{"id":8289,"date":"2023-08-30T12:47:55","date_gmt":"2023-08-30T10:47:55","guid":{"rendered":"https:\/\/www.easistent.ro\/?p=8289"},"modified":"2023-09-28T11:05:19","modified_gmt":"2023-09-28T09:05:19","slug":"cadrul-i-parihs-caracteristici-principale-si-modalitati-de-utilizare-in-cadrul-proiectelor-de-implementare-a-practicilor-bazate-pe-dovezi","status":"publish","type":"post","link":"https:\/\/www.easistent.ro\/?p=8289","title":{"rendered":"Cadrul i &#8211; PARIHS \u2013 Caracteristici principale \u0219i modalit\u0103\u021bi de utilizare \u00een cadrul proiectelor de implementare a practicilor bazate pe dovezi"},"content":{"rendered":"\n<p>Cadrul integrat &#8211; Promoting Action on Research Implementation in Health Services, i-PARIHS, (2016) a rezultat din \u00eembun\u0103t\u0103\u021birea cadrului PARIHS (2002). Nevoia de \u201erafinare\u201d a cadrului ini\u021bial a fost identificat\u0103 prin analiza critic\u0103 a literaturii (peste 40 de lucr\u0103ri PARIHS elaborate \u00een perioada 2008-2016) [1] din care au rezultat urm\u0103toarele limit\u0103ri importante \u00een utilizarea eficient\u0103 a acestui concept:<\/p>\n\n\n\n<ol type=\"1\"><li>Tendin\u021ba de a adapta dovezile conform experien\u021bei clinice locale, ceea ce \u00eenseamn\u0103 c\u0103 rareori erau preluate dovezile rezultate din revizuiri sistematice sau ghiduri clinice \u0219i aplicate \u00een mod direct \u00een cadrul unui proiect de implementare<em>.<\/em> \u00cen general, recomand\u0103rile erau discutate \u0219i revizuite de c\u0103tre facilitatori \u0219i completate cu un set de criterii de audit.<\/li><li>E\u0219ecul \u00een recunoa\u0219terea rolului central al persoanelor implicate \u00een implementare \u0219i lipsa de claritate \u00een <em>\u00een\u021belegerea<\/em> constructelor \u0219i sub-constructelor cadrului.<\/li><li>Focus pe <em>rolul de facilitator<\/em> \u0219i mai pu\u021bin pe <em>procesul de facilitare<\/em>.<\/li><li>Lipsa unei defini\u021bii clare a <em>implement\u0103rii cu succes<\/em>.<\/li><\/ol>\n\n\n\n<p>S\u0103 ne reamintim, din articolul anterior, structura cadrului ini\u021bial PARIHS. Modelul se bazeaz\u0103 pe Cadrul conceptual elaborat de Kitson et al, 1998 [2], care a pornit de la ipoteza conform c\u0103reia <a><strong>implementarea cu succes <\/strong><\/a><strong>este o func\u021bie a interac\u021biunii dinamice dintre trei constructe<\/strong> (Dovezi, Context \u0219i Facilitare) <strong>\u00eenso\u021bite de o serie de sub-constructe aferente<\/strong> (Figura 1).<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.easistent.ro\/new\/wp-content\/uploads\/2023\/08\/cercetare.png\"><img width=\"894\" height=\"290\" src=\"https:\/\/www.easistent.ro\/new\/wp-content\/uploads\/2023\/08\/cercetare.png\" alt=\"\" class=\"wp-image-8275\" srcset=\"https:\/\/www.easistent.ro\/new\/wp-content\/uploads\/2023\/08\/cercetare.png 894w, https:\/\/www.easistent.ro\/new\/wp-content\/uploads\/2023\/08\/cercetare-300x97.png 300w, https:\/\/www.easistent.ro\/new\/wp-content\/uploads\/2023\/08\/cercetare-768x249.png 768w\" sizes=\"(max-width: 894px) 100vw, 894px\" \/><\/a><figcaption>Fig. 1. Implementarea cu succes a dovezilor cercet\u0103rii \u00een practica clinic\u0103,<br>cadrul conceptual PARIHS (adaptat dup\u0103 Kitson et al, 1998)<\/figcaption><\/figure>\n\n\n\n<p>\u00cen continuare sunt descrise modific\u0103rile constructului ini\u021bial PARISH \u00een raport cu limit\u0103rile identificate prin analiza critic\u0103 a literaturii.<\/p>\n\n\n\n<h2><strong>1. Tendin\u021ba de a adapta dovezile conform experien\u021bei clinice locale<\/strong><\/h2>\n\n\n\n<p>Dac\u0103 constructul DOVEZI a cadrului original PARIHS [3] aborda dovezile \u021bin\u00e2nd cont de sub-constructe aferente: informa\u021biile din cercetare, experien\u021ba clinic\u0103 a personalului medical \u0219i experien\u021ba pacientului, cadrul revizuit i-PARIHS include o abordare explicit\u0103 a modului \u00een care caracteristicile cunoa\u0219terii influen\u021beaz\u0103 <strong>difuzarea \u0219i integrarea<\/strong> <strong>cuno\u0219tin\u021belor<\/strong> \u00een diferite contexte clinice. \u00cen majoritatea studiilor, s-a observat c\u0103, de cele mai multe ori, <strong>recomand\u0103rile de practic\u0103<\/strong> extrase din ghiduri clinice sau din analize sistematice, \u00eenainte de implementare, erau supuse unui <strong>proces de \u201eadaptare\u201d <\/strong>[4,5,6] prin:<\/p>\n\n\n\n<ul><li>\u00cenfiin\u021barea unui grup local de stakeholderi\/p\u0103r\u021bi interesate (reprezentan\u021bi ai pacien\u021bilor, clinicieni, cercet\u0103tori \u0219i manageri) cu rolul de a lua \u00een considerare dovezile \u0219i de a stabili priorit\u0103\u021bile la nivel local.<\/li><li>Armonizarea dovezilor cu priorit\u0103\u021bile \u0219i practicile locale, \u00een scopul asigur\u0103rii compatibilit\u0103\u021bii dintre schimbarea practicii \u0219i contextul clinic.<\/li><\/ul>\n\n\n\n<p>Prin urmare, \u00een cadrul i-PARIHS, constructul \u201eDOVEZI\u201d a fost redenumit \u201eINOVA\u021aIE\u201d pentru a se sublinia <strong>rolul fundamental al cercet\u0103rii \u00een implementarea dovezilor.<\/strong> Dovezile sunt un tip de cunoa\u0219tere \u0219i reprezint\u0103 principale resurse care pot genera schimbarea \u0219i \u00eembun\u0103t\u0103\u021birea practici clinice. Acest fenomen a fost descris de Roger \u00een <em>Teoria difuz\u0103rii inova\u021biilor<\/em> [4,5] pled\u00e2nd pentru <strong>adecvarea noilor cuno\u0219tin\u021be (dovezi) \u00een raport cu practica existent\u0103, identificarea avantajelor \u0219i testarea lor prealabil\u0103.<\/strong> Astfel, \u201eINOVA\u021aIA\u201d devine constructul central al cadrului i-PARIHS, care eviden\u021biaz\u0103 rolul esen\u021bial al dovezilor \u00een inovare. \u00cen contextul proiectelor de implementare, principalele <strong>caracteristici ale inova\u021biei<\/strong> sunt:<\/p>\n\n\n\n<ul><li>Sursele de cuno\u0219tin\u021be;<\/li><li>Claritatea dovezilor ob\u021binute prin studii de cercetare;<\/li><li>Gradul de adecvare a dovezilor cu practica clinic\u0103 cu valorile existente (compatibilitate sau contestabilitate);<\/li><li>Gradul de utilizare facil\u0103 a dovezilor;<\/li><li>Avantajul implement\u0103rii dovezilor;<\/li><li>Testabilitatea prin implementarea dovezilor la scar\u0103 mic\u0103;<\/li><li>Rezultatele observabile ob\u021binute din implementarea dovezilor.<\/li><\/ul>\n\n\n\n<h2><strong>2. E\u0219ecul \u00een recunoa\u0219terea rolului central al persoanelor implicate \u00een implementare<\/strong> <strong>\u0219i lipsa de claritate \u00een \u00een\u021belegerea constructelor \u0219i sub-constructelor cadrului.<\/strong><\/h2>\n\n\n\n<p>O dat\u0103 cu identificarea acestei limit\u0103ri, cadrului actualizat i-PARIHS i s-a atribuit un nou construct denumit \u201eDESTINATAR\u201d [7]. Destinatarii sunt persoane care pot fi afectate sau care pot influen\u021ba implementarea, at\u00e2t la nivel individual, c\u00e2t \u0219i la nivel colectiv de echip\u0103 (pacien\u021bi, personal clinic \u0219i manageri). Aceast\u0103 extensie permite cadrului i-PARIHS s\u0103 ia \u00een considerare impactul pe care indivizii \u0219i echipele \u00eel pot avea \u00een sus\u021binerea unei inova\u021bii\/schimb\u0103ri \u00een practica clinic\u0103, prin integrarea de dovezi (cuno\u0219tin\u021be noi) [7,8]. Aceast\u0103 necesitate a fost eviden\u021biat\u0103 \u00een studiile implementate prin apari\u021bia no\u021biunii de <em>\u201elinii mentale colective\u201d,<\/em> care au influen\u021bat preluarea dovezilor \u00een practic\u0103 manifestat\u0103 prin u\u0219urin\u021ba integr\u0103rii dovezilor \u00een practica clinic\u0103, sau din contr\u0103, prin rezisten\u021ba la schimbare [9,10,11]. Implicarea activ\u0103 a stakeholderilor \u00een analizarea opiniilor, valorilor \u0219i atitudinilor lor cu privire la realizarea obiectivelor propuse \u00een proiectele de implementare ar putea contribui la gestionarea rezisten\u021bei la schimbare \u0219i la sustenabilitatea proiectelor de implementare. \u00cen acest context, rezisten\u021ba la schimbare ar putea fi o mare consumatoare de resurse (timp, energie, finan\u021be).<\/p>\n\n\n\n<p>Rela\u021bia dintre inova\u021bie \u0219i destinatari este interdependent\u0103, facilitatorul av\u00e2nd rolul de a identifica barierele \u00een implementare \u0219i de a elabora strategii adecvate pentru aceste bariere [12]. Principalele caracteristici ale destinatarilor sunt:<\/p>\n\n\n\n<ul><li>Motiva\u021bia;<\/li><li>Valorile \u0219i credin\u021bele;<\/li><li>Abilit\u0103\u021bile \u0219i cuno\u0219tin\u021bele;<\/li><li>Resursele disponibile \u0219i capacitatea lor de sus\u021binere;<\/li><li>Implicarea liderilor de opinie locali;<\/li><li>Colaborarea \u0219i munca \u00een echip\u0103;<\/li><li>Existen\u021ba re\u021belelor de schimbare;<\/li><li>Puterea \u0219i autoritatea;<\/li><li>Recunoa\u0219terea limitelor proprii.<\/li><\/ul>\n\n\n\n<p>\u201eCONTEXTUL\u201d r\u0103m\u00e2ne un construct de baz\u0103 \u00een i-PARIHS, \u00eens\u0103 focusat pe delimitarea specific\u0103 a nivelului de context: micro, mezo \u0219i macro &#8211; context, care ar putea ac\u021biona pentru a permite sau pentru a constr\u00e2nge implementarea. \u00cen cadrul PARIHS, contextul a fost definit \u00een termeni de resurse, cultur\u0103, leadership \u0219i orientare c\u0103tre evaluare \u0219i \u00eenv\u0103\u021bare, f\u0103r\u0103 a se \u021bine cont de o delimitare clar\u0103 a contextului micro (contextul local al sec\u021biei\/departamentului\/unit\u0103\u021bii sau context organiza\u021bional). De asemenea, nu a fost considerat impactul pe care sistemul de s\u0103n\u0103tate \u2013 contextul extern \u2013 l-ar putea avea asupra proceselor \u0219i rezultatelor implement\u0103rii (factori contextuali la nivel mezo \u0219i macro) [13,14] De exemplu, \u00een unele studii de cercetare, sistemul extern (na\u021bional) de management al calit\u0103\u021bii \u00een s\u0103n\u0103tate a reprezentat un motor pentru introducerea de schimb\u0103ri care s\u0103 contribuie la \u00eembun\u0103t\u0103\u021birea calit\u0103\u021bii serviciilor medicale la nivel local [15].<\/p>\n\n\n\n<p>\u00cen consecin\u021b\u0103, \u00een cadrul i-PARIHS, intervine o distinc\u021bie clar\u0103 a contextului intern micro (local imediat \u0219i organiza\u021bional) \u0219i a contextului extern mezo \u0219i macro (sistemul de s\u0103n\u0103tate \u00eenso\u021bit de cadrul politic \u0219i de reglementare specific). Prin cadrul politic specific sunt vizate politicile de s\u0103n\u0103tate na\u021bionale, inclusiv standarde na\u021bionale de calitate, proceduri \u0219i protocoale de referin\u021b\u0103. Caracteristicile principale ale diferitelor tipuri de context sunt reprezentate \u00een tabelul urm\u0103tor [16].<\/p>\n\n\n\n<figure class=\"wp-block-table is-style-stripes\">\n<table style=\"border: 1px solid #dddddd; text-align: left; padding: 8px;\"><tbody style=\"border: 1px solid #dddddd; text-align: left; padding: 8px;\"><tr style=\"border: 1px solid #dddddd; text-align: left; padding: 8px;\"><td>Context local imediat (sec\u021bie, departament\/unitate)<\/td><td class=\"has-text-align-left\" data-align=\"left\">Context organiza\u021bional<\/td><td>Context extern (sistem medical na\u021bional)<\/td><\/tr><tr style=\"border: 1px solid #dddddd; text-align: left; padding: 8px;\"><td>Sus\u021binere formal\u0103 \u0219i informal\u0103 a leadership-ului<br>Cultur\u0103 organiza\u021bional\u0103 local\u0103<br>Experien\u021b\u0103 anterioar\u0103 cu privire la inovare \u0219i schimbare<br>Mecanisme de integrare a schimb\u0103rii<br>Procese de evaluare \u0219i feedback<br>Educa\u021bie profesional\u0103 continu\u0103<\/td><td class=\"has-text-align-left\" data-align=\"left\">Priorit\u0103\u021bi organiza\u021bionale<br>Leadership \u0219i sus\u021binere managerial\u0103<br>Cultur\u0103 organiza\u021bional\u0103<br>Structur\u0103 organiza\u021bional\u0103<br>Istoria inova\u021biei \u0219i schimb\u0103rii practicilor clinice \u00een organiza\u021bie<br>Capacitate de absorb\u021bie a inova\u021biei<br>Re\u021bele de formare profesional\u0103 continu\u0103 adaptate pe nevoi educa\u021bionale<\/td><td>Politici \u0219i priorit\u0103\u021bi de s\u0103n\u0103tate<br>Stimulente \u0219i mandate pentru inovare \u00een organiza\u021bii<br>Cadre de reglementare<br>(In) stabilitatea mediului<br>Re\u021bele \u0219i rela\u021bii inter-organiza\u021bionale<\/td><\/tr><\/tbody><\/table><figcaption>Tabel. Caracteristici principale ale contextului micro, mezo \u0219i macro (adaptat dup\u0103 Harvey and Kitson, 2016)<\/figcaption><\/figure>\n\n\n\n<h2><strong>3. Focus pe rolul de facilitator \u0219i mai pu\u021bin pe procesul de facilitare.<\/strong><\/h2>\n\n\n\n<p>\u00cen cadrul i-PARIHS, \u201eFACILITAREA\u201d reprezint\u0103 un construct de baz\u0103, \u00eens\u0103 focusul facilit\u0103rii migreaz\u0103 pe rolul de activare a implement\u0103rii prin evaluarea impactului inova\u021biei \u0219i a r\u0103spunsului destinatarilor la schimbare, lu\u00e2nd \u00een considerare caracteristicile contextuale. \u00cen FACILITARE, sunt esen\u021biale at\u00e2t rolul facilitatorului, c\u00e2t \u0219i procesul de facilitare care este constituit din strategii \u0219i ac\u021biuni adecvate pentru implementarea cu succes a inova\u021biei. Prin urmare, succesul sau insuccesul implement\u0103rii este atribuit <strong>capacit\u0103\u021bii facilitatorului<\/strong> de gestionare a procesului de facilitare a inova\u021biei (schimb\u0103rii) care s\u0103 permit\u0103 destinatarilor s\u0103 implementeze interven\u021bii adaptate contextului intern \u0219i extern.<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><a href=\"https:\/\/www.easistent.ro\/new\/wp-content\/uploads\/2023\/08\/cercet.png\"><img width=\"558\" height=\"407\" src=\"https:\/\/www.easistent.ro\/new\/wp-content\/uploads\/2023\/08\/cercet.png\" alt=\"\" class=\"wp-image-8274\" srcset=\"https:\/\/www.easistent.ro\/new\/wp-content\/uploads\/2023\/08\/cercet.png 558w, https:\/\/www.easistent.ro\/new\/wp-content\/uploads\/2023\/08\/cercet-300x219.png 300w\" sizes=\"(max-width: 558px) 100vw, 558px\" \/><\/a><\/figure><\/div>\n\n\n\n<p>La nivel interna\u021bional, rolul facilitatorului \u00een sus\u021binerea implement\u0103rii schimb\u0103rilor \u00een practica clinic\u0103 a fost introdus \u00een anii 1980 [17,18], \u00een mare parte fiind asociat cu \u00eembun\u0103t\u0103\u021birea calit\u0103\u021bii \u00een \u00eengrijirile medicale primare [18,19]. \u00cen acest sens, facilitatorii utilizeaz\u0103 <strong>strategii de facilitare<\/strong>, care de cele mai multe ori sunt:<\/p>\n\n\n\n<ul><li>utilizarea instrumentelor de audit \u0219i feedback;<\/li><li>crearea de consens interactiv, inclusiv \u00een stabilirea obiectivelor;<\/li><li>utilizarea instrumentelor de \u00eembun\u0103t\u0103\u021bire a calit\u0103\u021bii, ca de exemplu ciclul PDSA (Plan-Do-Study-Act).<\/li><\/ul>\n\n\n\n<p>Facilitarea poate fi realizat\u0103 de unul sau mai mul\u021bi <strong>facilitatori instrui\u021bi<\/strong>, care sus\u021bin navigarea destinatarilor (indivizi \u0219i echipe) prin procesele complexe de schimbare \u0219i provoc\u0103rile contextuale ce pot fi \u00eent\u00e2mpinate pe parcursul implement\u0103rii. Facilitatorii pot fi interni cadrului de implementare, externi sau mic\u0219ti (interni \u0219i externi).<\/p>\n\n\n\n<p>Pentru a-\u0219i \u00eendeplini rolul \u00een mod eficient, facilitatorii ar trebui s\u0103 de\u021bin\u0103 cuno\u0219tin\u021bele \u0219i abilit\u0103\u021bile necesare pentru a ac\u021biona \u00eentr-un mod flexibil \u0219i receptiv \u00een adaptarea \u0219i abordarea inova\u021biei la: (a) problematica particular\u0103 (practica ce necesit\u0103 \u00eembun\u0103t\u0103\u021bire), (b) contextul \u0219i (c) persoanele implicate (destinatarii inova\u021biei) [21,22]. De asemenea, facilitatorul trebuie s\u0103 aib\u0103 o \u00een\u021belegere consolidat\u0103 \u00een ceea ce prive\u0219te:<\/p>\n\n\n\n<ul><li>natura inova\u021biei (obiectul implement\u0103rii);<\/li><li>indivizii \u0219i echipele care trebuie s\u0103 pun\u0103 \u00een aplicare schimbarea (destinatarii);<\/li><li>mediul de lucru (context local, organiza\u021bional \u0219i al sistemului de s\u0103n\u0103tate).<\/li><\/ul>\n\n\n\n<p>Din acest motiv, \u00een cadrul proiect\u0103rii \u0219i realiz\u0103rii studiilor de implementare care utilizeaz\u0103 modelul i-PARIHS, o importan\u021b\u0103 esen\u021bial\u0103 este atribuit\u0103 etapelor de recrutare, selec\u021bie, preg\u0103tire \u0219i dezvoltare profesional\u0103 a facilitatorilor.<\/p>\n\n\n\n<h2><strong>4. Lipsa unei defini\u021bii clare a implement\u0103rii cu succes.<\/strong><\/h2>\n\n\n\n<p>\u00cen cadrul i-PARIHS, implementarea cu succes (SI) rezult\u0103 din facilitarea (F) unei inova\u021bii (I) cu destinatarii viza\u021bi (D) \u00een contextul lor (C), adic\u0103 SI = F(I,D,C).<\/p>\n\n\n\n<p>Prin urmare, implementarea cu succes este definit\u0103 ca atingerea obiectivelor de implementare, inclusiv:<\/p>\n\n\n\n<ul><li>Adoptarea \u0219i integrarea inova\u021biei \u00een practic\u0103;<\/li><li>Implicarea activ\u0103 a destinatarilor (indivizi, echipe \u0219i alte p\u0103r\u021bi interesate);<\/li><li>Reducerea\/minimizarea varia\u021biei contextului pe parcursul implement\u0103rii inova\u021biei.<\/li><\/ul>\n\n\n\n<p>\u00cen acest sens, exist\u0103 o serie de teorii care contribuie la definirea implement\u0103rii cu succes a inova\u021biei.<\/p>\n\n\n\n<p><em>Teoria lui Weiner<\/em> [23] consider\u0103 <strong>schimbarea comportamentului colectiv<\/strong> ca fiind un element cheie \u00een preg\u0103tirea organiza\u021bional\u0103 pentru schimbare, fiind cunoscut faptul c\u0103, schimbarea comportamentelor are la baz\u0103 angajamentul \u00een schimbare al destinatarilor (dorin\u021ba de a produce schimbarea practicii) \u0219i eficacitatea schimb\u0103rii (capacitatea lor de a schimba practicile neconforme).<\/p>\n\n\n\n<p><em>Teoriile lui Carl Rogers<\/em> [24] \u0219i <em>John Heron<\/em> [25] au influen\u021bat perspectiva teoretic\u0103 asupra facilit\u0103rii prin organizarea \u0219i implementarea etapelor de furnizare a interven\u021biilor adecvate, instruirea continu\u0103 a destinatarilor cu privire la implementarea interven\u021biilor, convingerea \u0219i chiar constr\u00e2ngerea destinatarilor de a ac\u021biona \u00een sensul schimb\u0103rii.<\/p>\n\n\n\n<p><em>Sistemul Deming<\/em> de cuno\u0219tin\u021be profunde \u00een scopul \u00eembun\u0103t\u0103\u021birii practicii clinice, cu accent pe \u00een\u021belegerea sistemelor, proceselor, \u00eenv\u0103\u021b\u0103rii experien\u021biale \u0219i interac\u021biunii umane [26] reprezint\u0103 o teorie care promoveaz\u0103 implicarea local\u0103 \u0219i asumarea procesului de implementare a \u00eembun\u0103t\u0103\u021birii, \u00een special \u00een g\u00e2ndirea modului \u00een care facilitatorii \u00ee\u0219i exercit\u0103 rolul \u00een practic\u0103.<\/p>\n\n\n\n<p>Alte teorii sunt \u00een leg\u0103tur\u0103 cu complexitatea procesului de schimbare [27,28], capacitatea de absorb\u021bie a organiza\u021biei [29], formare profesional\u0103 continu\u0103 [30], leadership \u0219i cultura organiza\u021bional\u0103 [31]. O importan\u021b\u0103 deosebit\u0103 o reprezint\u0103 teoria cu privire la <strong>sus\u021binerea schimb\u0103rii pe termen lung<\/strong> (sustenabilitate). O astfel de teorie este <em>Teoria procesului de normalizar<\/em>e [32,33] care recunoa\u0219te importan\u021ba interac\u021biunii destinatarilor \u00een contextul lor \u0219i propune patru mecanisme esen\u021biale de ac\u021biune: coeren\u021b\u0103, participare cognitiv\u0103, ac\u021biune colectiv\u0103 \u0219i monitorizare reflexiv\u0103.<\/p>\n\n\n\n<p>\u00cen concluzie, cadrul i-PARIHS revizuit este un model adecvat, utilizat la nivel interna\u021bional \u00een proiectele de implementare a practicilor bazate pe dovezi. Acest cadru pozi\u021bioneaz\u0103 facilitarea ca ingredient activ al implement\u0103rii, cu rol \u00een evaluarea \u0219i adecvarea inova\u021biei care urmeaz\u0103 s\u0103 fie implementat\u0103 de destinatarii viza\u021bi \u00een contextul lor local, organiza\u021bional \u0219i al sistemului de s\u0103n\u0103tate. Facilitarea este opera\u021bionalizat\u0103 printr-o re\u021bea de facilitatori care aplic\u0103 o serie strategii de \u00eembun\u0103t\u0103\u021bire cu rol \u00een structurarea procesului de implementare, angajarea \u0219i gestionarea rela\u021biilor dintre p\u0103r\u021bile interesate cheie, precum \u0219i identificarea barierelor \u00een calea implement\u0103rii \u00een context specific.<\/p>\n\n\n\n<p><strong>Autori:<\/strong><\/p>\n\n\n\n<ol type=\"1\"><li>Mariana Zazu \u2013 Specialist \u00een Dezvoltare Organiza\u021bional\u0103, OAMGMAMR Filiala Bucure\u0219ti; Director adjunct al Centrului Rom\u00e2n de Cercetare \u00een \u00cengrijiri de S\u0103n\u0103tate: Centru de Excelen\u021b\u0103 JBI<\/li><li>Andreea N\u0103stase \u2013 Departamentul Profesional-\u015etiin\u0163ific de Cercetare \u015fi Dezvoltare a profesiei, OAMGMAMR Filiala Bucure\u0219ti<\/li><\/ol>\n\n\n\n<p><strong>Surse de documentare:<\/strong><\/p>\n\n\n\n<p>[1] Helfrich C, Damschroder L, Hagedorn H, Daggett G, Sahay A, RitchieM, et al. A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework. Implement Sci. 2010;5:82.<\/p>\n\n\n\n<p>[2] Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. 1998. Quality in Health Care 7, 149\u2013159.<\/p>\n\n\n\n<p>[3] Rycroft-Malone J, Seers K, Titchen A, Harvey G, Kitson A, McCormack B. What counts as evidence in evidence-based practice? J Adv Nurs. 2004;47:81\u201390.<\/p>\n\n\n\n<p>[4] Rogers EM. Diffusion of innovations. 4th ed. New York: The Free Press; 1995.<\/p>\n\n\n\n<p>[5] Rogers EM. Diffusion of innovations. 5th ed. New York: Free Press; 2003.<\/p>\n\n\n\n<p>[6] Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82(4):581\u2013629.<\/p>\n\n\n\n<p>[7] Rycroft-Malone J, Seers K, Chandler J, Hawkes C, Crichton N, Allen C, et al. The role of evidence, context, and facilitation in an implementation trial: implications for the development of the PARIHS framework. Implement Sci.2013;8(1):28.<\/p>\n\n\n\n<p>[8] Flodgren G, Parmelli E, Doumit G, Gattellari M, O\u2019Brien MA, Grimshaw J et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2011 Aug 10;(8):CD000125.<\/p>\n\n\n\n<p>[9] Kislov R, Harvey G, Walshe K. Collaborations for leadership in applied health research and care: lessons from the theory of communities of practice. mplement Sci. 2011;6:64.<\/p>\n\n\n\n<p>[10] Gabbay J, May A. Evidence based guidelines or collectively constructed \u201cmindlines?\u201d Ethnographic study of knowledge management in primary care. BMJ. 2004;329:1013.<\/p>\n\n\n\n<p>[11] Wieringa S, Greenhalgh T. 10 years of mindlines: a systematic review and commentary. Implement Sci. 2015;10:45.<\/p>\n\n\n\n<p>[12] Harvey G, Kitson A. Translating evidence into healthcare policy and practice: single versus multi-faceted implementation strategies\u2014is there a simple answer to a complex question? Int J Health Policy Manag. 2015;4(3):123\u20136.<\/p>\n\n\n\n<p>[13] Damschroder L, Aron D, Keith R, Kirsh S, Alexander J, Lowery J. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.<\/p>\n\n\n\n<p>[14] Flottorp S, Oxman A, Krause J, Musila N, Wensing M, Godycki-Cwirko M, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement Sci. 2013;8(1):35.<\/p>\n\n\n\n<p>[15] Harvey G, Kitson A, Munn Z. Promoting continence in nursing homes in four European countries: the use of PACES as a mechanism for improving the uptake of evidence-based recommendations. Int J Evid Based Healthc. 2012;10(4):388\u201396.<\/p>\n\n\n\n<p>[16] Harvey G, Kitson A. PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice. Implementation science. 2015 Dec;11(1):1-3.<\/p>\n\n\n\n<p>[17] Harvey G, Loftus-Hills A, Rycroft-Malone J, Titchen A, Kitson A, McCormack B, et al. Getting evidence into practice: the role and function of facilitation. J Adv Nurs. 2002;37(6):577\u201388.<\/p>\n\n\n\n<p>[18] Fullard E, Fowler G, Gray M. Facilitating prevention in primary care. BMJ. 2004;289:1585\u20137.<\/p>\n\n\n\n<p>[19] Engels Y, van den Hombergh P, Mokkink H, van den Hoogen H, van den Bosch W, Grol R. The effects of a team-based continuous quality improvement intervention on the management of primary care: a randomised controlled trial. Brit J Gen Pract. 2006;6:781\u20137.<\/p>\n\n\n\n<p>[20] Liddy C, Laferriere D, Baskerville B, Dahrouge S, Knox L, Hogg W. An overview of practice facilitation programs in Canada: current perspectives and future directions. Healthc Policy. 2013;8:58\u201367.<\/p>\n\n\n\n<p>[21] Morrell C, Harvey G. The clinical audit handbook: improving the quality of health care. London: Bailli\u00e8re Tindall; 1999.<\/p>\n\n\n\n<p>[22] Ritchie MJ, Kirchner JE, Parker LE, Curran GM, Fortney JC, Pitcock JA, Bonner LM, Kilbourne AM. Evaluation of an implementation facilitation strategy for settings that experience significant implementation barriers. Implement Sci. 2015;10 Suppl 1:A46.<\/p>\n\n\n\n<p>[23] Weiner B. A theory of organizational readiness for change. Implement Sci. 2009;4(1):67.<\/p>\n\n\n\n<p>[24] Rogers CR. Freedom to learn\u2014a view of What Education Might Become. Charles Merrill: Columbus, Ohio; 1969.<\/p>\n\n\n\n<p>[25] Heron J. The facilitator\u2019s handbook. London: Kogan Page; 1989.<\/p>\n\n\n\n<p>[26] Deming WE. Out of the crisis. Cambridge, Massachusetts: MIT Press; 2000.<\/p>\n\n\n\n<p>[27] Plsek PE, Greenhalgh T. The challenge of complexity in health care. BMJ. 2001;323:625\u20138.<\/p>\n\n\n\n<p>[28] Downe S. Beyond evidence-based medicine: complexity and stories of maternity care. J Eval Clin Pract. 2010;16(1):232\u20137.<\/p>\n\n\n\n<p>[29] Harvey G, Jas P, Walshe K. Analysing organisational context: case studies on the contribution of absorptive capacity theory to understanding interorganisational variation in performance improvement. BMJ Qual Saf. 2015;24(1):48\u201355.<\/p>\n\n\n\n<p>[30] Senge PM. The fifth discipline: the art and practice of the learning organization. New York: Doubleday; 1990.<\/p>\n\n\n\n<p>[31] Schein EH. Organizational culture and leadership. 3rd ed. San Francisco: Jossey-Bass; 2004.<\/p>\n\n\n\n<p>[32] May C, Finch T. Implementation, embedding, and integration: an outline of Normalization Process Theory. Sociology. 2009;43(3):535\u201354.<\/p>\n\n\n\n<p>[33] May C, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S, et al. Development of a theory of implementation and integration: normalization Process Theory. Implement Sci. 2009;4(1):29.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Cadrul integrat &#8211; Promoting Action on Research Implementation in Health Services, i-PARIHS, (2016) a rezultat din \u00eembun\u0103t\u0103\u021birea cadrului PARIHS (2002). Nevoia de \u201erafinare\u201d a cadrului ini\u021bial a fost identificat\u0103 prin analiza critic\u0103 a literaturii (peste 40 de lucr\u0103ri PARIHS elaborate \u00een perioada 2008-2016) [1] din care au rezultat urm\u0103toarele limit\u0103ri importante \u00een utilizarea eficient\u0103 a [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":8275,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[152,155],"tags":[],"_links":{"self":[{"href":"https:\/\/www.easistent.ro\/index.php?rest_route=\/wp\/v2\/posts\/8289"}],"collection":[{"href":"https:\/\/www.easistent.ro\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.easistent.ro\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.easistent.ro\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.easistent.ro\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=8289"}],"version-history":[{"count":8,"href":"https:\/\/www.easistent.ro\/index.php?rest_route=\/wp\/v2\/posts\/8289\/revisions"}],"predecessor-version":[{"id":8297,"href":"https:\/\/www.easistent.ro\/index.php?rest_route=\/wp\/v2\/posts\/8289\/revisions\/8297"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.easistent.ro\/index.php?rest_route=\/wp\/v2\/media\/8275"}],"wp:attachment":[{"href":"https:\/\/www.easistent.ro\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=8289"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.easistent.ro\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=8289"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.easistent.ro\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=8289"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}