health Organization 's Safe Surgery Saves Lives program . We prospect ively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery . We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist . The primary end point was the rate of complications , including death , during hospitalization within the first 30 days after the operation . RESULTS The rate of death was 1.5 % before the checklist was introduced and declined to 0.8 % afterward ( P=0.003 ) . Inpatient complications occurred in 11.0 % of patients at baseline and in 7.0 % after introduction of the checklist ( P<0.001 ) . CONCLUSIONS Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals Background Service development innovation in health technology and practice is viewed as a pressing need within the field of mental health yet is relatively poorly understood . Macro-level theories have been criticised for their limited explanatory power and they may not be appropriate for underst and ing local and fine-grained uncertainties of services and barriers to the sustainability of change . This study aim ed to identify context ual influences inhibiting or promoting the acceptance and integration of innovations in mental health services in both National Health Service ( NHS ) and community setting s. Methods A comparative study using qualitative and case study data collection methods , including semi-structured interviews with key stakeholders and follow-up telephone interviews over a one-year period . The analysis was informed by learning organisation theory . Drawn from 11 mental health innovation projects within community , voluntary and NHS setting s , 65 participants were recruited including service users , commissioners , health and non-health professionals , managers , and caregivers . The methods deployed in this evaluation focused on process- outcome links within and between the 11 projects . Results Key barriers to innovation included resistance from corporate departments and middle management , complexity of the innovation , and the availability and access to re sources on a prospect i ve basis within the host organisation . The results informed the construction of a proposed model of innovation implementation within mental health services . The main components of which are context , process , and outcomes . Conclusions The study produced a model of conducive and impeding factors drawn from the composite picture of 11 innovative mental health projects , and this is discussed in light of relevant literature . The model provides a rich agenda to consider for services wanting to innovate or adopt innovations from elsewhere . The evaluation suggested the importance of study ing innovation with a focus on context , process , and outcomes Background Despite recent high- quality evidence for their cost-effectiveness , thiazides are underused for controlling hypertension . The goal of this study was to design and test a practice -based intervention aim ed at increasing the use of thiazide-based antihypertensive regimens . Methods This quasi-experimental study was carried out in general medicine ambulatory practice s of a large , academically-affiliated Veterans Affairs hospital . The intervention group consisted of the practitioners ( 13 staff and 215 trainees ) , nurses , and patients ( 3,502 ) of the teaching practice ; non-r and omized concurrent controls were the practitioners ( 31 providers ) and patients ( 18,292 ) of the non-teaching practice s. Design of the implementation intervention was based on Rogers ' Diffusion of Innovations model . Over 10.5 months , intervention teams met weekly or biweekly and developed and disseminated informational material s among themselves and to trainees , patients , and administrators . These teams also review ed summary electronic-medical-record data on thiazide use and blood pressure ( BP ) goal attainment . Outcome measures were the proportion of hypertensive patients prescribed a thiazide-based regimen  , and the proportion of hypertensive patients attaining BP goals regardless of regimen . Thirty-three months of time-series data were available ; statistical process control charts , change point analyses , and before-after analyses were used to estimate the intervention 's effects . Results Baseline use of thiazides and rates of BP control were higher in the intervention group than controls . During the intervention , thiazide use and BP control increased in both groups , but changes occurred earlier in the intervention group , and primary change points were observed only in the intervention group . Overall , the pre-post intervention difference in proportion of patients prescribed thiazides was greater in intervention patients ( 0.091 vs. 0.058 ; p = 0.0092 ) , as was the proportion achieving BP goals ( 0.092 vs. 0.044 ; p = 0.0005 ) . At the end of the implementation period , 41.4 % of intervention patients were prescribed thiazides vs. 30.6 % of controls ( p < 0.001 ) ; 51.6 % of intervention patients had achieved BP goals vs. 44.3 % of controls ( p < 0.001 ) . Conclusion This multi-faceted intervention appears to have result ed in modest improvements in thiazide prescribing and BP control . The study also demonstrates the value of electronic medical records for implementation research , how Rogers ' model can be used to design and launch an implementation strategy , and how all members of a clinical microsystem can be involved in an implementation effort 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 practice s. 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 underst and how it has been used and operationalized , and to highlight its strengths and limitations . Methods We conducted a qualitative , critical synthesis of peer- review ed PARIHS literature published through March 2009 . We synthesized findings through a three-step process using semi-structured data abstract ion 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 prospect ively 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 vali date 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 , prospect i ve 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 Objective Implementation of a surgical checklist depends on many organisational factors and on socio-cultural patterns . The objective of this study was to identify barriers to effective implementation of a surgical checklist and to develop a best use strategy . Setting 18 cancer centres in France . Design The authors first assessed use compliance and completeness rates of the  surgical checklist  on a r and om sample of 80 surgical procedures performed under general or loco-regional anaesthesia in each of the 18 centres . They then developed a typology of the organisational and cultural barriers to effective checklist implementation and defined each barrier 's contents using data from collective and semi-structured individual interviews of key staff , the results of an email question naire sent to the 18 centres , and direct observations over 20 h in two centres . Results The study consisted of 1440 surgical procedures , 1299 checklists , and 28 578 items . The mean compliance rate was 90.2 % ( 0 , 100 ) . The mean completion rate was 61 % ( 0 , 84 ) . 11 barriers to effective checklist implementation were identified . Their incidence varied widely across centres . The main barriers were duplication of items within existing checklists ( 16/18 centres ) , poor communication between surgeon and anaesthetist ( 10/18 ) , time spent completing the checklist for no perceived benefit , and lack of underst and ing and timing of item checks ( 9/18 ) , ambiguity ( 8/18 ) , unaccounted risks ( 7/18 ) and a time-honoured hierarchy ( 6/18 ) . Conclusions Several of the barriers to the successful implementation of the surgical checklist depended on organisational and cultural factors within each centre . The authors propose a strategy for change for checklist design , use and assessment , which could be used to construct a feedback loop for local team organisation and national initiatives Background Data of the German Competence Network for Community-Acquired Pneumonia showed a gap between the recommendations of the national guideline for management of community-acquired pneumonia ( CAP ) and the routine care . We developed and evaluated an implementation strategy to improve the quality of care of patients with CAP . Method A prospect i ve , r and omised , controlled trail was conducted within CAPNETZ . In four local clinical centres ( LCC ) , the guideline was implemented by different strategies . The other four LCC served as control group . Indicators for guideline adherence comprised initial site of treatment , initial antibiotic treatment and duration of antibiotic treatment . As patient-related factors , we assessed the effect of guideline implementation on 30-day mortality and length of hospital stay . Results Active guideline implementation yielded an increased proportion of guideline adherence to the length of antibiotic treatment in out patients ( + 9.2 % ) , the recommended antibiotic treatment ( + 
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Obstacles in implementation are the mirror image of these : for example , when people fail to prepare , have insufficient capacity for implementation or when the setting is resistant to change , then care quality is at risk , and patient safety can be compromised .