Academy of Nutrition and Dietetics: Revised 2021 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Management of Food and Nutrition Systems.

Management of food and nutrition systems (MFNS) encompasses the varied roles of registered dietitian nutritionists (RDNs) with administrative responsibilities for food and nutrition services within an organization. RDNs in MFNS are frequently employed in acute care, but also expand into a multitude of other settings in which management of nutrition and foodservice is required, for example, foodservice departments in assisted living and post-acute and long-term care; colleges and universities, kindergarten through grade 12 and pre-kindergarten schools and childcare; retail foodservice operations; correctional facilities; and companies that produce, distribute, and sell food products. RDNs in MFNS aim to create work environments that support high-quality customer-centered care and services, attract and retain talented staff, and foster an atmosphere of collaboration and innovation. The Management in Food and Nutrition Systems Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has revised the Standards of Professional Performance (SOPP) for RDNs in MFNS for 3 levels of practice: competent, proficient, and expert. The SOPP describes 6 domains that focus on professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Indicators outlined in the SOPP depict how these standards apply to practice. The standards and indicators for RDNs in MFNS are written with the leader in mind-to support an individual in a leadership role or who has leadership aspirations. The SOPP is intended to be used by RDNs for self-evaluation to assure competent professional practice.

[KASID Guidance for Clinical Practice Management of Adult Inflammatory Bowel Disease during the COVID-19 Pandemic: Expert Consensus Statement].

The coronavirus disease 2019 (COVID-19) pandemic has reduced the ability to prevent or control chronic disease due to the concerns about safety in accessing health care. Inflammatory bowel disease (IBD) is a chronic condition requiring long- term sustained treatment, which is difficult in the current panedemic situation. The Korean Association for the Study of Intestinal Diseases (KASID) has developed an expert consensus statement on the clinical practice management of adult inflammatory bowel disease during the COVID-19 pandemic. This expert consensus statement is based on guidelines and clinical reports from several countries around the world. It provides recommendations to deal with the risk of COVID-19 and medication use in IBD patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and emphasizes the importance of right treatment approach to avoid worsening of the disease condition in IBD patients.

Basics of practice management: managing many for the care of one.

In today's changing health care landscape, it has become necessary that providers have a fundamental understanding of practice management as pertinent to the care they provide. The reproductive endocrinology and infertility (REI) practice is a uniquely complex setting with many component parts, necessitating frequent assessment and collaboration to provide safe, quality, and cost-effective care. In this review, we aim to describe the basics of medical practice management, divided into six sections: practice models; operations; patient safety; patient experience; employee recruitment; development, and satisfaction; and technology. These topics will be presented with a focus on the application of these principles to the REI practice.

Building a smart FNA cart: When Google meets cytology.

BACKGROUND: The appropriate management of a fine needle aspiration (FNA) supply cart and equipment set up is essential to ensure the smooth and optimal operation of a busy FNA clinic. We applied Lean strategies such as value stream mapping (VSM), the 5S method (Sort, Set in order, Shine, Standardize, Sustain), and Kanban to remove waste and improve patient flow in an FNA clinic. METHODS: The workflow analysis suggested that existent problems such as suboptimal inventory management and unavailability of standard operating procedures (SOPs) caused a 10% to 85% increase in total procedure time. To improve inventory management, we created a 2-bin Kanban system. We used the "Scan to Web" app and a Google Drive form to create a cost-effective electronic inventory management system. We distributed the essential SOPs in the format of video clips using our YouTube channel and leveraged barcode technology to access the links. RESULTS: Upon completion of our process improvement project, we succeeded to eliminate the stock-out events and maintain a process cycle efficiency of 87%. The 5S audit checklist result increased from 6% to 100% implementation, which is consistent with focused improvement. The developed inventory system enabled us to track the supply usage, forecast demands, and improve the accuracy of orders. CONCLUSIONS: Lean methods such as VSM, 5S, and Kanban combined with open source technologies can be implemented to ensure material availability, track inventory, and provide immediate access to SOPs on demand. The developed system also led to increased efficiency and improved flow, as well as responsiveness to changes in demand.

Sustainability of an Interprofessional Collaborative Practice Model for Population Health.

Sustainability is an important concept in implementation science, yet little about sustainability is published in leadership journals. Leaders are charged on a daily basis with initiating programs that make a difference; however, they are often not well prepared to design effective strategies to sustain their efforts. In a value-based health care industry where facilitating access to care, enhancing the patient experience, improving health outcomes, and reducing the cost of care are imperative, creating sustainability strategies that achieve these results is key. In this article, we describe the successful efforts within an academic-practice partnership to implement a sustainable interprofessional collaborative practice model emphasizing transitional care coordination in chronic disease management for advancing population health with underserved populations. A sustainability framework is presented along with lessons learned.

Promoting professional behaviour in general practitioner training practices: The views of practice managers.

BACKGROUND AND OBJECTIVES: General practitioners (GPs) are required by the Australian professional colleges of general practice - The Royal Australian College of General Practitioners and The Australian College of Rural and Remote Medicine - to practise a high standard of professional behaviour. General practice registrars (GPRs) learn this in their training practices not only from their general practice supervisors, but also the practice managers (PMs). Little is known of PMs' views of the meaning of the term 'professional behaviour' and how they view their role in GPR education. METHOD: Nineteen semi-structured interviews with PMs were conducted. Saturation was reached and consensus achieved on the analysis. RESULTS: PMs held nuanced views on the meaning of the term 'professional behaviour' and actively promoted and modelled this to their staff, including GPRs. PMs believed they had a role in GPR education. DISCUSSION: Practice managers are well placed to model and teach professional behaviour, and their skills should be further used to educate GPRs.

Impact of the Four-Hour Rule/National Emergency Access Target policy implementation on emergency department staff: A qualitative perspective of emergency department management changes.

OBJECTIVE: It has been 10 years since the ACEM Access Block Solutions Summit and 5 years since the introduction of the Four-Hour Rule/National Emergency Access Target (4HR/NEAT) policy. The impact of this policy on ED management and on ED staff has been poorly understood. The aim of the present study was to identify changes in ED management resulting from the policy based on ED staff experiences. METHODS: Semi-structured interviews were conducted and transcribed, imported to NVivo 11 and analysed using a combination of content, thematic analysis and phenomenological focus within a theoretical framework known as the 'logic model'. RESULTS: One hundred and nineteen ED staff participated in 2015-2016 to assess the impact of the policy implementation. Participants were drawn from 16 EDs in New South Wales, Queensland, Western Australia and Australian Capital Territory. In relation to ED management, three themes were identified: changes in ED management; activities and changes driven by the hospital in relation to 4HR/NEAT; and participant experiences in relation to policy compliance by staff. CONCLUSIONS: Policy implementation is a complex process that had both positive and negative consequences on how ED staff managed the implementation of the 4HR/NEAT policy and how it changed their work environment. Understanding the perceptions of staff involved in policy implementation has significance for the design of future implementation strategies. The biggest insight from the present study is that ED management is very complex and the policy generated multiple positive and negative changes demonstrating the wide range of processes involved in this area of health services research.

Infrastructures for healthcare: From synergy to reverse synergy.

The Danish General Practitioners Database has over more than a decade developed into a large-scale successful information infrastructure supporting medical research in Denmark. Danish general practitioners produce the data, by coding all patient consultations according to a certain set of classifications, on the entire Danish population. However, in the Autumn of 2014, the system was temporarily shut down due to a lawsuit filed by two general practitioners. In this article, we ask why and identify a political struggle concerning authority, control, and autonomy related to a transformation of the fundamental ontology of the information infrastructure. We explore how the transformed ontology created cracks in the inertia of the information infrastructure damaging the long-term sustainability. We propose the concept of reverse synergy as the awareness of negative impacts occurring when uncritically adding new actors or purposes to a system without due consideration to the nature of the infrastructure. We argue that while long-term information infrastructures are dynamic by nature and constantly impacted by actors joining or leaving the project, each activity of adding new actors must take reverse synergy into account, if not to risk breaking down the fragile nature of otherwise successful information infrastructures supporting research on healthcare.

Competitive Advantage of MBA for Physician Executives: A Systematic Literature Review.

In response to systemic challenges facing the US healthcare system, many medical students, residents and practicing physicians are pursuing a Master in Business Administration (MBA) degree. The value of such proposition remains poorly defined. The aim of this review is to analyze current literature pertaining to the added value of MBA training for physician executives (PEs). We hypothesized that physicians who supplement their clinical expertise with business education gain a significant competitive advantage. A detailed literature search of four electronic databases (PubMed, SCOPUS, Embase and ERIC) was performed. Included were studies published between Jan 2000 and June 2017, focusing specifically on PEs. Among 1580 non-duplicative titles, we identified 23 relevant articles. Attributes which were found to add value to one's competitiveness as PE were recorded. A quality index score was assigned to each article in order to minimize bias. Results were tabulated by attributes and by publication. We found that competitive domains deemed to be most important for PEs in the context of MBA training were leadership (n = 17), career advancement opportunities (n = 12), understanding of financial aspects of medicine (n = 9) and team-building skills (n = 10). Among other prominent factors associated with the desire to engage in an MBA were higher compensation, awareness of public health issues/strategy, increased negotiation skills and enhanced work-life balance. Of interest, the learning of strategies for reducing malpractice litigation was less important than the other drivers. This comprehensive systemic review supports our hypothesis that a business degree confers a competitive advantage for PEs. Physician executives equipped with an MBA degree appear to be better equipped to face the challenge of the dynamically evolving healthcare landscape. This information may be beneficial to medical schools designing or implementing combined dual-degree curricula.

Management education within pharmacy curricula: A need for innovation.

OBJECTIVE: To encourage the academy to pursue innovative management education strategies within pharmacy curricula and highlight these experiences in a scholarly dialogue. SUMMARY: Management has often been a dreaded, dry, and often neglected aspect of pharmacy curricula. With the release of Center for Advancement of Pharmacy Education (CAPE) Educational Outcomes 2013 as well as Entry-Level Competencies Needed for Community Pharmacy Practice by National Association of Chain Drug Stores (NACDS) Foundation, National Community Pharmacists Association (NCPA), and Accreditation Council for Pharmacy Education (ACPE) in 2012, managerial skills have seen a new emphasis in pharmacy education. Further, management has greater emphasis within ACPE "Standards 2016" through adoption of CAPE Educational Outcomes 2013 into the standards. Previous literature has shown success of innovative learning strategies in management education such as active learning, use of popular television shows, and emotional intelligence. The academy must build a more extensive scholarly body of work highlighting successful educational strategies to engage pharmacy students in an often-dreaded subject through applying the Scholarship of Teaching and Learning.

O gerenciamento de enfermagem em projetos de pesquisa interprofissionais: relato de experiência / Gestión de proyectos de investigación en enfermería interprofesional: relato de experiencia / Management of nursing interprofessional research projects: experience report

RESUMO Introdução: O profissional enfermeiro, como formação tem seus eixos de atuação nas áreas de gerencia, assistência, ensino e pesquisa. Cada vez mais, enfermeiros ocupam cargos de gestores nos serviços de saúde. E nos últimos anos vem se inserindo em projetos de pesquisa, para desenvolver ações de enfermagem baseada em evidências. Objetivo: Relatar a experiência do profissional enfermeiro que exerce a função de coordenador de um centro de exames onde são coletados os dados da pesquisa multicêntrica intitulada "Condições de Vida e Saúde da População de Pomerode - SHIP-BRAZIL", da Universidade de Blumenau, Santa Catarina, Brasil, em parceria com a Universidade de Greifswald, Alemanha. Método: Trata-se de uma pesquisa qualitativa, com abordagem descritiva, através do relato de experiência do profissional. O período de análise foi de julho de 2013 a dezembro de 2015. A coleta de dados fez-se por relato oral, e a análise feita a partir da análise se conteúdo. Resultados: A experiência vivenciada descreve o processo de gestão de estrutura física do centro de exames, gestão de custos, gestão de pessoas, gestão do cuidado e as ferramentas gerenciais utilizadas neste processo. Conclusão: o relato elucida o papel essencial do enfermeiro no processo de estruturação e manutenção do centro de exames, bem como sua postura de liderança e contribui para atuação futura de enfermeiros na área gestão em pesquisa(AU)

RESUMEN Introducción: el profesional de enfermería, debido a su formación, tiene como principales áreas de actividad: las de gestión, atención, enseñanza e investigación. Cada vez más, las enfermeras ocupan puestos de dirección en los servicios de salud. Y en los últimos años se ha ido entrando en proyectos de investigación para desarrollar acciones de enfermería basadas en la evidencia. Objetivo: presentar la experiencia de la enfermera profesional que lleva a cabo la función de coordinador de un centro de exámenes donde se recogen los datos del estudio multicéntrico "Condiciones de Vida y Salud Pomerode Población - ENVÍO-BRASIL". Métodos: se trata de una investigación cualitativa con enfoque descriptivo de la Universidad de Blumenau, Santa Catarina, Brasil, en colaboración con la Universidad de Greifswald, Alemania, a través de la experiencia profesional. El período de revisión: a partir de julio de 2013 hasta diciembre de 2015. La recolección de datos se llevó a cabo mediante la presentación de informes orales, y el análisis del análisis es el contenido. Resultados: la experiencia vivida describe el proceso de la estructura física de la gestión del centro de exámenes, gestión de costes, gestión de personas, gestión y las herramientas de gestión utilizadas en este proceso de atención. Conclusión: el informe deja claro el papel esencial de la enfermera en el proceso de estructuración y mantenimiento del centro de examen, así como su posición de liderazgo y contribuir a la evolución futura de las enfermeras en el manejo de las áreas de investigación(AU)

ABSTRACT Introduction: The nurse professional, as a training, has its axes of action in the areas of management, assistance, teaching and research. Increasingly, nurses occupy managerial positions in health services. And in the last few years he has been working on research projects to develop evidence-based nursing actions. Objective: To report the experience of the nurse practitioner who performs the function of coordinator of an examination center where the data of the multicenter research entitled "Conditions of Life and Health of the Population of Pomerode - SHIP-BRAZIL", of the University of Blumenau, Santa Catarina, Brazil, in partnership with the University of Greifswald, Germany. Methods: It is a qualitative research, with a descriptive approach, through the experience report of the professional. The period of analysis was from July 2013 to December 2015. The data collection was done by oral report, and the analysis made from the analysis if content. Results: Experienced experience describes the physical structure management process of the exam center, cost management, people management, care management and the management tools used in this process. Conclusion: The report elucidates the essential role of the nurse in the process of structuring and maintaining the examination center, as well as its leadership position and contributes to the future performance of nurses in the area of research management(AU)

Risk Stratification Methods and Provision of Care Management Services in Comprehensive Primary Care Initiative Practices.

PURPOSE: Risk-stratified care management is essential to improving population health in primary care settings, but evidence is limited on the type of risk stratification method and its association with care management services. METHODS: We describe risk stratification patterns and association with care management services for primary care practices in the Comprehensive Primary Care (CPC) initiative. We undertook a qualitative approach to categorize risk stratification methods being used by CPC practices and tested whether these stratification methods were associated with delivery of care management services. RESULTS: CPC practices reported using 4 primary methods to stratify risk for their patient populations: a practice-developed algorithm (n = 215), the American Academy of Family Physicians' clinical algorithm (n = 155), payer claims and electronic health records (n = 62), and clinical intuition (n = 52). CPC practices using practice-developed algorithm identified the most number of high-risk patients per primary care physician (282 patients, P = .006). CPC practices using clinical intuition had the most high-risk patients in care management and a greater proportion of high-risk patients receiving care management per primary care physician (91 patients and 48%, P =.036 and P =.128, respectively). CONCLUSIONS: CPC practices used 4 primary methods to identify high-risk patients. Although practices that developed their own algorithm identified the greatest number of high-risk patients, practices that used clinical intuition connected the greatest proportion of patients to care management services.

Strategies for building a successful ultrasound guided FNA practice in department of pathology-Experience at a university hospital.

INTRODUCTION: Although pathology services focused on fine needle aspiration (FNA) biopsy of superficial palpable masses with on-site cytological evaluation are available in a wide range of clinical and academic settings, the addition of ultrasound (US) guidance into FNA practice by a cytopathologist group can be challenging. An US-FNA service provided by a cytopathologist in the department of Pathology is a relatively new practice in the field of medicine. This report summarizes our experience and strategies in achieving this objective and our successful preliminary results. MATERIALS AND METHODS: The US-FNA service includes (1) an FNA procedure to be performed by a cytopathologist under US guidance; (2) onsite adequacy evaluation and diagnosis to be done by the same cytopathologist; and immediate patient consultation and sample triaging carried out by the same cytopathologist in an FNA suite within the department of Pathology. The FNA suite including a procedure room equipped with a portable US machine, an exam/procedure table, a mobile cabinet with FNA supplies, a counter with sink, and a reception room with waiting area is set-up. RESULTS: The establishment of the US-FNA service is successful. There is an incremental growth of the service over the first 8 months. Among the 114 cases performed during the first 8 months, the case type distribution is shown to be 50% thyroid nodules, 33% lymph nodes, 5.5% salivary gland masses, 3.5% breast masses, and 8% soft tissue masses. CONCLUSIONS: The authors' initial 8 months experience and strategies in setting up a new US-FNA practice in a new institution are discussed to highlight obstacles encountered and approaches that promoted the successful establishment of a new service. A conservative approach, focusing on building partnerships with existing clinical services, can be successfully implemented in most institutions, if appropriate strategies are applied. The main strategy is to ensure that the best interests of patients remain the primary focus and that everything possible is done to improve the quality and effectiveness of patient care by providing the best possible diagnostic US-FNA service, to enable optimal clinical management.

Ixcellence Network®: an international educational network to improve current practice in the management of cervical dystonia or spastic paresis by botulinum toxin injection.

Botulinum toxin is a well-established treatment for a number of conditions involving muscle hyperactivity, such as focal dystonia and spastic paresis. However, current injection practice is not standardized and there is a clear need for structured training. An international group of experts in the management of patients with cervical dystonia (CD) and spastic paresis created a steering committee (SC). For each therapeutic area, the SC developed a core slide set on best practice, based on the literature. International sites of expertise were identified for training and courses were designed to include lectures and casebased learning. Where possible, courses received accreditation from the European Union of Medical Specialists (UEMS). Each course was peer reviewed by the SC, the UEMS accreditation board and the attendees themselves (through evaluation questionnaires). Attendees' feedback was shared with the SC and the trainers to tailor future training sessions. From the program launch in 2012 to December 2014, 328 physicians from 34 countries were trained in a total of 58 courses; 67% of the courses focused on spastic paresis and 33% on CD. Of the 225 (69%) physicians who completed feedback forms, 95% rated their course as 'above average/excellent' in meeting the preset learning objectives. Most (90%) physicians declared that attending a course would lead them to change their practice. The development of the 'Ixcellence Network' for continuous medical education in the fields of spastic paresis and CD has provided a novel and interactive way of training physicians with previous experience in botulinum toxin injection.

Compreensão dos enfermeiros gerentes sobre o processo de enfermagem / Comprensión de los enfermeros gerentes sobre el proceso de enfermería / Head nurses' understanding of the nursing process

RESUMO Este estudo teve como objetivo compreender o Processo de Enfermagem na perspectiva do gerente de enfermagem. O método adotado foi a abordagem qualitativa na vertente da fenomenologia, segundo a estrutura do fenômeno situado. Para coleta de dados, empregou-se entrevista focalizada com os participantes que foram definidos no decorrer do estudo, perfazendo nove depoimentos. A análise dos depoimentos revelou os temas: Instrumentalização da Sistematização da Assistência de Enfermagem (SAE); Sentimentos dos profissionais no desenvolvimento da SAE e o Processo gerencial e a SAE. Nesse artigo, o recorte foi o tema Processo gerencial e a SAE. Esse tema desvelou que os termos administrar e cuidar se opõem, complementam-se e se aproximam, permitindo compreender que a finalidade da gerência é propiciar cuidado. Entretanto, há uma dicotomia no processo assistencial: o cuidado é frequentemente exercido pelos técnicos e auxiliares de enfermagem e o gerenciamento, exclusivamente pelo enfermeiro, o qual afasta-se de seu propósito principal, o gerenciamento do cuidado.

RESUMEN Este estudio tuvo como objetivo comprender el Proceso de Enfermeríaen la perspectiva del gerente de enfermería. El método adoptado fueel abordajecualitativoen la vertiente fenomenológica, segúnla estructura delfenómeno situado. Para la recolección de datos, fue utilizada entrevista focalizada conlos participantes que fueron definidos a lo largo del estudio, totalizando nueve relatos. El análisis de los relatos revelólos temas: Instrumentalización de la Sistematización de la Atención de Enfermería (SAE); Sentimientos de los profesionales en el desarrollo de la SAE yel Proceso gerencial yla SAE. En este artículo, el recorte fue el tema Proceso gerencial yla SAE. Este tema reveló que los términos administrar y cuidar se oponen, se complementany se aproximan, permitiendo comprender que la finalidad de la gerencia es propiciar cuidado. Sin embargo, hay una dicotomía en el proceso de atención: el cuidado es frecuentemente ejercido por los técnicos y auxiliares de enfermeríayla gestión, exclusivamente por el enfermero, el quese aleja de su propósito principal, la gestión del cuidado.

ABSTRACT This study aimed to understand the Nursing Process in the perceptions of the nurse's managers. The methodology adopted was a qualitative approach named phenomenology, referencing the structure of the situated phenomenon. For data collection we used focused interview. The participants were defined during the study, resulting in nine statements. After careful review of the statements revealed the following topics: Instrumentalization of the systematisation of nursing care (SNC); Feelings of the nurse's managers in the development of SNC and the Management process and the SNC. Hence, the terms management and care should not be opposed but complementary. This approach allows to us understanding that the purpose of management is to provide care. However, there is dichotomy of these actions, care, often exercised by technicians and nursing assistants, and management exclusively by nurses, setting it apart from its main purpose, the management of care.

Clinical leadership and hospital performance: assessing the evidence base.

BACKGROUND: A widespread assumption across health systems suggests that greater clinicians' involvement in governance and management roles would have wider benefits for the efficiency and effectiveness of healthcare organisations. However, despite growing interest around the topic, it is still poorly understood how managers with a clinical background might specifically affect healthcare performance outcomes. The purpose of this review is, therefore, to map out and critically appraise quantitatively-oriented studies investigating this phenomenon within the acute hospital sector. METHODS: The review has focused on scientific papers published in English in international journals and conference proceedings. The articles have been extracted through a Boolean search strategy from ISI Web of Science citation and search source. No time constraints were imposed. A manual search by keywords and citation tracking was also conducted concentrating on highly ranked public sector governance and management journals. Nineteen papers were identified as a match for the research criteria and, subsequently, were classified on the basis of six items. Finally, a thematic mapping has been carried out leading to identify three main research sub-streams on the basis of the types of performance outcomes investigated. RESULTS AND CONTRIBUTION: The analysis of the extant literature has revealed that research focusing on clinicians' involvement in leadership positions has explored its implications for the management of financial resources, the quality of care offered and the social performance of service providers. In general terms, the findings show a positive impact of clinical leadership on different types of outcome measures, with only a handful of studies highlighting a negative impact on financial and social performance. Therefore, this review lends support to the prevalent move across health systems towards increasing the presence of clinicians in leadership positions in healthcare organisations. Furthermore, we present an explanatory model summarising the reasons offered in the reviewed studies to justify the findings and provide suggestions for future research.

Protocol for a process evaluation of a cluster randomised controlled trial to improve management of multimorbidity in general practice: the 3D study.

INTRODUCTION: As an increasing number of people are living with more than 1 long-term condition, identifying effective interventions for the management of multimorbidity in primary care has become a matter of urgency. Interventions are challenging to evaluate due to intervention complexity and the need for adaptability to different contexts. A process evaluation can provide extra information necessary for interpreting trial results and making decisions about whether the intervention is likely to be successful in a wider context. The 3D (dimensions of health, drugs and depression) study will recruit 32 UK general practices to a cluster randomised controlled trial to evaluate effectiveness of a patient-centred intervention. Practices will be randomised to intervention or usual care. METHODS AND ANALYSIS: The aim of the process evaluation is to understand how and why the intervention was effective or ineffective and the effect of context. As part of the intervention, quantitative data will be collected to provide implementation feedback to all intervention practices and will contribute to evaluation of implementation fidelity, alongside case study data. Data will be collected at the beginning and end of the trial to characterise each practice and how it provides care to patients with multimorbidity. Mixed methods will be used to collect qualitative data from 4 case study practices, purposively sampled from among intervention practices. Qualitative data will be analysed using techniques of constant comparison to develop codes integrated within a flexible framework of themes. Quantitative and qualitative data will be integrated to describe case study sites and develop possible explanations for implementation variation. Analysis will take place prior to knowing trial outcomes. ETHICS AND DISSEMINATION: Study approved by South West (Frenchay) National Health Service (NHS) Research Ethics Committee (14/SW/0011). Findings will be disseminated via a final report, peer-reviewed publications and practical guidance to healthcare professionals, commissioners and policymakers. TRIAL REGISTRATION NUMBER: ISRCTN06180958.