Implementation of clinical guidelines in the youth healthcare A case study regarding the implementation of the adapted guideline regarding the detection of children with language disorders.
Michelle de Groot – 1540033 – MPA – July 2012
Daily Supervisor: Bettie Carmiggelt Nederlands Centrum Jeugdgezondheidszorg Churchilllaan 11, 7e etage 3527 GV Utrecht 030 7600405 Supervisors: Dr. Frans Pijpers Nederlands Centrum Jeugdgezondheidszorg Churchilllaan 11, 7e etage 3527 GV Utrecht 030 7600405 Tjerk Jan Schuitmaker Athena Institute, VU University of Amsterdam De Boelelaan 1085 1081 HV Amsterdam 020 598 7031
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Acknowledgements This report was written as a product of the internship of the second year of the study Management, Policy Analysis and Entrepreneurship in Health and Life Sciences at the Vrije Universiteit Amsterdam. This internship was conducted at the Dutch Centre of Youth Health and this report is mainly intended as a recommendation for this organisation in regard to the implementation of a possible new guideline. First of all, I would like to thank the interviewees for their willingness to cooperate in my research. Furthermore, I would like to thank the Dutch Centre of Youth Health for ensuring a pleasant environment to conduct my research and especially Bettie Carmiggelt and Frans Pijpers for their comments and recommendations regarding my work. Last but not least I would like to thank Tjerk Jan Schuitmaker for critically reviewing my report.
Michelle de Groot 5 July 2012, Utrecht
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Abstract Five to ten per cent of the children in the Netherlands suffer from a language disorder. Late treatment of a language disorder can cause social and emotional problems. In 2011 the NCJ together with the NSDSK set up a pilot with a new way of working, in which children are better screened concerning language development. This pilot seems promising and could be an adjustment to the current guideline for the Netherlands. Within this pilot extra questions are added to the Van Wiechen monitoring system. If a child scores low, it will be referred to the audiology centre. If the child scores doubtful, two home visits are planned which are used to help the parents to stimulate the language development. In order to smoothen out the implementation process beforehand this research was done. It focuses on the preconditions set by organisations which are not involved in the pilot. By doing so, alterations to the guideline could be made in advance, making it easier to implement it later on. This guideline was also used as a case study, as some of the results are applicable to guideline implementation in general. The conceptual framework used, is a model of implementation by Fleuren et al. (2004), which defines four different areas where preconditions could arise. These areas are the innovation itself, the person using the innovation, the organisation and the socio-economic environment. To research which preconditions were present throughout the Netherlands, eleven people were interviewed. These people were all responsible for implementation in their organisation, and had a function as staff physician, policy advisor or manager. The semi-structured interviews were transcribed and coded through the before mentioned framework. Overall the interviewees responded positive regarding the guideline. The extra questions added on top of the Van Wiechen monitoring system did not seem like a problem time wise. The house visits however need to be proven effective before organisations would be willing to implement this. Also there should not be a large increase in the number of house visits, otherwise the budget the organisations have will not be sufficient. Would this be the case than also the municipalities need to be convinced of the effectiveness of these home visits. Also the referral to the audiology centre is not preferred by all of the organisations, as they also have other options, like for instance an ENTphysician. The most important thing seems to be the communication towards everyone involved. In the case regarding this guideline this would be the medical professional, the management, the parents and the municipalities. Parents especially need to be approached, as they need to be willing to accept this way of working and also the information they receive through this way of working. This is something that needs to be taken into account when a guideline is made out of the pilot.
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Summary in Dutch Achtergrond - Vijf tot tien procent van de Nederlandse kinderen heeft een taalstoornis. Een taalstoornis is een aandoening waarbij het gehoor in orde is, maar het taalbegrip verstoort. Als deze stoornis niet tijdig wordt onderkend, kan deze mogelijkerwijs emotionele, sociale en psychische problemen veroorzaken voor het kind. Om de signalering van deze taalstoornis te verbeteren is het NCJ samen met het NSDSK een pilot gestart in 2012 met een nieuw protocol voor het contactmoment van tweejarigen. Dit nieuwe protocol bestaat uit extra vragen van het VTO-taalinstrument toegevoegd aan de onderdelen 41 en 42 van het Van Wiechen onderzoek. Hierop kunnen kinderen onvoldoende (0-1), twijfelachtig (2-3) of goed (4) scoren. De kinderen die onvoldoende scoren worden verwezen naar het audiologisch centrum. Degene die twijfelachtig scoren krijgen een huisbezoek van een verpleegkundige. Tijdens dit huisbezoek wordt gekeken naar de interactie van ouders en kind en krijgen de ouders advies over hoe zij de taalontwikkeling van het kind beter kunnen stimuleren. Methode - Als de resultaten van deze pilot goed zijn, zal er mogelijkerwijs een richtlijn van gemaakt worden. Om de mogelijke implementatie van deze richtlijn te vergemakkelijken is dit onderzoek opgezet. De basis van het onderzoek is gebaseerd op het implementatie model van Fleuren et al (2004). Elf interviews zijn gehouden met stafartsen, beleidsmedewerkers of managers werkzaam binnen de jeugdgezondheidszorg. Deze mensen bezitten allemaal een functie waar ze invloed hebben op het implementatieproces en daardoor een goed overzicht kunnen geven van welke voorwaardes er zijn voordat deze mogelijke richtlijn geïmplementeerd kan worden. Verder zijn er ook resultaten die in het algemeen toepasbaar zijn voor de implementatie voor richtlijnen. Resultaten en Discussie - De geïnterviewden waren enthousiast over de extra vragen die bovenop het Van Wiechen onderzoek kwamen, omdat hierdoor waarschijnlijk beter een inschatting gemaakt kan worden van de taalontwikkeling van het kind. De huisbezoeken waren echter wel een punt waar commentaar op was. Veel organisaties hadden zelf al projecten lopen die een beeld gaven van de taalomgeving van het kind of de ouders hielpen bij de stimulatie van taal. Het plegen van huisbezoeken zou, als de pilot aantoont dat er meer uitgevoerd moeten worden dan normaal, ook extra kosten met zich meebrengen. Mocht dit het geval zijn, dan moeten er duidelijke bewijzen zijn dat de huisbezoeken effectief zijn, anders wordt het lastig voor organisaties om de financiering rond te krijgen. Een ander punt waar niet alle ondervraagden het mee eens waren was de directe verwijzing naar het audiologisch centrum. Mocht dit een richtlijn worden dan zouden de ondervraagden graag ook de andere mogelijkheden van verwijzen hierin opnemen. Dit zouden bijvoorbeeld de KNO-arts of een logopedist kunnen zijn. Iets wat nu nog niet aanwezig is in de pilot, maar wat de ondervraagden graag zouden terugzien in de richtlijn is een integratie met het geven van een indicatie voor de Voor- en Vroegschoolse Educatie (VVE). De kinderen die twijfelachtig scoren zouden bijvoorbeeld in aanmerking komen voor VVE, aangezien hier een te kort aan taalstimulatie aan de grondslag van hun score zou kunnen liggen. Mocht dit inderdaad geïntegreerd worden met de richtlijn, dan is het van belang om ook peuterspeelzalen en kinderdagverblijven mee te nemen in de verspreiding van de richtlijn. Zij zijn immers degene die de VVE uitvoeren.
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Voor de implementatie van richtlijnen in het algemeen is het zeer belangrijk dat er duidelijk over gecommuniceerd wordt. Dit werd door alle geïnterviewden aangedragen op verschillende punten. Voor de planning van de scholing voor een richtlijn is het bijvoorbeeld belangrijk dat organisaties ruim van te voren weten wanneer zij een richtlijn kunnen verwachten. Ook zou het prettig zijn als zo vroeg mogelijk duidelijk wordt wat de grote verschillen zullen zijn en welke materialen een organisatie bijvoorbeeld moet aanschaffen. Ook het leveren van kant-en-klare scholing zou een goede manier zijn om de implementatie van richtlijnen te ondersteunen. Een veelgenoemde optie is het beschikbaar stellen van e-learning modules. Een suggestie voor een nieuw onderdeel voor de richtlijn was een managementdeel, wat specifiek geënt is op het management. Hierin staan voor hen de belangrijkste feiten, dus wat moet er geregeld worden en wat voor effecten heeft dit. Naast de communicatie met de jeugdgezondheidszorg organisaties, zal er ook een goede communicatie richting de mensen betrokken bij het vervolgtraject nodig zijn. Daarnaast is ook communicatie richting de ouders belangrijk, aangezien deze ook te maken krijgen met een nieuwe manier van werken. Het nut van deze manier van werken moet ook bij de ouders duidelijk zijn, anders zou er weerstand kunnen ontstaan bij bijvoorbeeld de huisbezoeken. Aanbevelingen - De aanbevelingen voor deze richtlijn zijn dan ook om goed te kijken naar het verwijzingsproces en eventuele andere mogelijkheden, zoals een KNO-arts, op te nemen. Daarnaast zal er te allen tijde goed en duidelijk gecommuniceerd moeten worden naar de jeugdgezondheidszorg organisaties, de ouders en andere mensen die in aanraking komen met de gevolgen van de nieuwe richtlijn. Verder moet er goed gekeken worden naar de uitkomsten van de pilot. Als hieruit blijkt dat er opvallend meer huisbezoeken afgelegd moeten worden, dan zal hier een probleem kunnen ontstaan. Voor implementatie van deze richtlijn zou dan ook goed met gemeentes moeten worden gepraat. Als laatste wordt er gevraagd om een integratie van de verwijzing naar VVE met dit model. Dit is iets dat door bijna alle ondervraagden werd aangedragen. In het algemeen geldt dat de richtlijnen zoals ze nu geleverd worden, met een samenvatting en een flow-chart erbij, als goed worden ervaren. Wel is er vraag naar een management sectie, waar de informatie bij elkaar staat die van belang is voor het management bij het implementeren van de richtlijn. Daarnaast wordt duidelijke communicatie zeer op prijs gesteld. Dit houdt ook in dat er ruim van te voren gecommuniceerd wordt over de richtlijnen die er aan komen en wat voor scholing en materialen er nodig zijn. De scholing kan vergemakkelijkt worden als er al bijvoorbeeld bestaande presentaties worden geleverd. Als laatste zouden de organisaties graag ook ondersteuning zien in de continuering van de richtlijnen door bijvoorbeeld het opzetten van opfriscursussen.
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Contents Acknowledgements .......................................................................................................................... 3 Abstract ............................................................................................................................................. 4 Summary in Dutch ............................................................................................................................ 5 Contents ............................................................................................................................................ 7 Abbreviations .................................................................................................................................... 9 1
Introduction ........................................................................................................................... 10
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Conceptual and Theoretical Framework ............................................................................... 12 2.1 Language disorders ............................................................................................................... 12 2.2 Pilot ....................................................................................................................................... 12 2.3 Guidelines and standards ..................................................................................................... 13 2.3 Implementation of guidelines ............................................................................................... 14 2.4 Health Technology Assessment ............................................................................................ 17 2.5 Sub questions ........................................................................................................................ 17
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Methodology ......................................................................................................................... 18 3.1 Literature Research ........................................................................................................... 18 3.2 Interviews.......................................................................................................................... 18 3.3 Interviewees...................................................................................................................... 19 3.4 Analysis ............................................................................................................................. 19
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Results ................................................................................................................................... 21 4.1
Interviews .......................................................................................................................... 21
4.2 Most important preconditions for implementation for the innovation ............................... 21 4.2.1 Based on evidence ......................................................................................................... 21 4.2.2 Manageability in practice............................................................................................... 22 4.2.3 Differences with the old working method ..................................................................... 22 4.2.4 Home visits ..................................................................................................................... 23 4.2.5 Design of the Guideline.................................................................................................. 23 4.3 Most important preconditions for implementation for the user ......................................... 24 4.3.1 Continuation .................................................................................................................. 24 4.4 Most important preconditions for implementation for the organisation ............................ 25 4.4.1 Communication .............................................................................................................. 25 4.4.2 Schooling and planning .................................................................................................. 25 4.4.3 Own projects .................................................................................................................. 26 4.5 Most important preconditions for implementation for the socio-economic environment . 27 4.5.1 Parents ........................................................................................................................... 27 4.5.2 Preschool education ...................................................................................................... 28
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4.5.3 Municipalities ................................................................................................................. 28 5
Discussion .............................................................................................................................. 30 5.1 Guidelines ......................................................................................................................... 30 5.2 Subject popularity ................................................................................................................. 30 5.3 Referral ................................................................................................................................. 31 5.4 Schooling ............................................................................................................................... 31 5.5 Differences in the two different age groups ......................................................................... 32 5.6 Funding home visits .............................................................................................................. 32 5.7 Other stakeholders ............................................................................................................... 32 5.8 Limitations ............................................................................................................................ 33
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Conclusion ............................................................................................................................. 34
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Recommendations................................................................................................................. 35 7.1 Recommendations for the guideline uniform language screening ...................................... 35 7.2 Recommendations for guidelines in general ........................................................................ 35
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Reflection............................................................................................................................... 36 Conceptual Model....................................................................................................................... 36 Health Technology Assessment .................................................................................................. 36
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List of References .................................................................................................................. 38
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Appendices ............................................................................................................................ 40
Appendix I : Model of the Pilot ................................................................................................... 40 Appendix II: Concept e-mail for interviewees ............................................................................ 42 Appendix III: Interview Outline (Dutch) ...................................................................................... 43 Appendix IV: Time Table ............................................................................................................. 44
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Abbreviations
English
Dutch
NCJ
Dutch Centre for Youth Health
Nederlands Centrum Jeugdgezondheid
NSDSK
Dutch Centre for the Deaf and Hearing Impaired Child
Nederlands Centrum voor het Dove en Slechthorende Kind
VTO-LSI/VTO
Early On Detection Language Screening Vroegtijdige Onderkenning Taalscreening Instrument Instrument
VVE
Preschool Education
Voor- en Vroegschoolse Educatie
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1 Introduction In the Netherlands 5-10% of the children suffer from a language disorder (de Koning, et al., 2004). A child is diagnosed with a language disorder when the accumulation of the language is lagged compared to that of peers. Language disorder can be further specified into two categories. Specific language disorder does not have an underlying cause and the language disorder is the main problem. Secondary language disorder, however, can be caused by for instance autism (Bishop, 1992). Currently no guideline is present for the detection of language disorders in children of the age of two years old. (van Agt, 2011) Good detection however is important, because children with a language disorder who do not receive treatment are likely to develop emotional, social or learning problems (van Daal, 2010). By not having a uniform and tested way of detecting children with language disorders, children can be misdiagnosed, positive as well as negative, more easily. In 2011 the Dutch Centre for Youth Health (NCJ), together with the Dutch Foundation for Deaf and Hearing Impaired Children (NSDSK), started a pilot with an improved and uniform screening for language disorders. This pilot takes place in five youth healthcare institutions and will run until mid2012. When the pilot has been successful, with more accurate diagnosis, the pilot will be turned into a guideline for the detection of language disorders. The method used in the pilot is the standard Van Wiechen monitoring system, hereafter the Van Wiechen, extended with items from the Early On Detection Language Screening Instrument (VTO-LSI) (See appendix I for more information). This method has already proven successful in detecting children with a language disorder at the age of two (de Koning, et al., 2004) (van Agt, 2011). Next to this method another difference is the use of a set cut-off point for either redirecting children or providing them with care. This last option is also not a general way of working and is meant for children who have a doubtful score regarding the language items in the test and need further diagnosis. Every guideline encounters its own barriers when implemented and has its own preconditions to beforehand. A guideline is a documented way of how medical professionals should work. This research will identify the preconditions regarding the improved guideline for the detection of children with a language disorder as the guideline is not implemented yet. This will be done on middle management level, as these are the ones whose support is important for the implementation of guidelines, as they can provide resources to make this able (Conroy & Shannon, 1995). Different phases need to be passed to reach a complete implementation. These four phases are known as dissemination, adoption, implementation and continuation. All of these phases have their own pitfalls regarding the environment, organisation, the user and the intervention (Fleuren & de Jong, 2006) (Fleuren M. A., de Jong, Filedt Kok-Weimar, & van Leerdam, 2002).
Research aim The aim of this research is to identify the preconditions which are mentioned as important by managers and staff physicians towards the implementation of the improved guideline regarding the identification of children with a language disorder in the youth healthcare centres. Furthermore the aim is to connect the findings with the general implementation of clinical guidelines in the youth healthcare.
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Research question Which preconditions, according to medical professionals and managers, need to be taken into account in order to successfully implement the improved clinical guideline regarding the identification of children with a language disorder and which implications do these preconditions have regarding implementing guidelines in youth healthcare in general?
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2 Conceptual and Theoretical Framework This chapter will provide more in-depth information regarding the main concepts of this study which are mentioned in the introduction as well as more information regarding the problem statement. Next to this, also the theory behind the set-up of the research is provided and the sub questions are formulated.
2.1 Language disorders A child is diagnosed with a language disorder when a slower or different learning process of the language is present in regards to his peers. This is no guarantee that there is actually a disorder as children differ in their development. On the other hand 90-95% of the children pass the items at two years of age. Approximately 5-10% of the toddlers has a language disorder (de Koning, et al., 2004). (van Agt, 2011). Language disorders can have different causes. Also the development of a language disorder differs from child to child (van Daal, 2010). When a child has a language disorder, he or she has no hearing problems but does not comprehend what is said or can make him- or herself clear. Different factors can lay at the cause of this disorder. Primary language disorders, also known as specific language disorder, cannot be lead back to mental or physical problems, hearing loss or emotional disorders. The only and therefore primary handicap is the language disorder (Bishop, 1992). Two to six per cent of the children has a specific language disorder (van Agt, 2011). In secondary language disorders different impairments or disorders are behind the language disorder. This can be on emotional, psychological, cognitive or neurological level (Law, Garrett, & Nye, 2004). Language disorders have a great impact on performance in school and social encounters. Through identifying children with this disorder at an early age better measures can be taken to provide support for them. This is important as language is something we accumulate over time and build up from experience. The later children are provided with care, the less the learning of language takes place. Children with a language disorder therefore have a higher risk regarding emotional, social and behavioural issues. When nothing is done regarding the language disorder the chance increases that someone will not be able to participate fully in society (van Daal, 2010). When children can be identified accurately, more children can be helped and less problems will occur, as for both primary and secondary language disorders good therapies are available (van Agt, 2011).
2.2 Pilot Different actors in the field feel there is a need for an improved guideline for language disorder detection in children of two years of age. Currently different institutions use different tests next to the Van Wiechen to detect language disorders (Spaai, Wenners-Lo-A-Njoe, Hameeteman-Hoekstra, Van der Stege, & van Agt, 2008). The NCJ (Dutch Centre for Youth Health) has started, together with the NSDSK (Dutch Foundation for the Deaf and Hearing Impaired Children), a pilot regarding the use of a uniform test for the identification of children with a language disorder in the latter half of 2011. This pilot consists of five institutions responsible for the identification where four of these institutions used the Van Wiechen monitoring system extended with two items from the VTO Language Screening Instrument (VTO-LSI).
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The other institution already used the VTO-LSI next to the Van Wiechen monitoring system. This institution started two years ago, and joined the pilot. This last institution has already proven successful in their method of using the VTO-LSI as well as the van Wiechen monitoring system. More children with a language disorder were correctly identified at 24 months of age (van Schie, Rip, van Denderen , Wiefferink , & Uilenburg, 2011). This institution has already implemented their method throughout their whole institution. There are differences between this method and the method used in the pilot of NCJ, which may cause different outcomes in regards to the evaluation of the pilot. The difference between the current working method of youth health centres and the pilot lies in the protocol which is executed and the follow-up. In the current working method only the Van Wiechen monitoring system is used. In the pilot three questions of the VTO-LSI are included, together called the integrated model. In this integrated model questions 41 and 42 have been extended with the VTO-approach. In the integrated model the parent is asked whether and in which situations the child can speak two or more words. If this is not the case the additional questions of the VTO-LSI are asked. Through screening with the VTO-LSI incorporated into the normal screening less special education is needed at eight years old. Compared to the screening with only the Van Wiechen a reduction of 33% in attendance to special education was measured. Next to this, also the costs were reduced when the VTO-LSI was held once at two years of age (van Agt, 2011). When the Van Wiechen monitoring system is used as a funnel towards the VTO, as is done in the pilot, more children are identified with a language disorder (de Koning, et al., 2004). More than 50% of the children with a language disorder are detected, which is a good score, as language disorders are hard to trace (Spaai, Wenners-Lo-A-Njoe, Hameeteman-Hoekstra, Van der Stege, & van Agt, 2008). Next to the method which is different, the pilot also uses a set cut-off point for either referring children or providing them with care. The maximum a child can score is a four, which indicates that everything is fine. Referring is done when a child scores zero or one on the test. The child and parents are redirected to an audiology centre for further research. When a child scores two or three on the test care at home is provided by a schooled nurse or speech therapist as this score does not give a definite diagnose. This providing of care is not a general way of working and is meant for children who might have a language disorder. Through giving guidance at home it becomes more apparent if there is a language disorder or if the impaired speech is caused by, for instance, not enough stimulus from the environment. The children who receive care have two house visits by a nurse to instruct the parents about how they should help their child and a check-up to see if the parents followed the advice. After six months the children who receive care are tested to establish whether the language disorder is truly present or not.
2.3 Guidelines and standards A medical or clinical guideline in the Dutch youth healthcare is “a document with recommendations and operation and measurement instructions to support the decision making of healthcare professionals, this is founded on results of scientific research and the discussion and opinions based
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upon this, with a main focus on effective and efficient action.” 1 (RIVM / Centrum Jeugdgezondheidszorg, 2007)1. A clinical guideline is not something that functions as a law about how a procedure needs to be executed. However, they are a good guide towards diagnosis and what good care should be. Most guidelines are based on evidence from scientific research or in practice. In short a guideline will give answer to the what, when and why questions when diagnosing and or treating a patient. It is a document which can give aid in coming to a diagnosis, making decisions or setting up plans. Since 1998 special guidelines for the Dutch Youth Healthcare have been implemented (Fleuren M. A., 2010). The difference with the clinical guidelines for regular heath care is that these guidelines are more focused on signalling problems, education and advising and redirecting the children and parents. Guidelines are mostly evidence and/or practice based. In the youth healthcare in the Netherlands all guidelines have a pilot project to measure the outcomes of the new guideline. This has as an advantage that the guideline is tested in practice and can be altered through those experiences. The disadvantage is that it costs more time, as this pilot has to be finished before further negotiation towards the guideline is possible (de Wit, 2011). Next to the guidelines in the Dutch health care system, also care standards are present. These standards are based on laws and guidelines, and represent the idea of how good care should be given shape. The standards also take the experience of the patient into consideration, whereas the guidelines mainly focus on the medical aspect of a diagnosis (Longalliantie, 2009). In the youth healthcare system the terms standard and guideline have become interchangeable, where the youth healthcare standards are actually more similar to guidelines (RIVM / Centrum Jeugdgezondheidszorg, 2007). Guidelines have been experienced as assuring the quality and uniformity of an assessment or treatment. Guidelines can also be made for advice, guidance and prevention. Especially in the youth health care were young children are assessed or treated by many different medical experts uniformity is necessary (Fleuren & de Jong, 2006). Next to this, another benefit that comes with standardising measurements these can be used in statistical analysis of for instance the population of a city. Nevertheless, not all medical professionals are eager to use medical guidelines as some of them see them as a limitation to their profession (Cabana, et al., 1999). Therefore this research can provide some insight in what should be taken into account when implementing a guideline and in specific the guideline based on the pilot described above.
2.3 Implementation of guidelines Implementation is a methodical and systematic introduction of innovations or improvements which are evidence or practice based, and has as a main aim to structurally change the way of working (Fleuren M. A., de Jong, Filedt Kok-Weimar, & van Leerdam, 2002). According to Conroy and Shannon (1995) implementation of clinical guidelines and standards follows a path, an innovation process, with different phases which all have their own obstacles. Next to this, each guideline encounters its own barriers and pitfalls (Conroy & Shannon, 1995).
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Een richtlijn is een document met aanbevelingen, adviezen en handelingsinstructies ter ondersteuning van de besluitvorming van professionals in de zorg, berustend op de resultaten van wetenschappelijk onderzoek en met daarop gebaseerde discussie en aansluitende meningsvorming, gericht op het expliciteren van doeltreffend en doelmatig handelen.
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The first of the four phases of the innovation process is dissemination, sending out the message that a new guideline is present. The second phase, adoption, consists out of distributing the new guideline. This calls for making people aware of the new guideline and also making the best effort that the medical expert is willing to work with the new guideline. The third phase, which is called implementation, starts with the expert trying out the new guideline in the field. In this phase it becomes apparent whether a guideline works in practice. The last phase, continuing, is Figure 1: Model of implementation by Fleuren et al. (2004) turning the guideline into automatism (Fleuren & de Jong, 2006). Throughout the phases different determinants have influence on the implementation of the guideline. These determinants have been divided into five categories which represent the characteristics of the institution that has to implement the new innovation as well as the strategy of the implementation. These categories are the strategy, the socio-economic environment, organisation, the person (user) and the intervention (Fleuren, Wiefferink, & Paulussen, 2004). Within these five categories, preconditions play an important part regarding the characteristics of the categories. These can be for instance the amount of money which is available or how the time management of an organisation is given shape. If an implementation wants to be successful, it is necessary to gain insight regarding these categories in each of the phases (Fleuren & de Jong, 2006). All of the characteristics of the determinants need to be investigated before full implementation can take place (Fleuren M. A., 2010).
Characteristics of the Innovation The characteristics of the innovation have been given shape in the pilot. How these characteristics are experienced in the field is the subject of three other researches currently being executed at the NCJ. The big outlines of the innovation are described above under the heading ‘pilot ’ and can also be found in appendix I. These characteristics of the innovation, the pilot as described, will be the starting point for this research. Although these characteristics are set, the research could show things regarding the intervention which have not been thought of. For instance relevance for implementing the innovation can be perceived differently and can be demotivating for some (Fleuren M. A., 2010).
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Characteristics of the User When a new guideline needs to be implemented, the opinions of managers and medical professionals who have to work with the guideline need to be taken into account (de Wit, 2011). To get consensus regarding a guideline it is important to involve the management, consisting out of managers and staff physicians. Through doing so the implementation can be fitted more towards the demands of the different areas where the implementation needs to take place as the management has an overview and the power to decide (Conroy & Shannon, 1995). In this research the managers and staff physicians are the ones who are interviewed as they have the most influence regarding the implementation of a guideline organisation wide. Characteristics of the Organisation The current research focusses on youth health clinics, which are mostly part of the municipal health organisations. This has an effect that not just one doctor or nurse needs to be convinced of the new guideline, but it should fit the entire organisation. Next to this, the size of the organisation as well as the design of the organisation could be of importance, although literature does not give a clear view and even disagrees with one another regarding this subject (Fleuren, Wiefferink, & Paulussen, 2004). Research does show that every organisation uses their own way to implement new guidelines (Fleuren & de Jong, 2006). This implies that different organisations could have different preconditions regarding the implementation of a new guideline. This could for instance be caused by their own way of handling language disorders in this particular research.
Characteristics of the Socio-Economic Environment Government can have influence through for example laws and grants which can increase or decrease the animosity to engage in the implementation and use of a guideline. Other socio-economic influence can be for instance the peer pressure between different organisations to perform in a certain way. Also pressure from for instance patients, whether they are gathered in an organisation or not, can cause more willingness to implement a guideline. In short, the socio-economic environment is everything and everyone from outside the organisation which can influence the willingness to implement a guideline (Fleuren M. A., 2010).
Characteristics of the Innovation Strategy Also the way the implementation is given shape needs to be taken into account. Implementation can be handled in a youth healthcare organisation top-down, from managers to staff, as well as bottomup, from staff to management, or a combination of these two. This last option, the combination of both, creates the biggest support towards a new implementation as everyone is involved. (Fleuren M. A., 2010) Before implementing a guideline it is necessary to assess the preconditions that have to be met to implement the guideline as successful as possible. In this research the focus will be on the characteristics that are given by the middle management and staff physicians, which are required in the implementation strategy to optimally implement the guideline.
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2.4 Health Technology Assessment This research is in origin a health technology assessment, but with the more future-minded content of a constructive technology assessment. Health technology assessment is a policy analysis which focuses on the medical, social, financial and ethical implications of the distribution and use of a technology in the healthcare sector (McGregor & Brophy, 2005). This technology can be defined as any intervention which can be used to prevent, diagnose or cure a disease, or provide long term care or rehabilitation. In the case of health technology assessment the focus lies mainly on the consequences, but less on what could be changed to ensure an easier implementation (Schot & Rip, 1997). This type of assessment, where the focus lies on how something can be implemented in a more easy way, is called constructive technology assessment. It focuses on early interaction with the people who will be influenced by the new technology, in this research being the guideline and the managers in the different organisations. The difference between the health technology assessment and the constructive technology assessment is that the guideline is not seen as a given fact, but also as something that can be changed throughout the process (Schot & Rip, 1997). The combination of the analysis of the pilot and the assessment of the guideline in the other organisations will lead, hopefully, to an easier implementation. The pilot will show more about the implications regarding the care giving, the outcomes and practical problems, which can be analysed thoroughly. The identified implications by other organisations regarding the guideline need to be made clear. This leads to ideas about what could be changed or provided per organisation or in the guideline in order to be able to implement the guideline successfully. This research is therefore part of the health technology assessment, as it might influence the final outcome of the guideline.
2.5 Sub questions
Are there any alterations regarding the guideline as it is right now according to managers and staff physicians, which would make the guideline easier to implement and which are these? Are there preconditions, according to managers and staff physicians, regarding the people that need to work with the guideline which need to be met for implementation of the guideline for the detection of children with a language disorder, and which are these? Are there preconditions, according to the managers and staff physicians, regarding the organisation that need to be met for implementation of the guideline for the detection of children with a language disorder, and which are these? Are there preconditions, according to managers and staff physicians, regarding the sociopolitical environment that need to be met for implementation of the guideline for the detection of children with a language disorder, and which are these? Can any of the preconditions be led back to general recommendations regarding the implementation of new guidelines in the youth healthcare?
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3 Methodology This research is a qualitative research, as the ideas and opinions behind implementation were researched and this can be done more in depth with qualitative research (Denzin & Lincoln, 2005). The research was build up out of three phases. The first phase consisted out of searching and reading literature to create a background for the research and give more in-depth information regarding the different concepts. The second phase existed out of gathering data through arranging, conducting and transcribing interviews. The last phase was the analysis of the data and discussing the results of this data, as well as a reflection on this research.
3.1 Literature Research Before starting the data collection of this research a literature research was done regarding the concepts which are mentioned in the introduction. The literature was found with the help of search engines, being PubMed, Captise and Google Scholar. In these search engines different search words were used in English as well as in Dutch. These were among other words Clinical Guideline, Implementation, Youth Healthcare, Language Impairment or Disorder, Constructive Technology Assessment, Health Technology Assessment. Synonyms of these words have also been searched as well as the combination of some of these terms. Next to the use of search engines, also the websites of the NCJ, TNO and RIVM were studied to gain more knowledge regarding guidelines and their implementation in the youth healthcare. These three institutions can be seen as knowledge institutes regarding the subject of implementing guidelines and youth healthcare. The NCJ also provided information regarding the pilot they have set up. Finally, literature regarding this research present at the NCJ was used. Literature was selected on title. After this the abstracts were read and based on this it was decided if the article would contribute to the research. Next to this, also the reference lists of the articles found was used to find more articles regarding the subject.
3.2 Interviews Through the NCJ different managers and staff physicians were contacted with the question if they wanted to participate in the research through an interview. This research focused on managers and staff physicians as they have an impact on whether a guideline is implemented and how it is implemented (de Wit, 2011). Next to this, the other actors involved in the guideline were contacted in the pilot and in the research of two fellow students. The participation in the research for an interviewee consisted out of reading a concept of the adjusted part of the guideline and an interview held at the office of the different organisations. The concept of the adjusted part of the guideline was sent in an e-mail which also contained some more information regarding the research and the purpose of the research. The e-mail can be found in appendix II. Through providing the interviewees with some background information and also the guideline, they are already informed regarding the subject and could have thought about it. This has as a consequence that their answers might have been influenced by the amount of overthinking the situation and maybe thinking of subjects that would not have been thought of in first notice. However it was mainly meant as a timesaver during the interview. 18
The interviews were based on a pre-set structure, a so-called semi structured interview (DiCiccoBloom & Crabtree, 2006). This set-up can be found in appendix III. The questions were set up broad, but the probing questions are based on the theoretical and conceptual framework. The interviewee was asked to give their consent to tape the interview. This taping is done to be able to listen back the interview and transcribe it. This has as an advantage that more information can be taken out of the interview and also takes away the uncertainty of what was said. Next to this, immediately after the interview the most important subjects of the interview were summarised, in order to have a clear view of what the interview was about. Next to this, it also gives a good impression of what was focused on by the interviewer. The tape of the interview was literally transcribed and was done with the help of Express Scribe. This transcription added extra information to the summary and this final summary was sent back to the interviewee to make sure that all information is correct. The corrections and extra information the interviewees gave in regards to the summaries were also taken into account in the results section.
3.3 Interviewees In total 21 possible interviewees were contacted with the e-mail which can be found in appendix II. The possible interviewees were working at different organisations throughout the Netherlands, which has as an advantage that a good representation of the opinion throughout the Netherlands can be given. The interviewees all needed to be people who are involved in the process of implementing guidelines in their own organisations. The interviewees were gathered through contacts of the NCJ and referrals received on the original mail. The goal was to interview at least ten people, this goals was reached as eleven people were interviewed. The aim is to at least interview ten people was set to have a good probability to reach saturation. According to Denzin and Lincoln (2005) saturation is collecting data until no new information can be found. For this research and the limited amount of time the goal was to reach saturation in the main categories, this way the sub questions and research question can be answered with certainty.
3.4 Analysis The transcriptions were labelled and coded. After this the information was placed in categories with the use of the conceptual frame work, and the use of the four determinants that were given. These were the preconditions for the intervention, the user, the organisation and the socio-economic environment. The fifth category of coding was focused on items that were in general applicable for the implementation of guidelines. The coding was done shortly after transcribing the interviews. After some time the interviews were read again back to back to further establish the coding and the overall categories. This was done four times in total to give a good overview of the data. Through the coding the categories and the preconditions that are present in the field can be described. As Denzin and Lincoln (2005) state coding is a way of studying the data and providing a foundation for further blending the different interviews. The coding provided the base for the results, discussion, conclusion and advice which is given at the end of this research. The different codes were divided to the categories earlier described by the researcher. Some of the codes were
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applicable to more than one of the categories and therefore placed in both. Next to the five categories, codes have been created for quotes that do not fit any of the categories, but were relevant for the research. These results have been compared to the outcomes of the literature and discussed, which led to the conclusion. This conclusion is an advice on the preconditions which are important to take into account regarding the implementation of the new guideline.
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4 Results In this chapter the data from the research will be presented by answering the different sub questions. Before this, a description of the interviewees is provided to give an overview of the data resources. The four sub questions regarding the guideline itself, the people, organisation and socioeconomic environment are answered in their own paragraphs. As there were more results than initially thought of, the text regarding the sub questions is divided in paragraphs with headings which all discuss one subject. Furthermore at the end of the paragraph a summation is given regarding which results are applicable only to this research and which are applicable for implementation of guidelines in general.
4.1 Interviews In total nine interviews were held with eleven interviewees. Of these eleven, seven were staff physicians and two were managers. Furthermore also two policy advisors were interviewed, these interviewees did not have extremely different answers and knew as much as the subject as the other interviewees. Therefore these interviews are also used in the results. The intention to have interviews throughout the Netherlands did not completely success. The organisations of the interviewees were mainly in regions on the edges of the Netherlands. Only one organisation in the centre of the Netherlands could be interviewed. The organisations in the bigger cities, e.g. Amsterdam or Utrecht, were either involved in the pilot, or not able to participate at the moment. The size of the organisations of the interviewees differed from approximately 1200 births per year to roughly 7000 births per year. These size differences could also influences the different preconditions the organisations have for the implementation of a guideline. Organisations in youth healthcare can be either responsible for 0-4 or 0-19 years of age. Both types of organisations were interviewed, also to view if there were differences between these types of organisations in regards to the implementation of guidelines. Unfortunately, one interview with two interviewees was not recorded due to a technical difficulty and could therefore not be transcribed. This problem however was known during the interview, and handwritten notes were made as much as possible. Of these interviews only a summary is available as data.
4.2 Most important preconditions for implementation for the innovation This sub chapter presents the preconditions regarding the innovation.
4.2.1 Based on evidence One of the preconditions which was mentioned and emphasized by most of the interviewees in regard to the guideline is that it needs to have proof. Guidelines can be based on different sources such as expert opinion or scientific research. The guidelines which are provided based on either experience in practice or through scientific research are experienced as easier acceptable than for instance an expert opinion according to interviewees. This has to do with, among other factors, the how the evidence is gathered in these different ways of developing a guideline. As one interviewee 21
stated: “[…] If something already had a long run and problems already have been taken out and it has been used a little in practice […] than I imagine professionals will be more willingly to use it (guideline) than when you provided them with an excellent theoretical based academic piece […]”.2 This also has to do with the translation of a guideline into practice The effect of proof for a guideline can be found in the willingness of executive health personnel to execute the guideline. It seems to be important for medical professionals, as well as for the parents of the child to be clear on why certain things are done in this way. If this is clear the guideline will be used more often and probably more effectively as the surroundings also agree on the way of working.
4.2.2 Manageability in practice The second important precondition which is mentioned by most of the interviewees is the manageability in practice of the guideline. This has to do with for instance the amount of time the new intervention takes in regard to the old guideline. Within a visit of a child, twenty minutes are available to do the entire check-up, which does not only include the language items, but also a physical check-up a movement items. Al these items need to be checked in the contact moment of two years, which is the age this guideline focuses on. When a guideline is practice based, the feeling of the interviewees is that it would be more applicable than when an expert wrote it based on theory. The manageability of the guidelines also depends on whether everyone can work with it, regardless from their background. Next to the people who need to work with the new guideline, the guideline should also be applicable in almost every situation. This indicates that the guideline should also be given form in such a way that for instance non-Dutch speaking parents also can be assisted through this guideline. In short, the guideline should be able to fit as many scenarios and people as possible.
4.2.3 Differences with the old working method A third factor which is mentioned as an influence on the implementation of guideline is the difference between the current working method and the method described in the guideline. This specific guideline regarding the detection of language disorders does not have a major impact on the current way of working, as many of the organisations are actually looking for some more in-depth detection for language and speech-problems. The current way of working, using on only the Van Wiechen was described as “absolutely insufficient3” by an interviewee and further explained by the next quotation: “Many of the items for two and half years of age regarding language can already be executed by all children of two years of age”.4 The extra questions that are involved in the method of working of the pilot do not take much more time and it seems to the interviewees as if this way of working can be easily implemented in the standard way of working.
2
[…] Als iets al een langduriger traject heeft gelopen en een aantal kinderziektes zijn eruit gehaald en het is al een beetje door de praktijk omarmd […] dan kan ik me voorstellen dat professionals daar eerder mee aan de slag gaan dan wanneer het een theoretisch goed onderbouwd academisch stuk is […] 3 Absoluut onvoldoende. 4 Het huidige Van Wiechen bij twee jaar vind ik absoluut onvoldoende, […] want veel van de items van tweeënhalf jaar, wat betreft taal, die kunnen kinderen allemaal al bij twee jaar.
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4.2.4 Home visits There are however some concerns in regards to the home visits. Not all of the organisations are convinced that this will add something to the treatment of the children, as they already have their own ways of looking at the home situation and educating the parents. One organisation for instance uses the information of the visit to the child health clinic, a meeting with the parents and the information from child day care or kindergarten to set out the further path for the child regarding the language and speech development. For this organisation the information from the day care or kindergarten is very important, and this was lacking in the current guideline. If the home visits would be something that could be implemented really depended on how much house visits extra the new guideline caused. Organisations already preform some home visits on different themes, and these home visits for language could fall under these. These home visits are in the basic care package and should therefore not cause problems in regards to funding. However many of the municipalities are cutting budgets, and in some cases cuts are made in regards to the home visits. This can lead to an obstacle if the guideline becomes the new way of working.
4.2.5 Design of the Guideline The form of the guideline as it is nowadays is commented on as being good. The information regarding the guideline often consist out of the guideline, which is a thick document with all the medical and practical information, a smaller summary and a flow chart which contains the most important information and actions that need to be performed. The interviewees saw this as giving a good overview of what needed to be done. Moreover, they considered the document to be convenient as not everybody needed to read the whole document, as they were often thick and not all of the information was necessary to understand what you needed to do in practice. One interviewee explained it as: “The guidelines keep getting thicker. So almost no-one reads the whole guideline anymore, I don’t believe you can ask that from an employee. […] Most of the nurses aren’t interested in that (scientific proof), they just want to know in short what do I have to do, why do I have to do that and why is it important.”5. Next to this, other interviewees also mention the lack of time as a reason to only read the summary. A part that was missed by some of the interviewees was a management part; “I would like it if the guideline already had some tools for implementation […] You could think about adding a part, a management section [..], that also the organisation knows this are the consequences of the guideline”. 6 . By adding this particular section the management can immediately see which implications the new guideline has for their organisation on management level, without needing to understand all of the medical information. Also the importance of the guideline needs to be explained in this document. This could also stimulate management to be more positive and well informed in case of new guidelines and their implementation. As the management is pointed out by
5
Die richtlijnen worden steeds dikker. Dus er is bijna niemand meer die de hele richtlijn leest, ik vind ook niet dat je dat kan verwachten van een medewerker. […]De meeste verpleegkundige die zijn er (wetenschappelijke onderbouwing) echt niet in geïnteresseerd, die willen gewoon kort weten wat moet ik doen, waarom en waarom is het belangrijk. 6 Wat ik ook fijn vindt is als er bij de richtlijn toch ook al wat handvatten staan voor de implementatie. […] Je zou kunnen denken aan een stuk, een vaste paragraaf voor het management […], dat de organisatie ook weet van oh dit zijn de consequenties van de richtlijn.
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most of the interviewees as having the final say in decisions regarding implementation, this would be a good tool to make sure the management is well informed before making their decision. Interviewees also mentioned that it would be positive if some of the guidelines come with a schooling programme already attached, for instance a standard presentation that can be adapted to the organisation. Through doing so, the implementation of the guideline would take less time from the staff responsible for the schooling, which again makes for an easier implementation. More information regarding the opinion and advices of interviewees regarding schooling can be read later on in the chapter regarding the organisation.
Preconditions for the Guideline
Guideline
General
• Evidence or Practice Based • Manageable in Practice • Difference with Original Protocol • Management Section within Guideline • Continuation
Guideline
Specific
• Home Visits need Proof
4.3 Most important preconditions for implementation for the user In this sub chapter the preconditions regarding the person are presented. The only real result which came forward in regard to the person who needs to work with the guideline was the difficulty they had with continuation of the guideline.
4.3.1 Continuation One of the organisations already used a part of the protocol as described in this guideline and was involved in the design of the method used in the pilot. The big benefit for this organisation could be that the guideline would provide some more pressure to work according to the protocol. The protocol was implemented in this organisation approximately ten years ago. In the data of digital dossier it can be seen that the protocol is not always followed as more children with a language disability are noticed, than the method of working is registered. This new way of working probably slipped away a bit during the years according to the interviewee. This is also something to take into account for the continuation of the guideline when implemented in other organisations. This is also something that is pointed out by other interviewees, that the dissemination and adaptation a guideline can be done fairly easily, but the continuation of the working method is often the most difficult. Especially when the new way of working is quite different from the original 24
protocol which the medical professional used. People tend to be set in their ways, and the only way to really prevent people from slipping back in old working ways refreshment courses should also be provided. Support in continuation of the guidelines could perhaps be something which the NCJ could provide. This is something that many of the interviewees missed. By providing refreshment courses or other ways to refresh the memory about a certain subject the guideline is actively maintained. By doing so also the way the subjects are refreshed can be regulated more.
Preconditions for the User
User
General
• Continuation through for instance refreshment courses
4.4 Most important preconditions for implementation for the organisation This sub chapter provides the preconditions mentioned for the organisation. As some of the subjects can be placed in either the chapter regarding the intervention or this particular chapter, the choice is made to deepen out some of the preconditions earlier mentioned.
4.4.1 Communication The first step for implementation seems to be that the organisations need to be provided with enough information in advance in regards to the publication date of the guideline and what the big differences are going to be in regards to the old guideline. By doing so, organisations can already take time out of their schooling schedule to use for this particular subject. Next to this, organisations are also able to provide some feedback if this would be desirable. The announcement should also contain an indication of when the guideline can be expected. The sooner people know when they can expect something, the more they can arrange.
4.4.2 Schooling and planning An important factor to keep in mind for the organisations when providing a new guideline is schooling as this importance was stressed by almost all of the interviewees. The amount of time which can be used for schooling differs between organisations. A new guideline almost always requires schooling to prepare staff for the new way of working. This guideline will require less schooling for the physicians as for the nurses, as some nurses will need to be trained for the house visits. Overall this was not viewed as a large bottleneck, as long as the schooling was not so extensive that extra budget needed to be provided. Most of the schooling plans are made a year in advance and to be able to do this the subjects need to be informed in time. This was something that more than half of the interviewees felt was important and which was also important for the implementation of guidelines. However, there was 25
not one real point when all of the organisations planned this. Most organisations start planning around the summer holiday for the upcoming year. Some interviewees felt that most of the guidelines are not announced before that time according, which can give difficulties in the scheduling. The interviewees who mentioned this point felt like there should be more consideration from the organisations that provided guidelines towards the planning of schooling. If a guideline was made out of the pilot in the course of the next year, it would be possible to implement it in 2014 at the earliest in most of the organisations. However, some of the organisations do plan in open slots for new and unexpected schooling, which could be used for an example this guideline. How the schooling is provided by the organisation which developed the guideline is also an important point. When for instance a standard presentation is available it becomes easier to provide schooling, instead of needing to put together a presentation themselves. Another option could be schooling sessions provided by another organisation. Interviewees also mention for instance a list with possible key speakers who the organisations could invite to start of the schooling. The easier it becomes to provide the schooling, the more willingly organisations will be to provide it. Four of the nine organisations mentioned e-learning as a possible solution to the scheduling problem. The organisations which already dealt with the e-learning about female circumcision were enthusiastic towards this way of providing schooling. The big advantage was that people could do this when they had time and wanted to do it themselves. A deadline was set when you should have done the e-learning, but you could choose your own moment. This could maybe also be a way to provide the schooling for the current guideline. Through providing e-learning and this bigger time span, the new guideline becomes less demanding on the medical professionals as well as the scheduling of the schooling and the people responsible for this. The NCJ themselves are launching their first e-learning modules this year.
4.4.3 Own projects Next to schooling, the programmes which are already running in the different municipalities the organisations are responsible for need to be taken into account. Different organisations had already programmes which were focused on stimulating and educating the parents about how to talk to your child to provide a better language learning environment. Almost all had a programme running which focused on how parents should read to and with their children. This specific kind of programme could still run sideways from the guideline, as overall this does not interfere with the way of working. It can be that for some parents it would be a duplication of what they had learned in the home visits, but as most of the reading programmes are voluntarily followed this should not be a problem. Other programmes were more focused on the screening of the children in kindergarten or preschool. These programmes were often set up to observe the child in its natural environment. The home visits also could do this. Some interviewees however felt that the information from the kindergarten or preschool was so valuable that they would like to keep this method of working in the new guideline. Although own language screening programmes are already running, interviewees saw one guideline as a better option than a cluster of small programmes which were not proven effective. One interviewee mentioned that the current situation could be described as “a patchwork of advice and guidance”7. In some of the organisations every municipality had their own project in regards to the language and speech development of children. This made it difficult for the youth health 7
Het is een lappendeken aan adviezen en verwijzingen
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organisation to keep a clear and complete picture of how a child is developing and which actions need to be or already have been undertaken. A uniform guideline could solve this situation and provide more overview for these organisations.
Preconditions for the Organisation
Organisation
General
• Communication • Providing enough information for schooling • E-learning as a good altnerative for regular schooling • Schooling materials included would be preferable
Organisation
Specific
• Some of the own language screening programmes need to be taken into account
4.5 Most important preconditions for implementation for the socio-economic environment In this chapter the results regarding the socio-economic environment are given. This topic received the most preconditions directly connected to the uniform language signalling guideline.
4.5.1 Parents Parents need to be willing to participate; this is pointed out by several interviewees as being the main concern when hearing about the guideline. This already was experienced as a bottleneck in other guidelines and home visits for example with obesity. Some interviewees mentioned the fact that especially the home visits can be experienced as a violation of their privacy. Parents would be more likely to participate when the method of working has been proven according to the interviewees, as they can see the reasons why when explained. Most the interviewees also point out that the cut-off points as used in this guideline can be experienced as threatening by the environment of the child. One interviewee mentioned: “I think it is good that we get clear guidelines for what is going on and the cut-off points, well, […]. What do they imply and is this not too binding. […] That’s something I question.” 8.In most cases now the physicians give the parents some time to accept the fact that their child might need some special 8
En ik denk dat het goed is dat we duidelijke richtlijnen gaan krijgen voor wat er aan de hand is en dat je afkapwaardes hebt, ja […]. Wat moet dat inhouden en of het niet erg dwingend is. […] Daar heb ik wel mijn vraagtekens bij.
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attention, when this is needed. Parents are often not directly willing to undertake action as they need to get used to the idea. This is often argued with comments like he or she will grow out of it or they know someone that also started talking at a later age. These parents often need some more time and convincing, before giving in. On the other hand, the interviewees also mentioned that by giving the parents time sometimes valuable time was lost. Often an early intervention shows the most results and this could not be performed if parents were given the option to come back for instance three months later. An option suggested by an interviewee to make this introduction of a new working method also more known to the parents, is by publishing an article in a magazine for parents. By making people aware of why referrals or a house visit are necessary before they actually take their child to be tested, the outcomes of the test might be more easy to accept. This could also lead to less hesitation and more opportunity to have early interventions.
4.5.2 Preschool education Something which is mentioned by ten interviewees, but is lacking in the guideline, was the combination with pre-school education (Voor- en vroegschoolse educatie, VVE). As one of the interviews stated: “It would be a real pity if the step of kindergarten or preschool facilities would not be included.”9 VVE focuses on providing a stimulating language environment for children who do not receive this at home, or need to be stimulated more in regards to language and speech development. VVE is provided for children with parents who both do not have an education degree exceeding primary school. Next to this, a low score on the communication part of the Van Wiechen and for instance an analysis of the language environment of the child can also give reason to provide an indication for VVE in some organisations. Not all of the organisations are allowed to give an indication for VVE, but most of them have a say in whether a child should be referred to VVE. This is most often based on the environment analysis of data provided during the consultation, the parents and the kindergarten. Many of the interviewees asked whether it would be possible to build in the indication for VVE. Especially for the children with doubtful scores, 2 or 3 in the pilot could possibly benefit from this preschool education. One remark, which was made by multiple interviewees, was that children normally were referred earlier on, 18-21 months. The moment of two years old could be another moment to select and refer children to the VVE programme.
4.5.3 Municipalities If the pilot shows that more home visits are needed than before, municipalities need to be willing to spend money for this extra care. In many of the municipalities budget cuts are being made in general and also for the public health care. Therefore it could be more difficult to find financing for the home visits if this needed. On the other hand, language is a hot subject according to the interviewees and it could be that therefore it would be easier to find financing at the moment. As the guideline is not yet written and the pilot is still running, it cannot be stated that the guideline could take advantage of this popularity as it is not known when and if it will be published. 9
Wat ik heel jammer zou vinden als die stap van de peuterspeelzaal of van de voorschoolse voorzieningen niet erin zou komen.
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Preconditions for the Socio- Economic Environment
Environment
General
• Municipalities need to be convinced if extra budget is needed
Environment
Specific
• Parents need to be willing to cooperate • Special communication towards the parents could promote this • A referral to VVE should be included
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5 Discussion Some of the answers given by the interviewees did not match each other or provided more questions overall. This chapter describes and gives an analysis of the results presented before in this report. Possible bottleneck which should be kept in mind when further developing the guideline are described.
5.1 Guidelines The definition of a guideline used in this report is that it is a recommendation for a funded and efficient way of working. In the youth healthcare guidelines are often set as the method to work by. Not all of the interviewees gave the same interpretation of the word guideline. Most of them agreed that if this was the new way of working, it should be implemented and done provided that the pilot had good outcomes and improved the detection of language disorders. However, also other voices were heard, where the guideline was interpreted as something more of a direction to work by, not literally the way you should work. As literature states not all professionals are keen on the use of guidelines as they feel it is a hindrance in preforming their work and also a loss of their own professional knowledge (Cabana, et al., 1999). Next to the literature, also some interviewees mentioned their view on guidelines which did not meet the definition given in the conceptual framework. One interviewee stated: “By constantly implementing guidelines you could degrade a professional to a kind of executive if you’re not careful. Problem X, solution Y. […] And that is not something I agree on, I always look at what is the matter with this child and these parents in this context.” 10 Although not every situation is the same, unity is important for registration. This data can give insight in what is currently going on in society and can also provide a picture of the effect of a guideline. Therefore a guideline is also a policy instrument, as it can be provide data which influences the policy. Next to this, a guideline is based on either research or experience in practice and proven effective before implementation. This raises the question why you would not work this way. Overall a guideline is a good starting point for a way of working, but environment and other factors which have influence on the outcome of a guideline should not be forgotten.
5.2 Subject popularity Several interviewees pointed out language as a hot topic. In youth health, as in other sectors, different subjects get attention throughout a period of time. Right now, municipalities have language and speech development of children high on the agenda. As one interviewee stated: “[…] that (language screening) is something with which you can score as municipality”11. This attractiveness of the subject could also be the cause for so many projects within the different organisations. “If a
10
Door alsmaar richtlijnen te implementeren degradeer je zo’n professional als je niet oppast tot een soort uitvoerende. Probleem X, Oplossing Y. […] En daar ben ik absoluut niet voor, ik kijk wat is er met dit kind en deze ouders in deze context van belang. 11 Daar (taalscreening) kun je mee scoren als gemeente.
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speech therapist company comes along and has something to offer than they [municipalities] say yes. The municipality then does not see what is already going on.”12 When the guideline would be developed and implemented, it would be wise to do it as soon as possible. As long as the language is still hot in municipalities and organisations, they will probably be more willing to arrange schooling and a different way of working. This of course, counts for all the guidelines which are developed. As long as they fit current political interests or local interests it will become easier to implement it, than when a subject is completely not on the radar.
5.3 Referral One of the main concerns with the pilot, as it is right now, is the way the referral seems to be directly following the ‘bad news conversation’. This way parents who cannot accept the message right away, can be eased into the thought of their child having a difficulty or impairment. Every organisation uses his own form of this step between the consult and the definite referral. This extra time can also benefit the process of determining what is going on, as every child has a different development (van Agt, 2011). One organisation even planned the contact moments later, as there would be more certainty in regards to the development of a child. On the other hand the set cut-off points give the medical professional more support when delivering the news to the parents. It could be that parents can be convinced sooner if clear cut-off points have been determined. Next to this, children with a language development which is slower than normal have the most benefit from being helped as soon as possible (van Agt, 2011). Therefore the soothing of the parents might not always be the best option for the development of the child. The reaction of the parents to the cut-off points and the way of referring is something that will be evaluated in the pilot. The reactions of the parents as well as the medical professional are of importance in this case.
5.4 Schooling Most of the interviewees mentioned that information regarding new guidelines should be given far in advance. However, all of the organisations have a different point in the year where a new schoolings plan is made. The majority of the organisations have September of the year before as the date before a schooling plan needs to be done. It would be preferable to give some information on when to expect the guideline in the year before the set date for distributing the guideline. This of course is not always possible, as the development of guidelines is not something which is done overnight. In the research or the pilots regarding the guidelines delay could appear which directly influences the publishing of the guideline. This however can be communicated towards the organisations, so they can adjust their schooling plan again. As not all of the organisations have the same planning in when the subject of schooling days need to be known, the main conclusion seems to be that the communication on when a guideline can be expected should be very explicit and far in advance. Changes in the date of distribution also need to be communicated, as some of the interviewees found this lacking currently. This should not
12
Als er dan een logopediebedrijf langskomt die wat in de aanbieding heeft dan zeggen ze ja. En dan realiseert de gemeente niet wat er al ligt.
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take too much time, whereas the satisfaction with the guidelines will increase as pointed out by the interviewees.
5.5 Differences in the two different age groups An organisation for youth health can be responsible for 0-4, 0-19 or 5-19. As this research focuses on a guideline which is used in the contact moment of two years of age, the organisations of 0-4 or 0-19 were contacted. Differences were found between these organisations in regards to their own work methods and view on the guideline. The organisations which were 0-19 (mainly GGD's), often have their own speech therapists which could also see a child when in doubt. These organisations would prefer to have this option embedded in the guideline, whereas the organisations for 0-4 do not have this option. This is something that should be taken into account, next to the fact that organisations have their one or multiple own projects. Although many organisations mention that they are open to cancelling some of the projects to bring more unity in the way of working.
5.6 Funding home visits When nurses would perform the home visits, they are compensated for this through the general budget which is present in the organisations. This would not give problems with the funding, unless the number of home visits increases dramatically. For the speech therapists on the other hand it is a different story. Speech therapy needs to be funded by the insurance company and is not funded through public health care. Therefore using speech therapist could cause a problem with funding, as they need to declare this with the insurance company. The insurance company could state that it will not provide a compensation for the home visit. This provides a discussion point, because if it is easier to let nurses perform the home visits, why would you let speech therapists do so. The pilot will have to show if there is a big difference between the two. If it is the case that speech therapist are preferred above nurses, than the insurance companies should be informed about the guideline and also asked their opinion and to consider compensation for these home visits.
5.7 Other stakeholders One interviewee pointed out that it was important to also inform and contact the other stakeholders involved in this guideline. This is for instance the audiology centre, as they now will receive children who have been referred based on other methods than used before. This could for instance imply more children overall, or with a specific condition. Also speech therapist which work for themselves or commercial companies should be informed about the guideline, as this can also influence their work and their way of screening. A way to get these organisations and their employees involved is to publish articles in their professional journals or for instance provided the association of a certain group of people with the information. By communicating about the guideline as much as possible, it will be probably more accepted and easier to implement.
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5.8 Limitations Overall the data of the eleven interviews provided saturation on most of the topics described in the report. More interviews could have provided some more information in depth, but in general the same opinion was heard in the interviews. Although multiple organisations throughout the Netherlands were contacted, mostly interviews were held with organisations responsible for regions in the north, east and south of the country. Most of these organisations were responsible for more rural areas. This was due to the inability of organisations in the Randstad to cooperate, either because they were already involved in the pilot or because they did not have enough time. All the interviews were held by one interviewer, which can cause biased information. On the other hand, only having one interviewer also ensures the consistency of the interviews and the handling of the data. To ensure as little bias as possible all of the interviews were summarised and sent back to the interviewees. All of the interviewees stated that the summaries were a good representation of what they had said. This way the bias was kept as small as possible. One of the interviewees also expressed she felt pleased to be involved and give her opinion in regards to the guideline. Other interviewees also mentioned it was a good initiative to interview different people in regards to a guideline. It could be that by interviewing people, they automatically became more positive towards the guideline, as they felt they could fit it more to their wishes and needs. The results are provided through use of the conceptual framework which is presented in the equally named chapter. The data however was not as clean cut as the framework seems. Sometimes certain subjects were covering multiple sub questions. To prevent too much repetition in this report, choices were made on which subject belonged to which sub question. Discussion can be possible about this division, but another division would not change the final conclusion and recommendations.
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6 Conclusion Overall, the reactions on the part of the pilot regarding the addition of some questions of the VTOscreening were positive and the overall opinion was that a new or extra intervention regarding speech and language development was needed in addition to the Van Wiechen. As this pilot adds only a few questions to the normal protocol, this should not give any problems regarding the time which is set for a consult for a two year old. The follow-up of the scores however was more of a discussion point. None of the interviewees would automatically refer every child who scores low on these items to an audiology centre immediately. Some organisations preferred to give it some more time in certain cases or to do an environment screening before referring. Also the audiology centre as the only referral option did not meet the current working method of most of the organisation. Other referral options like for instance an ENT specialist should also be an option when for instance there is an indication that something is wrong with the hearing. This other referral methods should also be present in the guideline. The method for children with a doubtful score, and the house visits of nurses is something that first needs to be proven useful, before the interviewed organisations would see the value of this procedure. Some of the organisation already used house visits and visits to preschools as extra information about the surroundings of the child. Also the amount of home visits is important. If these would increase substantially through this guideline, the budget available in the different organisations would be a problem. The municipalities should also be convinced of the use of the guideline in this case. Something that was mentioned by all of the organisations was the indication and referral for VVE. It would be helpful if this was somehow linked to this protocol as it also focuses on the language stimulation of the environment. This was not the starting point of the guideline, as it was designed for detecting children with a language disorder, but nevertheless the guideline can contribute to providing a good indication whether VVE could help the child. Overall the communication was mentioned as an important for every implementation of guidelines. The more in advance people know a guideline is coming, the better they can prepare, by arranging schooling and required materials. This is something that could be improved as communication regarding guidelines is not always experienced as clear. Furthermore the provision of already designed schooling or a list of key speakers can stimulate the implementation of a guideline. The easier providing schooling becomes, the more likely people are to do it. Also something that could make schooling easier would be e-learning modules. Last, the interviewees would like some support in the continuation of guidelines. This could be given through for instance refreshment courses.
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7 Recommendations In this chapter recommendations in regards to the guideline uniform language screening and guidelines in general are given. Some of the recommendations are more considerations which should be thought of when designing the guideline.
7.1 Recommendations for the guideline uniform language screening
Value is given to the experiences of the parents and medical professionals who have worked in this pilot. The NCJ is currently evaluating the pilot and these results should be communicated towards medical professionals as well as to the parents if they plan on translating the pilot into a guideline.
Some of the organisations have their own speech therapists, whereas others have other steps between the consult and the referral. These need to be taken into account when deciding on the guideline and the referral methods used in the guideline.
Many of the organisations would like to link this way of working to a way of giving an indication for VVE. It could be that children with a doubtful score could benefit from VVE. This is something that also needs to be assessed and thought of when constructing the final guideline
As the subject of language is popular right now, the guideline should be created as soon as possible to profit from this popularity. It could be that things like financing or schooling are easier to arrange as long as the subject is popular.
7.2 Recommendations for guidelines in general
One of the key items mentioned by the interviewees is communication towards the organisations about the guideline. If people know in advance when a guideline is coming, they can plan schooling and get the materials ready in time.
Add a section for management, which clearly describes the impact of the new guideline and what is needed for the organisation. By doing so the management is better informed and can focus on the information they need, instead of reading the whole guideline, or being informed by someone of their staff.
Providing schooling materials also eases out the process of implementation. If for instance a presentation or a key speaker is already presented to the organisation, giving the schooling becomes easier. This would stimulate the organisations to implement a guideline.
Organisations point out that continuation is the hardest part of implementing a guideline. For instance refreshment courses, or other tools, could be developed to make also the continuation somewhat easier.
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8 Reflection In this chapter a reflection is given regarding the research used to write this report. It discusses the methods and conceptual model used in this research.
Conceptual Model The model of Fleuren et al. (2004) as depicted in the conceptual framework is a way of looking at the implementation of guidelines. This model depicts the different determinants as loose concepts that do not interact and can be separated from each other. During this research it soon became apparent that the different determinants also interact with one another and cannot be seen separate from each other. The picture therefore is in my opinion not complete as this interaction is not depicted. The same issue comes to mind with the phasing of the implementation. Although the four phases are there, they do not follow each other as perfectly depicted as in this flowchart, but flow together sometimes. An important finding was that people were already talking about the continuation, whereas the focus of the research lied on the initial implementation. This implies that the four phases cannot be seen separately or encountered separately as they influence one another. For instance, adoption can go more smoothly if the continuation is already in some shape been thought of. The different phases therefore also interact and influence each other. Although the reality of implementation of guidelines is not as perfect as the model suggests, the model does help with the structuring of a guideline and the research towards it. This also how it is mainly used in this research as a framework to guide the research. By viewing the phases and determinants apart from each other, a better overview can be created. This however, should be done with the interaction kept in mind. Otherwise the cause-action relation may not always be clear as a certain topic can have a starting point in another determinant for example as where it is mentioned later on.
Health Technology Assessment As stated before this research is a combination of a health technology assessment and a constructive technology assessment as the adjusted guideline is not yet into place and can be influenced by new information. The implementation of guidelines does not normally involve interviews with actors, whereas it could be helpful for the willingness as well as the quality of a guideline to include opinions of the field. The quality could be improved due to new ideas which had not come up in the pilot as these people have a fresh view on the matter. This idea was confirmed by some of the interviewees, as they mentioned feeling more involved and therefore perhaps more willingly to implement the new guideline. It also could also be that professionals are less objected towards guidelines if they feel they are involved in the process of making them. This however has not been researched and could be investigated further. If this research also heightens the willingness towards guideline it could even be beneficial for the use of guidelines. This form of research is not possible for every guideline implementation in practice due to time and financial limits. It could be that this way of involving people and the possible willingness that comes into being causes less costs and efforts in implementation. If this is the case a midway between this research, interviewing actors one by one, and not involving professionals at all should
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be sought. This could be done by meetings between one person from every organisation who is responsible for the implementation of guidelines for example. It would be interesting to assess whether this form of interventions has benefits for the implementation of guidelines.
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9 List of References (sd). Opgeroepen op Februari 2012, van NCJ: www.ncj.nl (sd). Opgeroepen op Februari 2012, van TNO: www.tno.nl (sd). Opgeroepen op Februari 2012, van RIVM: www.rivm.nl Bishop, D. V. (1992). The Underlying Nature of Specific Language Impairment. The Journal of Child Psychology and Psychiatry, 33(1), 3-66. Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H., Abboud, P.-A. C., et al. (1999). Why don't Physicians Follow Practical Clinical Guidelines?; A Framework for Improvement. Journal of the American Medical Association, 282(15), 1458-1465. Conroy, M., & Shannon, W. (1995). Clinical Guidelines: Their Implementation in General Practice. British Journal of General Practices, 371-375. de Koning, H. J., de Ridder-Sluiter, J. G., van Agt, H. M., Reep-van den Bergh, C. M., van der Stege, H. A., Korfage, I. J., et al. (2004). A Cluster-Randomised Trial of Screening of Language Disorders in Toddlers. Journal of Medical Screening, 11(3), 109-116. de Wit, J. (2011). Tussentijdse Evaluatie ZonMw-Programma Richtlijnen Jeugdgezondheid. Medical Point of View. ZonMw. Denzin, N. K., & Lincoln, Y. S. (2005). The Sage Handbook of Qualitative Research (3 ed.). United States of America: Sage Publications. DiCicco-Bloom, B., & Crabtree, B. F. (2006). The Qualititatve Research Interview. Medical Education, 40, 314-321. Fleuren, M. A. (2010). Essentiële activiteiten en infrastructuur voor de landelijke invoering en monitoring vna het gebruik van de JGZ-richtlijnen. TNO. Fleuren, M. A., & de Jong, O. R. (2006). Basisvoorwaarden voor implementatie en borging van de standaarden Jeugdgezondheidszorg. TNO. Fleuren, M. A., de Jong, O. R., Filedt Kok-Weimar, T. L., & van Leerdam, F. J. (2002). Implementatie van Standaarden in Jeugdgezondheidszorg. JGZ, 1(1), 11-13. Fleuren, M. A., Wiefferink, C. H., & Paulussen, T. G. (2004). Determinants of innovation within health care organizations: Literature review and Delphi-study. International Journal for Quality in Healthcare(16), 107-123. Law, J., Garrett, Z., & Nye, C. (2004). The efficacy of treatment for children with developmental speech and language delay/disorder: a meta-analysis. Journal of Speech, Language and Hearing Research(47), 924-943. Longalliantie. (2009). Voorstel voor de zorgstandaard COPD. Amersfoort. McGregor, M., & Brophy, J. M. (2005). End-User Involvement in Health Technology Assessment (HTA) Development: A Way to Increase Impact. International Journal of Technology Assessment in Health Care, 21(2), 263-267. RIVM / Centrum Jeugdgezondheidszorg. (2007). Richtlijnen Jeugdgezondheidszorg. Schot , J., & Rip, A. (1997). The Past and Future of Constructive Technology Assessment. Technological Forecasting and Social Change(54), 251-268. Spaai, G. W., Wenners-Lo-A-Njoe, V. T., Hameeteman-Hoekstra, M. A., Van der Stege, H. A., & van Agt, H. M. (2008). Vroegsignalering VTOtaal; Een Exploratief Onderzoek naar de Effectiviteit van een Protocol voor Risicoscreening. Logopedie en Foniatrie(3), 76-82.
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van Agt, H. M. (2011). Language Disorders in Children; Impact and the Effects of Screening. Erasmus University Rotterdam. van Daal, J. (2010). Taalspraakproblemen en gedragsproblemen: een verkenning van oorzaak en gevolg. Logopedie en foniatrie(1), 4-8. van Schie, C., Rip, R., van Denderen , M., Wiefferink , K., & Uilenburg, N. (2011). Tijdig signaleren van spraak-taalproblemen bij JGZ Kennemerland. JGZ, 43(3), 50-54.
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10 Appendices Appendix I : Model of the Pilot
Project Uniforme Taalsignalering Projectgroep: Bettie Carmiggelt*, Frans Pijpers*, Hanneke Romeijn**, Erica Stam** Noëlle Uilenburg*** * NCJ, **Adviescommissie Ontwikkelingsonderzoek, ***NSDSK, Correspondentie: Nederlands Centrum Jeugdgezondheid, Churchilllaan 11, 3527 GV Utrecht, 0307600411,
[email protected] Achtergrond Naar schatting 5 % van alle peuters en kleuters heeft problemen met de taal. Uit onderzoek blijkt dat vroegtijdige onderkenning en behandeling van taalproblemen bij jonge kinderen kan bijdragen aan het verminderen van het aantal kinderen dat deelneemt aan het speciaal onderwijs De Jeugdgezondheidszorg (JGZ) speelt een belangrijke rol in de vroegtijdige opsporing van spraak- en taalproblemen en gebruikt daarvoor het onderdeel ‘Communicatie’ van het Van Wiechen-onderzoek. Hierover heeft het vroegere RIVM/Centrum Jeugdgezondheid het standpunt ‘Signaleren van taalachterstanden door de jeugdgezondheidszorg’ gepubliceerd. In juli 2007 is een inventariserend rapport van TNO verschenen, waarin de onderzoekers concluderen dat er nog te weinig gegevens zijn over de sensitiviteit en specificiteit van beschikbare signaleringsinstrumenten om op dit moment deze veelbelovende instrumenten als standaard te kunnen inzetten in de Jeugdgezondheidszorg. Project Het Centrum Jeugdgezondheid heeft daarom samen met relevante partijen , NSDSK en Adviescommissie Ontwikkelingsonderzoek een plan van aanpak ontwikkeld om het onderdeel communicatie van het Van Wiechen-onderzoek met items uit andere veelbelovende taal/spraaksignaleringsinstrumenten aan te vullen. Hiermee ontstaat een instrument, dat bijdraagt aan een effectievere, meer eenduidige en doelmatige signalering van taalspraakstoornissen door de JGZ-professionals. Dit als overbrugging naar een (volledig) evidence-based JGZ-richtlijn. Doelstelling Het aanpassen van het onderdeel “Communicatie” van het Ontwikkelingsonderzoek JGZ op 2-jarige leeftijd met items uit de veelbelovende taalspraaksignaleringsinstrumenten. Uitvoering pilot In het voorjaar van 2012 worden in 5 organisaties de resultaten van het geïntegreerde model ( Van Wiechen en met extra elementen) vergeleken met een controlegroep met care as usual. Bij 4 organisaties worden de extra vragen alleen gesteld als het kind negatief scoort op het Van Wiechenitem en in 1 organisatie wordt bij alle kinderen dit model toegepast Werkwijze Geïntegreerde model 2-jarige leeftijd Kinderen met een score 0 of 1 op 2-jarige leeftijd worden direct naar het Audiologisch Centrum verwezen. Kinderen met een twijfelachtige score op 2-jarige leeftijd worden begeleid door jeugdverpleegkundigen of logopedisten en met 2,5 jaar vindt een herscreening in de JGZ plaats.
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Begeleiding van kinderen met een score 2-3 op 2-jarige leeftijd Kinderen met een score 2-3 worden in 3 organisaties door de jeugdverpleegkundige gedurende 3 maanden begeleid en in 1 organisatie door logopedisten. De NVLF heeft de scholing van de logopedisten verzorgd. Herbeoordeling 2,5-jarige leeftijd De kinderen met een twijfelachtige score (2 of 3) op 2-jarige leeftijd worden op de leeftijd van 2 jaar en 6 maanden opnieuw beoordeeld met behulp van de ontwikkelingskenmerken 41, 43 en 44. Indien de gecombineerde score van de 3 ontwikkelingskenmerken < 3 plussen is, wordt het kind naar het AC verwezen. Verwachte resultaten Uniforme signalering taalstoornissen. Meer en eerder verwijzen naar Audiologische centra Eerdere begeleiding en behandeling van taalstoornissen bij jonge kinderen Verwachte voordelen van deze werkwijze Herkenbaarheid van het Van Wiechen-onderzoek JGZ voor de werkers in de Jeugdgezondheidszorg vergroot de bereidwilligheid om ermee te gaan werken. De verandering wordt niet als een grote verandering ervaren. Kunnen benutten van een bestaande scholing- en certificeringstructuur, namelijk die van het Ontwikkelingsonderzoek JGZ, versnelt de invoering. Voorkomen van dubbelingen in het contactmoment voor het bepalen van ontwikkelingskenmerken, waardoor het minder belastend voor kind, ouder en onderzoeker is. Er is minder tijd nodig voor onderzoek op indicatie binnen de toch al beperkt beschikbare tijd. Er is één registratie via het DD JGZ en het zelfde ontwikkelingskenmerk hoeft slechts eenmaal geregistreerd te worden. Heldere communicatie mogelijk vanuit het Centrum Jeugdgezondheid over hoe JGZprofessionals dienen om te gaan met signalering van taalspraakstoornissen en het verder wetenschappelijk onderbouwen hiervan.
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Appendix II: Concept e-mail for interviewees Beste ….., Ik mail u voor mijn afstudeeronderzoek wat ik uitvoer bij het NCJ. Voor dit onderzoek zal ik mensen interviewen over het implementeren van een mogelijke nieuwe richtlijn gebaseerd op een lopende pilot. Onderstaand vindt u een beschrijving van deze richtlijn. Mijn vraag is of u geïnteresseerd bent om mee te werken aan mijn onderzoek. Het interview zal ongeveer een uur kosten en kan gewoon bij u op kantoor worden gehouden, mocht daar de voorkeur voor bestaan. Ik hoor graag van u, Met vriendelijke groet, Michelle de Groot
De richtlijn: Momenteel loopt er bij het NCJ een pilot voor uniforme taalsignalering waarbij er een aantal dingen veranderen ten opzichte van het signaleren van kinderen met taalproblemen zoals dat nu gebeurd. Een van de belangrijkste aanpassingen is dat als het Van Wiechen onderzoek geen uitsluitsel geeft op kenmerk 41 en 42 dat er verder onderzoek gedaan wordt door middel van onderdelen van het VTOtaalonderzoek. Hieruit kan vervolgens een score behaald worden van 0 t/m 4. De score heeft vervolgens invloed op de vervolgstappen. Bij een score van 4 heeft het kind een normale ontwikkeling en is er niks aan de hand Scoort een kind 0 of 1, dan wordt deze door verwezen naar een audiologisch centrum. Scoort het kind 2 of 3 punten dan krijgt het kind huisbezoeken van een verpleegkundige die hiervoor getraind wordt. Deze bezoeken zullen in elk geval twee keer plaatsvinden, eenmaal om de situatie thuis te analyseren en eenmaal om te zien of de ouders iets kunnen met het advies van het vorige huisbezoek. Vervolgens zal het kind na zes maanden nogmaals getest worden. Blijkt er dan nog steeds onvoldoende ontwikkeling te zijn dan wordt het kind alsnog doorverwezen naar een audiologisch centrum.
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Appendix III: Interview Outline (Dutch) Student van de VU, onderzoek bij het NCJ naar het implementeren van een richtlijn voor de opsporing van kinderen met taalstoornissen. Toestemming vragen voor het verwerken van de data in het onderzoek en het opnemen van het gesprek.
Kunt u iets over uzelf en uw organisatie vertellen? Organisatie 0-19 of 0-4. Functie. Eigen projecten
Wat vond u van de richtlijn als geheel? Moment om te checken of ze deze ook echt gelezen hebben. In het geval dat dit niet zo blijkt te zijn, of te ver weggezakt een pagina geven waar het in het kort nogmaals staat uitgelegd.
Waarom zou u deze wel of niet implementeren? Wat zijn de positieve punten en welke zijn negatief. Eventueel ook doorvragen naar een rangorde binnen de punten, dus wat lijkt het grootste voordeel dan wel nadeel.
Wat is van belang bij implementatie van een nieuwe richtlijn? Vier onderwerpen om op door te vragen: Omgevingsfactoren, Organisatie, Uitvoerende, Implementatie zelf
Vragen of de geïnterviewde verder nog wat wil zeggen. Bedanken voor het interview. De richtlijn: Momenteel loopt er bij het NCJ een pilot voor uniforme taalsignalering waarbij er een aantal dingen veranderen ten opzichte van het signaleren van kinderen met taalproblemen zoals dat nu gebeurd. Een van de belangrijkste aanpassingen is dat als het Van Wiechen onderzoek geen uitsluitsel geeft op kenmerk 41 en 42 dat er verder onderzoek gedaan wordt door middel van onderdelen van het VTOtaalonderzoek. Hieruit kan vervolgens een score behaald worden van 0 t/m 4. De score heeft vervolgens invloed op de vervolgstappen. Bij een score van 4 heeft het kind een normale ontwikkeling en is er niks aan de hand Scoort een kind 0 of 1, dan wordt deze door verwezen naar een audiologisch centrum. Scoort het kind 2 of 3 punten dan krijgt het kind huisbezoeken van een verpleegkundige die hiervoor getraind wordt. Deze bezoeken zullen in elk geval twee keer plaatsvinden, eenmaal om de situatie thuis te analyseren en eenmaal om te zien of de ouders iets kunnen met het advies van het vorige huisbezoek. Vervolgens zal het kind na zes maanden nogmaals getest worden. Blijkt er dan nog steeds onvoldoende ontwikkeling te zijn dan wordt het kind alsnog doorverwezen naar een audiologisch centrum.
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Appendix IV: Time Table
Month
February
March
April
May
June
Objectives
Writing Research Proposal Literature Research Go-No Go Meeting Writing Research Proposal Seeking Interviewees Planning and Conducting Interviews Planning and Conducting Interviews Transcribing Interviews
Analysis of Results Writing Report Writing Report Handing in First Draft Presentations at VU and NCJ Handing in Final Report
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