Organizational learning through experience has been found to be associated with enhanced firm performance. Organizational experiments are a method of experiential learning that enable organizations to learn from experience and gain context-specific knowledge of how and why to implement new knowledge. Pilot projects, a type of organizational experiment, involve making intentional, systematic efforts to gather and analyze feedback in order to accurately assess the action-outcome relationships of adopting new knowledge prior to embarking on full-scale implementation. Despite the popularity of pilot projects used to test products, programs, and services as well as reports on the outcomes of such experiments, there is a dearth of research focusing on how organizational learning occurs during organizational experiments, and on the processes and structural mechanisms of organizational experiments that contribute to organizational learning. A qualitative, multiple-case study of eight pilot projects was carried out within nursing units across five acute health care organizations during Fall 2008. Interviews were conducted with 32 individuals, including pilot project leaders, nursing program managers and direct care nurses. An inductive approach to data analysis was applied and themes identified. Results were compared to 14 propositions that were developed based on the knowledge transfer, innovation diffusion, and organizational learning literature, and which were bracketed before data analysis to allow findings to emerge from the data. The findings advance existing organizational learning, innovation diffusion, and knowledge transfer models by illuminating the complexity of organizational learning processes. Several processes and structural mechanisms of organizational experiments were found to facilitate single-loop organizational learning, leading to incremental changes to meet existing goals and objectives. Although double-loop organizational learning, which may result in fundamental changes in an organization’s assumptions, norms, policies, goals and objectives was not observed, the study revealed a number of processes and structural mechanisms that have the potential to encourage this type of learning. Studies of organizational experiments are rare. Future directions for research and theory development are suggested to build on the findings of this study. Practical implications are offered to organizations in any industry interested in realizing the potential that organizational experiments have for double-loop learning and enhanced organizational performance.

Ongoing structural and financial changes in the health care sector have resulted in increased risks for ethical dilemmas and moral distress. It is purported that increased ethical competence will help staff manage ethical dilemmas and hence decrease moral distress. To enhance ethical competence several approaches may be used – theoretical education, and methods focusing on reflection and decision-making abilities. Ethics rounds are a widespread systematic method hypothesized to improve ethical competence, nurture a reflective climate, and help in ethical decision-making. Despite its popularity, its effects on moral distress have hitherto never been evaluated in a controlled study. The purpose of this thesis was to evaluate the impact of an intervention, including ethics rounds; the hypothesis being that the intervention would decrease perceived moral distress. An additional aim was exploring the concept of moral distress in various health care establishments, including pharmacies. Focus groups were conducted to explore the concept of moral distress. To evaluate the intervention a scale assessing staff-perceived moral distress was designed, validated, and implemented. Results showed that moral distress is evident in diverse health care settings. Some factors associated with this were lack of resources, conflicts of interest, and rules that are incompatible with practice. An expanded definition of moral distress was presented. The training program was much appreciated by participants. However, no significant effects on perceived moral distress were found. Reasons could be that the intervention was too short or otherwise ineffective, there is no association between ethical competence and moral distress, the assessment scale was not sensitive enough, or management was not sufficiently involved. There is a need to further refine the various aspects of ethical dilemmas in clinical settings, and to evaluate the most efficient means to enhance skills for dealing with ethical dilemmas, for the benefit of staff, patients, institutions, and society.

Syftet med studien var att beskriva yrkeserfarna sjuksköterskors upplevelser av att arbeta med och stödja nyutexaminerade sjuksköterskor. En kvalitativ och beskrivande design användes. Undersökningsgruppen bestod av åtta kvinnliga sjuksköterskor från ett sjukhus i mellansverige. Huvudresultatet visade att de yrkeserfarna sjuksköterskorna var nöjda med nyutexaminerade sjuksköterskors arbetsinsats. En viktig aspekt var att nyutexaminerade sjuksköterskor frågade vid osäkerhet för att känna tillit. Sjuksköterskorna ansåg att stöd och uppskattning för att komma in i arbetet och gemenskapen var viktigt för att nyutexaminerade sjuksköterskor skulle känna sig trygga. Trots att sjuksköterskorna upplevde att nyutexaminerade sjuksköterskor var snabblärda, duktiga och nyfikna på att ta in ny lärdom i yrket, kom det dock fram att det fanns svårigheter att fokusera och prioritera rätt. Genomgående ansågs nyutexaminerade sjuksköterskor fokusera mer på dokumentation än omvårdnadsarbetet. Sjuksköterskorna betonade att mer praktik behövdes i grundutbildningen för att bättre förbereda nyutexaminerade sjuksköterskor i klinisk verksamhet. Vidare framkom det att längre introduktionstid behövdes i klinisk verksamhet för att komma in i rutinerna och sjuksköterskerollen. Slutsatsen visade att yrkeserfarna sjuksköterskor var nöjda med arbetsinsatsen från nyutexaminerade sjuksköterskor. Det ansågs viktigt att fråga vid osäkerhet och att mer fokus behövdes på omvårdnadsarbetet. Mer praktik ansågs nödvändigt för att lättare klara av den kliniska verksamheten. / The aim of the study was to describe professional experienced nurses' experiences of working with and supporting newly qualified nurses. A qualitative and descriptive design was used. The study group consisted of eight female nurses from a hospital in central Sweden. The main results showed that the professional experienced nurses were satisfied with the graduates’ nurses’ job performance. An important aspect was that newly qualified nurses asked if unsure to feel confident. The nurses felt that support and appreciation to get into work and community was important for newly qualified nurses to feel safe. Although the nurses felt that newly qualified nurses were quick to learn, skilled and curious to take on new learning in the profession, was however shown that there were difficulties to focus and 0Tprioritize the right0 Consistentlyconsidered graduates nurses to focus more on documentation than nursing. The nurses emphasized that more training was needed in basic education to better prepare graduate nurses for clinical practice. It was also found that longer introduction where needed in clinical practice to get into the routine and the nursing role. The conclusion showed that experienced nurses were satisfied with the effort from newly graduates’ nurses. It was considered important to ask if in doubt and that more focus was needed on nursing. More training was needed to help manage the clinical operations.

<p>Diss. (sammanfattning) Umeå : Umeå universitet, 2003</p> / digitalisering@umu

Organizational learning through experience has been found to be associated with enhanced firm performance. Organizational experiments are a method of experiential learning that enable organizations to learn from experience and gain context-specific knowledge of how and why to implement new knowledge. Pilot projects, a type of organizational experiment, involve making intentional, systematic efforts to gather and analyze feedback in order to accurately assess the action-outcome relationships of adopting new knowledge prior to embarking on full-scale implementation. Despite the popularity of pilot projects used to test products, programs, and services as well as reports on the outcomes of such experiments, there is a dearth of research focusing on how organizational learning occurs during organizational experiments, and on the processes and structural mechanisms of organizational experiments that contribute to organizational learning. A qualitative, multiple-case study of eight pilot projects was carried out within nursing units across five acute health care organizations during Fall 2008. Interviews were conducted with 32 individuals, including pilot project leaders, nursing program managers and direct care nurses. An inductive approach to data analysis was applied and themes identified. Results were compared to 14 propositions that were developed based on the knowledge transfer, innovation diffusion, and organizational learning literature, and which were bracketed before data analysis to allow findings to emerge from the data. The findings advance existing organizational learning, innovation diffusion, and knowledge transfer models by illuminating the complexity of organizational learning processes. Several processes and structural mechanisms of organizational experiments were found to facilitate single-loop organizational learning, leading to incremental changes to meet existing goals and objectives. Although double-loop organizational learning, which may result in fundamental changes in an organization’s assumptions, norms, policies, goals and objectives was not observed, the study revealed a number of processes and structural mechanisms that have the potential to encourage this type of learning. Studies of organizational experiments are rare. Future directions for research and theory development are suggested to build on the findings of this study. Practical implications are offered to organizations in any industry interested in realizing the potential that organizational experiments have for double-loop learning and enhanced organizational performance.

This paper describes the processes under taken by a student music therapist to improve her clinical practice and enhance the quality of service provided to children with profound and multiple disabilities. Using an Action Research model it aims to show how rigorous investigation of one's own practice can improve understanding of the clients and enhance students' abilities and confidence when carrying out placement work. An interview process with three registered music therapists preceded a 12 week action research process. Three cycles were undertaken with each lasting 4 weeks and the interview material informed the initial cycle. Clinical notes, a research journal and video recordings of sessions were three data gathering tools used to evaluate the success of techniques employed. This intensive critical analysis led to a greater awareness of in session communications and an improvement in techniques such as active waiting and repetition of activities. This in turn created increased opportunities for response to musical offerings by this client group.

Made available in DSpace on 2016-12-12T20:29:43Z (GMT). No. of bitstreams: 1 124164.pdf: 1309755 bytes, checksum: 01b55a1bf527bb4c3de6da0ec89cc049 (MD5) Previous issue date: 2015-06-22 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Knowledge is a key asset to keep organizations competitive, therefore it should be identified and managed. Hospitals, whether public or private, are knowledge-based organizations. Knowledge management studies relate its cycle in business and industry, but there is a gap regarding the knowledge management in hospitals as a way to improve clinical practice. This thesis proposes a knowledge management model for the purpose of filling this gap in clinical practice. Research in literature brought the key process elements for the development of a knowledge management model. This research was the basis for a case study. Specialists of a cystic fibrosis multi-service team of Hospital Infantil Joana de Gusmão were interviewed. This hospital is located in Florianópolis city, Santa Catarina state, Brazil. Because of this study, it was possible to verify the existence of a knowledge cycle in clinical practice and to identify the most relevant processes. Based on results, it was designed a knowledge management model to improve clinical practice for the analised team. / O conhecimento é um ativo fundamental para manter as organizações competitivas, portanto deve ser identificado e gerenciado. As unidades hospitalares, sejam elas públicas ou privadas, são organizações que têm suas ações baseadas no conhecimento. Estudos sobre gestão do conhecimento relatam como o ciclo acontece na prática em empresas e indústrias, porém há uma lacuna quanto à gestão do conhecimento como meio de aprimoramento das práticas clínicas em unidades hospitalares. Esta pesquisa de mestrado pretende contribuir para a redução dessa lacuna, por meio da proposição de um modelo de gestão do conhecimento para a melhoria da prática clínica. Em uma revisão da literatura, buscou-se levantar os principais elementos de processos para a construção de um modelo de gestão do conhecimento. Tais processos serviram de base para realização do estudo de caso, no qual foram entrevistados os membros da Equipe Multiprofissional de Atendimento ao Paciente Portador de Fibrose Cística do Hospital Infantil Joana de Gusmão, em Florianópolis, estado de Santa Catarina. Esta pesquisa possibilitou verificar a existência de um ciclo de uso do conhecimento na prática clínica da equipe e a identificação dos processos relevantes para a evolução dos procedimentos clínicos. Com base na análise dos resultados, foi elaborado um modelo de gestão do conhecimento que propicie melhorias no atendimento aos pacientes da unidade em estudo, e tal modelo é a principal contribuição desta pesquisa.

Electronic medical record databases (e.g. the Clinical Practice Research Datalink, CPRD) are increasingly used in epidemiological research. The CPRD has two formats of data: coded, which is the sole format used in almost all research; and free-text (or ‘hidden’), which may contain much clinical information but is generally unavailable to researchers. This thesis examines the ramifications of omitting free-text records from research. Cases with bladder (n=4,915) or pancreatic (n=3,635) cancer were matched to controls (n=21,718, bladder; n=16,459, pancreas) on age, sex and GP practice. Coded and text-only records of attendance for haematuria, jaundice and abdominal pain in the year before cancer diagnosis were identified. The number of patients whose entire attendance record for a symptom/sign existed solely in the text was quantified. Associations between recording method (coded or text-only) and case/control status were estimated (χ2 test). For each symptom/sign, the positive predictive value (PPV, Bayes' Theorem) and odds ratio (OR, conditional logistic regression) for cancer were estimated before and after supplementation with text-only records. Text-only recording was considerable, with 7,951/20,958 (37%) of symptom records being in that format. For individual patients, text-only recording was more likely in controls (140/336=42%) than cases (556/3,147=18%) for visible haematuria in bladder cancer (χ2 test, p<0.001), and for jaundice (21/31=67% vs 463/1,565=30%, p<0.0001) and abdominal pain (323/1,126=29% vs 397/1,789=22%, p<0.001) in pancreatic cancer. Adding text records reduced PPVs of visible haematuria for bladder cancer from 4.0% (95% CI: 3.5–4.6%) to 2.9% (2.6–3.2%) and of jaundice for pancreatic cancer from 12.8% (7.3–21.6%) to 6.3% (4.5–8.7%). Coded records suggested that non-visible haematuria occurred in 127/4,915 (2.6%) cases, a figure below that generally used for study. Supplementation with text-only records increased this to 312/4,915 (6.4%), permitting the first estimation of its OR (28.0, 95% CI: 20.7–37.9, p<0.0001) and PPV (1.60%, 1.22–2.10%, p<0.0001) for bladder cancer. The results suggest that GPs make strong clinical judgements about the probable significance of symptoms – preferentially coding clinical features they consider significant to a diagnosis, while using text to record those that they think are not.

Submitted by JÚLIO HEBER SILVA (julioheber@yahoo.com.br) on 2017-02-06T16:24:03Z No. of bitstreams: 2 Dissertação - Alba Valéria Sales Fortes - 2017.pdf: 2107907 bytes, checksum: 20ddc75af9d0330bcb42022d19b65776 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Rejected by Luciana Ferreira (lucgeral@gmail.com), reason: Júlio a data na citação está trocada. No guia está registrado: Obs.2: o primeiro ano da referência é o ano que vem na folha-de-rosto do documento e o segundo é o ano da defesa. Muitas vezes esses anos são os mesmos, quando não for, tomar cuidado para inserir no final da referência o ano da defesa. O sistema coloca de forma automática o ano de defesa, como sendo o que vem na folha-de-rosto do documento, mas se não for o mesmo deve-se corrigir. on 2017-02-08T10:29:59Z (GMT) / Submitted by JÚLIO HEBER SILVA (julioheber@yahoo.com.br) on 2017-02-08T15:43:55Z No. of bitstreams: 2 Dissertação - Alba Valéria Sales Fortes - 2017.pdf: 2107907 bytes, checksum: 20ddc75af9d0330bcb42022d19b65776 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2017-02-09T10:37:53Z (GMT) No. of bitstreams: 2 Dissertação - Alba Valéria Sales Fortes - 2017.pdf: 2107907 bytes, checksum: 20ddc75af9d0330bcb42022d19b65776 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2017-02-09T10:37:53Z (GMT). No. of bitstreams: 2 Dissertação - Alba Valéria Sales Fortes - 2017.pdf: 2107907 bytes, checksum: 20ddc75af9d0330bcb42022d19b65776 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2016-07-15 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / This paper aims to draw up a protocol on safe administration of medication intramuscularly to be made available to nursing staff. Methodology: descriptive study focused on the development of protocol for safe medication administration intramuscularly which were formulated based on the standards set by the scientific community, following pre-existing technical guidance grounded in clinical evidence, which were collected through a integrative literature review the following topics emerged: theoretical concepts related to anatomical issues for each drug administration region intramuscularly, as well as their graphic representations; factors that interfere directly and / or indirectly in making the decision as the best region of choice for the administration of injection; advantages and disadvantages of each region for drug administration and drug application techniques in the recommended intramuscular regions, with illustrations of them. Results: Prepared protocol with guidance on safe practices for administering medication intramuscularly, which includes the detailed description of the technique, images of anatomic regions, as well as key recommendations to this procedure, such as the correct choice of the site to be accessed, following recommended safety order, age, size of the needle, maximum volume to be injected. Conclusions: The activity of care, as well as complex, requires reliability to the assistance provided through insurance procedures and in this light, the construction of the protocol is notorious for carrying out the activities in which nursing is involved, since it is configured as a guiding instrument of care, promoting the work process of the nursing team regarding the safe administration of medications. The use of this instrument can help the practitioner to maximize therapeutic effects of administered medication, minimizing or eliminating injury to the patient and discomfort associated with intramuscular injections. / Este trabalho objetiva elaborar um protocolo sobre administração segura de medicamentos por via intramuscular a ser disponibilizado às equipes de enfermagem. Metodologia: Estudo descritivo voltado para a elaboração de protocolo para administração segura de medicamentos por via intramuscular os quais foram formulados com base nos padrões estabelecidos pela comunidade científica, seguindo orientações técnicas pré-existentes alicerçadas em evidências clínicas, as quais foram coletadas por meio de uma revisão integrativa da literatura que emergiu os seguintes tópicos: conceitos teóricos relacionados a questões anatômicas referentes a cada região de administração de medicamentos por via intramuscular, bem como suas representações gráficas; fatores que interferem direta e/ou indiretamente na tomada de decisão quanto a melhor região de escolha para administração de injetáveis; vantagens e desvantagens de cada região para administração medicamentosa e técnicas de aplicação de fármacos nas regiões intramusculares preconizadas, com ilustrações das mesmas. Resultados: Elaborado protocolo com orientações acerca de práticas seguras para administração de medicamentos por via intramuscular, o qual contempla a descrição minuciosa da técnica, imagens das regiões anatômicas, bem como recomendações essenciais a este procedimento, tais como escolha correta do local a ser acessado, seguindo ordem de segurança preconizada, faixa etária, tamanho da agulha, volume máximo a ser injetado. Conclusões: A atividade do cuidar, além de complexa, exige confiabilidade à assistência prestada por meio de procedimentos seguros e sob essa ótica, a construção do protocolo é notória para a execução das ações nas quais a enfermagem está envolvida, uma vez que se configura como um instrumento norteador da assistência prestada, favorecendo o processo de trabalho das equipes de enfermagem no tocante a administração segura de medicamentos. O uso deste instrumento pode ajudar o profissional a maximizar os efeitos terapêuticos da medicação administrada, minimizando ou eliminando lesões ao paciente e o desconforto associado com as injeções intramusculares.

Introdução: apesar das recomendações de todas as diretrizes sobre a doença arterial coronária e das evidências científicas de que o tratamento medicamentoso otimizado acrescido de intervenção sobre os fatores de risco e a melhoria do estilo de vida reduzem eventos cardiovasculares fatais não-fatais, essa terapêutica de prevenção secundária continua a ser subutilizada na prática clínica. Objetivos: Primário: demonstrar que a utilização de um programa de otimização da prática clínica em pacientes com doença arterial coronária estável aumenta a prescrição de medicamentos comprovadamente eficazes na prevenção secundária desta doença. Secundários: a) documentar a prática clínica vigente em termos de terapia medicamentosa e de medidas para a mudança do estilo de vida b) identificar as ferramentas utilizadas na estratégia para a otimização da prática clínica quanto à eficácia e aderência à medicação prescrita. Métodos: trata-se de um estudo de corte transversal para documentar a prática clínica vigente, seguido de componente longitudinal em que a utilização das ferramentas para a otimização da prática clínica foi avaliada por meio de novo corte transversal, com nova coleta de dados. Foram identificados retrospectivamente através dos prontuários, 710 pacientes consecutivos portadores de doença arterial coronária (Fase 1). Após a aplicação das ferramentas, foram incluídos 705 pacientes consecutivos atendidos no serviço com a coleta dos mesmos dados, para a análise comparativa. Além disso, foram selecionados do primeiro grupo, de forma aleatória, 318 prontuários de seis a doze meses após a primeira avaliação, para a coleta dos mesmos dados, que foram comparados com as informações iniciais destes mesmos pacientes. (Fase 3). Resultados: comparação entre Fase 1 e Fase 2: as características demográficas eram comparáveis entre os dois grupos. Quanto aos fatores de risco, houve melhora com diferença significativa para o tabagismo (p=0,019), dislipidemia (p<0,001) hipertensão arterial e atividade física regular (p<0,001). Quanto aos exames laboratoriais, não houve diferença estatisticamente significativa entre as duas populações. Comparando a prescrição dos fármacos recomendados, houve diferença significativa para IECA (67,2% versus 56,8%, p<0,001); ARA II (25,4% versus 32,9%, p=0,002) e betabloqueador (88,7% versus 91,9%, p=0,047). Comparação entre Fase 1 e Fase 3: os dados demográficos foram semelhantes, assim como as características clínicas, com exceção da doença arterial periférica obstrutiva: 31 pacientes (9,7%) e 42 (13,3%), p=0,007. Em relação aos fatores de risco, consideramos apenas os modificáveis tabagismo e atividade física. Para o tabagismo, considerando três categorias (nunca, ex-fumante e atual), não houve diferença significativa entre as duas fases. Para a atividade física, a proporção de pacientes sem informação para esta variável era elevada, 83,9% na primeira fase e 72,8% na terceira fase, dificultando a análise estatística. Quanto às medidas de exame físico, houve redução significativa do peso, p=0,044, pressão arterial sistólica e diastólica, p<0,001. Os exames laboratoriais não mostraram diferenças significativas entre as duas fases. Em relação à prescrição de medicamentos recomendados, houve diferença para IECA (64,8% versus 61,6%, p=0,011) e ARA II (27,0% versus 31,3%, p=0,035). Conclusão: com base nos resultados obtidos, o presente estudo permite concluir: não houve mudança significativa na utilização de medicamentos comprovadamente eficazes na prevenção secundária da DAC entre o período pré- e pós-intervenção; houve melhora significativa em relação ao tabagismo e atividade física na Fase 2; melhora substancial nos níveis de pressão arterial, tanto sistólica como diastólica na comparação tanto entre a Fase 1 e 2 como entre a Fase 1 e 3; a inclusão de enfermeiro treinado para gerenciar o processo é fundamental para a eficácia do programa; programas abrangentes de melhoria de qualidade assistencial em hospitais terciários e acadêmicos, provavelmente devem ser continuados por período de seguimento superior a um ano. / Background: despite guidelines recommendations on coronary artery disease treatment and scientific evidence confirming that optimal medical therapy added to risk factors and lifestyle management, reduce both fatal and non-fatal cardiovascular events, these secondary prevention strategies have been underutilized in clinical practice. Objectives: Primary: to demonstrate the utilization of a clinical improvement program in stable coronary artery disease patients would increase the evidence-proved treatment prescription in secondary prevention. Secondaries: a) to describe the ongoing clinical practice on medical therapy and lifestyle change counseling b) to identify tools to be utilized in the strategy to improve clinical practice, assessing efficacy and adherence to prescribed treatment. Methods: cross-sectional study to describe the ongoing clinical practice, followed by a longitudinal component in which the tools utilization to improve clinical practice was assessed by means of additional crosssectional data collection. 710 consecutive coronary artery disease patients were included after chart review following eligibility criteria (Phase 1). After tools implementation, within 6-month period, 705 patients were included (Phase 2) for comparative analysis. Randomly, 318 patients from Phase 1 were selected, 6-12 months after the first evaluation (Phase 3). Results: Phase 1 to Phase 2 comparison: demography was comparable. Concerning to risk factors, there were improvement on smoking (p=0,019), dyslipidemia (p<0,001), hypertension and physical activity (p<0,001). There were no statistical significant differences on laboratory results. By comparing the proven pharmacological treatment prescription, there was significant difference on ACEI (67,2% versus 56,8%, p<0,001); ARB II (25,4% versus 32,9%, p=0,002) and beta-blocker (88,7% versus 91,9%, p=0,047). Phase 1 to Phase 3 comparison: demography was comparable, as well as clinical characteristics, except peripheral artery disease: 31 patients (9,7%) and 42 (13,3%), p=0,007. Regarding risk factors, smoking and physical activity were considered. There was no significant difference on smoking rates taking into account three categories (never, ex-smoker and smoker). The proportion of patients without available data for physical activity was high, 83,9% (Phase 1) and 72,8% (Phase 3), making the data analysis not appropriated. Anthropometric measurement showed significant on weight reduction, p=0,044, both systolic and diastolic blood pressure, p<0,001. Laboratory results did not show significant differences. There was statistical significant difference on ACEI (64,8% versus 61,6%, p=0,011) and ARB II (27,0% versus 31,3%, p=0,035). Conclusion: based upon study results the following might be concluded: there was no significant change on the evidence-based pharmacological treatment utilization on secondary prevention coronary artery disease patients between pre and post-intervention Phases; there was significant improvement concerning smoking and physical activity in Phase 2; substantial improvement on blood pressure levels, both systolic and diastolic in both comparisons (Phase 1 to 2 and Phase 1 to 3); the inclusion of a case-manager for the process management is crucial for program efficacy; comprehensive programs for clinical practice improvement in tertiary academic hospitals should be pursued for longer follow-up period.