자연주의적 탐구조사(Naturalistic Inquiry)

According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

Purposeful sampling is widely used in qualitative research for the identification and selection of information-rich cases related to the phenomenon of interest. Although there are several different purposeful sampling strategies, criterion sampling appears to be used most commonly in implementation research. However, combining sampling strategies may be more appropriate to the aims of implementation research and more consistent with recent developments in quantitative methods. This paper reviews the principles and practice of purposeful sampling in implementation research, summarizes types and categories of purposeful sampling strategies and provides a set of recommendations for use of single strategy or multistage strategy designs, particularly for state implementation research.

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Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research.

Background Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not been found to be consistently effective. Objectives To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. Search strategy We searched the Cochrane Effective Practice and Organisation of Care Group's register up to January 2001. This was supplemented with searches of MEDLINE and reference lists, which did not yield additional relevant studies. Selection criteria Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. Data collection and analysis Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. Main results We included 85 studies, 48 of which have been added to the previous version of this review. There were 52 comparisons of dichotomous outcomes from 47 trials with over 3500 health professionals that compared audit and feedback to no intervention. The adjusted RDs of non-compliance with desired practice varied from 0.09 (a 9% absolute increase in non-compliance) to 0.71 (a 71% decrease in non-compliance) (median = 0.07, inter-quartile range = 0.02 to 0.11). The one factor that appeared to predict the effectiveness of audit and feedback across studies was baseline non-compliance with recommended practice. Reviewer's conclusions Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low.

Audit and feedback: effects on professional practice and healthcare outcomes

An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of “implementation outcomes” distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working “taxonomy” of eight conceptually distinct implementation outcomes—acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability—along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies.

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Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda

We describe different models of community care for persons with severe mental illness and review the research literature on case management, including the results of 75 studies. Most research has been conducted on the assertive community treatment (ACT) or intensive case management (ICM) models. Controlled research on ACT and ICM indicates that these models reduce time in the hospital and improve housing stability, especially among patients who are high service users. ACT and ICM appear to have moderate effects on improving symptomatology and quality of life. Most studies suggest little effect of ACT and ICM on social functioning, arrests and time spent in jail, or vocational functioning. Studies on reducing or withdrawing ACT or ICM services suggest some deterioration in gains. Research on other models of community care is inconclusive. We discuss the implications of the findings in terms of the need for specialization of ACT or ICM teams to address social and vocational functioning and substance abuse. We suggest directions for future research on models of community care, including evaluating implementation fidelity, exploring patient predictors of improvement, and evaluating the role of the helping alliance in mediating outcome.

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Models of community care for severe mental illness : A review of research on case management

Background: The Individual Placement and Support (IPS) model of supported em - ployment for clients with severe mental illness has been described as a standardi - zation of evidence-based supported employment. Although several reviews on the literature on its effectiveness have been conducted, the completion of several new studies suggests an updated review is warranted. Methods: We conducted a comprehensive literature search for randomized con - trolled trials of IPS, limiting our review to programs with high-fidelity IPS pro - grams, locating 11 studies. We examined the following competitive employment outcomes: employment rates, days to first job, annualized weeks worked, and job tenure in longest job held during the follow-up period. Findings: Across the 11 studies, the competitive employment rate was 61% for IPS compared to 23% for controls. About two-thirds of those who obtained competitive employment worked 20 hours or more per week. Among those who obtained a competitive job, IPS participants obtained their first job nearly 10 weeks earlier than did controls. Among IPS participants who obtained competitive work, dura - tion of employment after the start of the first job averaged 24.2 weeks per year, or 47% of the 52-week year. Conclusions: The current review is consistent with earlier reviews, although the evi - dence for high-fidelity IPS appears to be somewhat stronger here than in reviews evaluating studies with more heterogeneity in the supported employment models examined. The number, consistency, and effect sizes of studies of evidence-based supported employment establish it as one of the most robust interventions avail - able for persons with severe mental illness.

An update on randomized controlled trials of evidence-based supported employment.

Supported employment for people with severe mental illnesses is an evidence-based practice, based on converging findings from 4 studies of the conversion of day treatment to supported employment and 9 randomized controlled trials comparing supported employment to a variety of alternative approaches. These two lines of research suggest that between 40% and 60% of consumers enrolled in supported employment obtain competitive employment while less than 20% of similar consumers do so when not enrolled in supported employment. Consumers who hold competitive jobs for a sustained period of time show benefits such as improved self-esteem and better symptom control, although by itself, enrollment in supported employment has no systematic impact on nonvocational outcomes, either on undesirable outcomes, such as rehospitalization, or on valued outcomes, such as improved quality of life. The psychiatric rehabilitation field has achieved consensus on a core set of principles of supported employment, although efforts continue to develop enhancements. A review of the evidence suggests strong support for 4 of 7 principles of supported employment, while the evidence for the remaining 3 is relatively weak. Continued innovation and research on principles is recommended.

Supported employment: evidence for an evidence-based practice

Patients with severe mental disorders such as schizophrenia and co-occurring substance use disorders traditionally received treatments for their two disorders from two different sets of clinicians in parallel treatment systems. Dissatisfaction with this clinical tradition led to the development of integrated treatment models in which the same clinicians or teams of clinicians provide substance abuse treatment and mental health treatment in a coordinated fashion. We reviewed 36 research studies on the effectiveness of integrated treatment for dually diagnosed patients. Studies of adding dual-disorders groups to traditional services, studies of intensive integrated treatments in controlled settings, and studies of demonstration projects have thus far yielded disappointing results. On the other hand, 10 recent studies of comprehensive, integrated outpatient treatment programs provide encouraging evidence of the programs' potential to engage dually diagnosed patients in services and to help them reduce substance abuse and attain remission. Outcomes related to hospital use, psychiatric symptoms, and other domains are less consistent. Several program features appear to be associated with effectiveness: assertive outreach, case management, and a longitudinal, stage-wise, motivational approach to substance abuse treatment. Given the magnitude and severity of the problem of dual disorders, more controlled research on integrated treatment is needed.

Review of Integrated Mental Health and Substance Abuse Treatment for Patients With Dual Disorders

Supported employment for people with severe mental illness is an evidence-based practice, based on converging findings from eight randomized controlled trials and three quasi-experimental studies. The critical ingredients of supported employment have been well described, and a fidelity scale differentiates supported employment programs from other types of vocational services. The effectiveness of supported employment appears to be generalizable across a broad range of client characteristics and community settings. More research is needed on long-term outcomes and on cost-effectiveness. Access to supported employment programs remains a problem, despite their increasing use throughout the United States. The authors discuss barriers to implementation and strategies for overcoming them based on successful experiences in several states.

Gary R. Bond

Papers

Models of community care for severe mental illness : A review of research on case management

An update on randomized controlled trials of evidence-based supported employment.

Supported employment: evidence for an evidence-based practice

Review of Integrated Mental Health and Substance Abuse Treatment for Patients With Dual Disorders

Implementing Supported Employment as an Evidence-based Practice