The cycle of change: implementing best-evidence clinical practice

To improve health outcomes, effective and systematic mechanismsto foster the adoption of evidence-based guideline recommendationsinto routine practice need to be identified. A cyclical processfor achieving this objective involving three key phases is suggested. Phase 1. Writing actionable best-evidence guidelines that prioritizekey recommendations while indicating the levels of adoptionneeded for population health benefits to be accomplished. Phase 2. Developing implementation plans for the priority guideline recommendations.These should systematically consider skills training and accreditation;social influences including opinion leaders and patient influences;environmental factors; monitoring and feedback; and incentivesfor clinical change. Phase 3. Pilot testing the effectiveness of proposed approaches in producingthe desired clinical changes. If implementation requires systemchanges and evaluation at an organizational level, the use ofalternative research designs to the randomized controlled trialcould be considered. The purpose evaluation would be to enablerefinement of the implementation plans before widespread dissemination.     

The effectiveness of local adaptation of nationally produced clinical practice guidelines

BACKGROUND: Local adaptation is often reported in the literature to be an important strategy in achieving local ownership and relevance of guidelines in order to increase the likelihood of their uptake and implementation. However, the process is also potentially time-consuming and costly. OBJECTIVE: The aim of this study was to determine the impact of local adaptation of nationally produced clinical practice guidelines (CPGs) on the knowledge, attitude and reported practices of GPs. METHODS: Two Divisions of General Practice in Adelaide, Australia were selected and randomized to adapt a nationally produced CPG (on Stroke Prevention) by the National Health and Medical Research Council or use the original version. The order of the interventions was reversed for a second guideline (on management of Lower Urinary Tract Symptoms in Men). An identical multifaceted dissemination strategy was adopted for both sets of guidelines in the two divisions. Prior to the intervention, a random sample of 200 GPs from each Division was sent a postal survey about their knowledge, attitudes and reported practices. This was repeated 3 months after the dissemination phase. RESULTS: Sixty-one per cent (243/400) of the GPs responded to the initial survey and, of these, 76% (184/243) responded to the follow-up survey. Overall, awareness of both sets of guidelines was significantly increased. For stroke, 38% of respondents across both Divisions reported that their practice had changed as a result of the guidelines. For management of lower urinary tract symptoms in men, the corresponding proportion was 52%. Agreement with specific recommendations from both guidelines was also increased following their dissemination. However, these changes were independent of whether or not the guidelines had been locally adapted. The local adaptation process involved no substantive change in content and was estimated to cost AUD$5600 (per Division) independent of the costs of the dissemination process. CONCLUSIONS: Whilst this study found significant changes in knowledge, attitude and reported practice as a result of disseminating guidelines, it did not find any additional effect from the local adaptation process itself. This suggests that the emphasis and investment in promoting guideline implementation should be placed on multifaceted dissemination strategies rather than local adaptation per se.     

Knowledge translation and guidelines: a transfer, translation or transformation process?

Aim The case is made for conceptualising guidelines as more flexible, interpretative pieces of information that contain a mixture of factual evidence, evidence that requires interpretation and evidence that will be shaped and moulded by the particular context into which it will be introduced. By acknowledging this way of viewing guidelines, practitioners and researchers are more able to understand what works in terms of successful implementation. This perspective differs from rating the type of evidence within guidelines according to the nature of the evidence. Methods The approach used was based on a standard process of formulating theoretical arguments: presenting the background, making and justifying the case by presenting evidence on successful guideline implementation strategies. Having presented the reasons why we should relook at the way we conceptualise and use guidelines, the paper then contrasts the evidence derived from research with examples of practitioners' accounts of managing the introduction of guidelines in practice. From this a number of conceptualisations are presented that offer new ways of constructing multifaceted interventions for guideline implementation. Results A set of arguments has been presented that provide background evidence, draw broad conclusions, address the ongoing issues around non-spread of new information and offer different ways of constructing research studies. The arguments are built on empirical and experiential evidence and refer to several major studies. Conclusions Seven conclusions are drawn from the paper: guidelines are not 'literal' objects - they are complex communication vehicles that are used as catalysts to stimulate discussion, learning and debate across knowledge boundaries; current evidence on guideline implementation reinforces the need to look at complex, multifaceted interventions based on specific diagnosis of barriers to implementation; this process poses conceptual, theoretical and methodological challenges to the research community; research designs ought to consider the contribution of process models as well as causal models; the implication of such a move would be investment in more process studies before the setting up of expensive causal or intervention (RCT type) studies; refocusing of implementation research away from theories of behaviour change to more consideration of knowledge management is to be encouraged and organisational theory and theory formulation and testing ought to be heterogeneous rather than narrowly focused.     

Educational strategies to promote evidence-based community pharmacy practice: a cluster randomized controlled trial (RCT)

BACKGROUND: Community pharmacists have increasing involvement in the self-management of minor illness as a result of the availability of a wider range of over-the-counter (OTC) medicines. We undertook a randomized controlled trial (RCT) to assess the effectiveness and efficiency of educational strategies to implement evidence-based guidelines for the sale of OTC anti-fungals in the community pharmacy setting. OBJECTIVE: The aim of the study was to compare the effectiveness and efficiency of two guideline dissemination strategies in community pharmacy settings. METHODS: A 2 x 2 factorial, cluster RCT was conducted with 60 community pharmacies in the Grampian region of Scotland. The interventions included dissemination of an evidence-based guideline for OTC management of vulvovaginal candidiasis (thrush) by postal dissemination (control), educational outreach visit or attendance at a continuing professional education session. Pre- and post-intervention simulated patient visits were made to participating pharmacies. The simulated patients completed assessment forms following each visit. The primary outcome was the appropriateness (based upon the guidelines) of sale or no sale of OTC anti-fungals. RESULTS: There were no significant differences in the proportion of appropriate outcomes following educational outreach [odds ratio (OR) = 1.1; 95% confidence interval (CI) 0.52 to 2.45] or continuing professional education (OR = 0.88; 95% CI 0.41 to 1.91). CONCLUSIONS: Neither strategy was effective in improving the appropriateness of OTC management of vulvovaginal candidiasis by community pharmacy staff. Further research is needed to identify barriers to guideline implementation and evidence-based practice in this setting.     

Designing and implementing behaviour change interventions to improve population health

Improved population health depends on changing behaviour: of those who are healthy (e.g. stopping smoking), those who are ill (e.g. adhering to health advice) and those delivering health care. To design more effective behaviour change interventions, we need more investment in developing the scientific methods for studying behaviour change. Behavioural science is relevant to all phases of the process of implementing evidence-based health care: developing evidence through primary studies, synthesizing the findings in systematic reviews, translating evidence into guidelines and practice recommendations, and implementing these in practice. 'Behaviour change: Implementation and Health', the last research programme to be funded within the MRC HSRC, aimed to develop innovative ways of applying theories and techniques of behaviour change to understand and improve the implementation of evidence-based practice, as a key step to improving health. It focused on four areas of study that apply behaviour change theory:defining and developing a taxonomy of behaviour change techniques to allow replication of studies and the possibility of accumulating evidence; conducting systematic reviews, by categorizing and synthesizing interventions on the basis of behaviour change theory; investigating the process by which evidence is translated into guideline recommendations for practice; developing a theoretical framework to apply to understanding implementation problems and designing interventions. This work will contribute to advancing the science of behaviour change by providing tools for conceptualizing and defining intervention content, and linking techniques of behaviour change to their theoretical base.     

The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization

This study tests whether a managed behavioral health care organization can influence adherence to practice guidelines for the treatment of major depression in a randomized trial of guideline dissemination. Guidelines were disseminated to mental health clinicians (N=443) under one of three conditions: (1) a general mailing of guidelines to clinicians, (2) a mailing in which guidelines were targeted to a patient starting treatment with the clinician, and (3) no mailing of guidelines. The results showed no effects of guideline dissemination as measured by self-report of patients and clinicians and through episode characteristics derived from claims data, despite sentinel effects. Results also showed high rates of clinician-reported guideline adherence that were not detected in the claims data, indicating significant undertreatment of depression. Results suggest that mental health systems must look to other dissemination strategies to improve adherence to standards of care and raise the performance of independent practicing clinicians     

Organisational strategies for changing clinical practice: how trusts are meeting the challenges of clinical governance

OBJECTIVES: To describe the use, perceived effectiveness, and predicted future use of organisational strategies for influencing clinicians' behaviour in the approach of NHS trusts to clinical governance, and to ascertain the perceived benefits of clinical governance and the barriers to change. DESIGN AND SETTING: Whole population postal survey conducted between March and June 1999. SUBJECTS: Clinical governance leads of 86 NHS trusts across the South West and West Midlands regions. METHOD: A combination of open questions to assess the use of strategies to influence clinician behaviour and the barriers to clinical governance. Closed (yes/no) and Likert type ratings were used to assess the use, perceived effectiveness, and future use of 13 strategies and the predicted outcomes of clinical governance. RESULTS: All trusts use one or more of 13 strategies categorised as educational, facilitative, performance management, and organisational change methods. Most popular were educational programmes (96%) and protocols and guidelines (97%). The least popular was performance management such as use of financial incentives (29%). Examples of successful existing practice to date showed a preference for initiatives that described the use of protocols and guidelines, and use of benchmarking data. Strategies most frequently rated as effective were facilitative methods such as the facilitation of best practice in clinical teams (79%), the use of pilot projects (73%), and protocols and guidelines (52%). The least often cited as effective were educational programmes (42%) and training clinicians in information management (20%); 8% found none of the 13 strategies to be effective. Predicted future use showed that all the trusts which completed this section intended to use at least one of the 13 strategies. The most popular strategies were educational and facilitative. Scatterplots show that there is a consistent relationship between use and planned future use. This was less apparent for the relationship between planned use and perceived effectiveness. Barriers to change included lack of resources, mainly of money and staff time, and the need to address cultural issues, plus infrastructure support. The anticipated outcomes of clinical governance show that most trusts expect to influence clinician behaviour by improving patient outcomes (78%), but only 53% expect it to result in better use of resources, improved patient satisfaction (36%), and reduced complaints (10%). CONCLUSIONS: Clinical governance leads of trusts report using a range of strategies for influencing clinician behaviour and plan to use a similar range in the future. The choice of methods seems to be related to past experience of local use, despite equivocal judgements of their perceived effectiveness in the trusts. Most expect to achieve a positive impact on patient outcomes as a result. It is concluded that trusts should establish methods of learning what strategies are effective from their own data and from external comparison.     

Implementing guidelines for smoking cessation advice in Australian general practice: opinions, current practices, readiness to change and perceived barriers

OBJECTIVE: The aim of this study was to ascertain opinions, current practices, likely readiness to change and perceived barriers to change among Australian GPs in order to develop a plan to implement national guidelines for smoking cessation advice. METHOD: A postal survey of randomly selected GPs in New South Wales, Australia was carried out. RESULTS: We received 311 returned questionnaires (73% response rate). Only 34% of respondents reported providing cessation advice during every routine consultation with a smoker, in accordance with national guidelines. Specific evidence-based approaches recommended in guidelines were under-utilized, with only 54% 'always' or 'frequently' arranging follow-up, 32% providing written materials and 28% setting a 'quit date'. Respondents were no more likely to advise quitting completely than the less effective method of nicotine fading. More than one in four respondents (28%) indicated readiness to change their behaviour. Respondents rated their patients' lack of motivation and uninterest as the most important barriers to smoking cessation advice in general practice. Neither uncertainty about effective smoking cessation strategies nor lack of reimbursement for smoking cessation advice were identified as barriers. CONCLUSIONS: A multicomponent intervention to address suboptimal behaviour and barriers as revealed by this survey holds considerable potential to plan effective implementation of smoking cessation guidelines in general practice. The use of readiness to change as a tool to 'individualize' strategies for guideline implementation should be explored.     

ActCPG framework to learn about information user requirements of a clinical practice guideline

A clinical practice guideline is a knowledge uptake instrument that supports evidence-based decision making by clinicians. It represents a model of a clinical process that describes the sequence of actions, decisions and their outcomes, and the interface with other processes beyond the scope of a guideline. In domains outside healthcare, the computerization of business processes via information systems follows a very rigorous design labeled as the system development life cycle. Our argument is that the computerization of a clinical practice guideline is the equivalent of building an information system for a clinical process and therefore should follow a similarly rigorous design method. One of the first and also one of the most important steps in the system development life cycle is learning about user information requirements. This paper is about a user requirements elicitation and definition process customized to clinical practice guideline. We propose the novel ActCPG conceptual framework for elicitation of basic user requirements for developing computer-interpreted guidelines. This framework relies on Activity Theory to structure and decompose information coming from a clinical practice guideline and associated narrative. We illustrate operation of the ActCPG framework with an example of a practice guideline for a management of clinically obese children enrolled in the Children's Hospital of Eastern Ontario obesity program.     

Not of one mind: mental models of clinical practice guidelines in the Veterans Health Administration

OBJECTIVE: The purpose of this paper is to present differences in mental models of clinical practice guidelines (CPGs) among 15 Veterans Health Administration (VHA) facilities throughout the United States. DATA SOURCES: Two hundred and forty-four employees from 15 different VHA facilities across four service networks around the country were invited to participate. Participants were selected from different levels throughout each service setting from primary care personnel to facility leadership. STUDY DESIGN: This qualitative study used purposive sampling, a semistructured interview process for data collection, and grounded theory techniques for analysis. DATA COLLECTION: A semistructured interview was used to collect information on participants' mental models of CPGs, as well as implementation strategies and barriers in their facility. FINDINGS: Analysis of these interviews using grounded theory techniques indicated that there was wide variability in employees' mental models of CPGs. Findings also indicated that high-performing facilities exhibited both (a) a clear, focused shared mental model of guidelines and (b) a tendency to use performance feedback as a learning opportunity, thus suggesting that a shared mental model is a necessary but not sufficient step toward successful guideline implementation. CONCLUSIONS: We conclude that a clear shared mental model of guidelines, in combination with a learning orientation toward feedback are important components for successful guideline implementation and improved quality of care.     

Bridging the guideline-practice gap in critical care nutrition: a review of guideline implementation studies

Several clinical practice guidelines focusing on nutrition therapy in mechanically ventilated, critically ill patients are available to assist busy critical care practitioners in making decisions regarding feeding their patients. However, large gaps have been observed between guideline recommendations and actual practice. To be effective in optimizing nutrition practice, guideline development must be followed by systematic guideline implementation strategies. Systematic reviews of studies evaluating guideline implementation interventions outside the critical care setting found that these strategies, such as reminders, educational outreach, and audit and feedback, produce modest to moderate improvements in processes of care, with considerable variation observed both within and across studies. Unfortunately, the optimal strategies to implement guidelines in the intensive care unit are poorly understood, with scarce data available to guide our decisions on which strategies to use. The authors identified 3 cluster randomized trials evaluating the implementation of nutrition guidelines in the critical care setting. These studies demonstrated small improvements in nutrition practice, but no significant effect on patient outcomes. There are some data to suggest that tailoring guideline implementation strategies to overcome identified barriers to change might be a more effective approach than the multifaceted "one size fits all" strategy used in previous studies. Adopting this tailored approach to guideline implementation in future studies may help bridge the current guideline-practice gap and lead to significant improvements in nutrition practices and patient outcomes.     

Promoting the Implementation of Best-Practice Guidelines Using a Matrix Tool

Background/Objectives

Internationally, numerous clinical practice guidelines have been developed and disseminated with the intention of improving patient care. Research indicates that to improve practice in accord with clinical evidence, change is required by individual clinicians and teams of clinicians as well as at an organizational and policy level. A matrix framework has been developed by the Australian Cancer Network’s Guideline Implementation Steering Committee, using the theory of innovation adoption. The matrix is based on the characteristics of innovations that favor rapid adoption and wide acceptance. Within this construct, new clinical guidelines are equated to an ‘innovation’. The objective of the present study was to pilot this matrix tool to assess its usefulness for individuals and organizations aiming to develop strategies to promote guideline implementation in cancer care.

Methods

The matrix was piloted at a workshop with 50 attendees, primarily colorectal surgeons and oncologists. Six key areas relating to guidelines were included in the matrix: (i) compatibility with current practice; (ii) relative advantage over current practice; (iii) observability of outcomes; (iv) trialability; (v) simplicity of use; and (vi) perceived barriers. Three examples of guideline recommendations for the management of colorectal cancer were used during the pilot, covering evidence about best clinical care and psychosocial support: (i) people with high-risk rectal cancer should be referred for consideration of adjuvant preoperative or postoperative radiotherapy in a multidisciplinary setting; (ii) people with resected Dukes’ C (i.e. node-positive) colon cancer should be referred for consideration of adjuvant therapy in a multidisciplinary setting; and (iii) psychosocial interventions should be a component of care as they can improve the quality of life in patients with cancer. After discussion of the guideline examples, the attendees completed matrix tool forms to document their perceptions regarding the consistency of current practice with the example guidelines and barriers to practice change. Quantitative responses were assessed by frequency analysis and qualitative responses were assessed by thematic analysis.

Results

There was consistency in the perceived views of workshop attendees around the six key areas included in the matrix. The perceived barriers that were highlighted by the respondents included the lack of available resources (staff, equipment, and funding); lack of multidisciplinary clinics, referral processes, and access to appropriate services; and lack of knowledge of benefit. Perceived facilitators of change included lead clinicians, consumer advocates, government, service administration, professional colleges, and cancer organizations.

Conclusions

The pilot process indicated that the matrix is a tool that could be of use to groups and individuals aiming to develop targeted change strategies to promote evidence-based practice improvement.

     

Clinical judgment and clinical practice guidelines

Clinicians make judgments under conditions of uncertainty. Decision research has shown that in uncertain situations individuals do not always act rationally, coherently, or to maximize their expected utility. Advocates of clinical guidelines believe that these guidelines will eliminate some of the cognitive biases that the practitioner may introduce into the medical decision-making process in an attempt to reduce its uncertainty. Other physicians have grave doubts about guidelines' application in practice. Guideline implementation lags well behind their development. Studies of practicing physicians and a survey of clinicians in one specialty and setting indicate that experienced clinicians may be implementing guidelines selectively. Many clinicians are concerned that guidelines are based on randomized trials and do not reflect the complexity of the real world, in which a decision's context and framework are important. Their reluctance also may be due to the difficulty of applying general guidelines to specific clinical situations. The problem will only increase in the future. The patients of the 21st century will be older and have more complex disease states. Physicians will have more patient-specific therapies and need to exercise more sophisticated clinical judgment. They may be more willing to use guidelines in making those judgments if research can demonstrate guidelines' effectiveness in improving decision making for individual patients.     

The clinical guideline process within a managed care organization

Clinical practice guidelines have been available to clinicians for almost two decades, but the consistency of their implementation in practice remains highly variable. This paper describes the various processes and mechanisms used by one managed care organization to develop clinical guidelines and promote their adoption. Some of these mechanisms include provision of individual physician report cards, financial incentives, and various documentation tools that serve as reminders of guideline recommendations and provide an easy format to document recommended services. There have been measurement challenges in evaluating the effectiveness of selected interventions designed to enhance guideline compliance. Most of these challenges relate to reliability and validity concerns regarding the three primary data sources used in the evaluation process: medical records, administrative claims data, and member survey data. Some of the interventions the health plan has implemented to address these measurement challenges include using hybrid methods of data collection and developing collaborative partnerships with outside organizations to enhance the accuracy and completeness of the available data. Outcomes of these efforts are described, as are physician response and recommendations for future enhancement of practice guidelines.     

Paper tigers--do clinical guidelines improve health care quality in patients with testicular germ cell tumors in Germany?

In Germany, germ cell tumors are characterized by a marked excess mortality, i.e. a discrepancy between the actual mortality and the mortality expected with adequate implementation of the standard therapy. Moreover, Germany not only has a significantly increased mortality in an international comparison but also shows marked regional differences in the quality of medical care. This is partly due to difficulties in implementing the standard therapy. An attempt was made to improve the quality of medical care by setting up evidence-based diagnostic and therapeutic guidelines in 1996. Contrary to expectations, however, these guidelines have thus far remained largely ineffective, their implementation being hampered by a solely passive dissemination strategy. Added to this are inadequate medical care structures in which the guidelines cannot be properly implemented because of the organizational, social and professional context. Decisive for a quality improvement in the diagnosis, therapy and care of germ cell tumor patients is active dissemination of the guidelines supplemented by a change in the care structure. It is also important to establish indicators for measuring the success of guideline implementation and to perform continuous progress monitoring in order to specifically overcome evident barriers. Future research is required to create a better theoretical basis and to develop further strategies for guideline dissemination and implementation.     

What are hospitals doing about clinical guidelines?

OBJECTIVES: To assess the attitudes of senior hospital staff towards clinical guidelines, and to ascertain the perceived extent and benefits of their local use; to identify those hospitals with current or planned future written strategies for the systematic development of clinical guidelines, and the staff responsible for leading them; and to establish the essential elements of existing strategies, and the methods used to ensure the proper development, dissemination, implementation, and evaluation of local guidelines. DESIGN: Cross sectional survey. PARTICIPANTS: Senior staff of 270 acute hospitals in the United Kingdom (response rate 202/270 (75%)) in 1995. RESULTS: 197/199 (99%) of respondents thought that clinical guidelines were a good idea, and 176/196 (90%) were aware of some guideline activity occurring within their hospitals. The most important benefits of local guideline activity were increased healthcare efficiency and effectiveness, greater consistency of treatment, and team building. 174/194 (90%) of respondents were in favour of the development of a readily accessible national repository of evidence-based clinical guidelines. 38/201 (19%) of respondents had a clinical guidelines strategy and a further 91/201 (45%) said that they had plans to develop one in the near future. The need to improve clinical outcomes was most often reported as the reason for developing a strategy. Medical directors most commonly had formal responsibility to lead the strategy, but someone without formal responsibility ran the operation in half the hospitals. Only 18/36 (50%) of strategies gave advice on the development of guidelines; and only a few strategies made explicit statements on which clinical services to target for guideline development, or the methods to be used for their validation and promotion. Some strategies lacked explicit statements on methods to monitor adherence, routine review, and update of guidelines. Internal literature searches (29/31 (94%)), the use of national guidelines (29/32 (91%)), local consensus conferences (28/32 (88%)), and peer group review (21/24 (88%)) were the most popular methods of validation used in hospitals with a strategy. Methods used to promote the dissemination, implementation, and evaluation of clinical guidelines included clinical audit (31/32 (97%)), peer review (25/30 (83%)), continuing education (23/29 (79%)), targeting of opinion leaders (17/26 (65%)), use of structured case notes (14/31 (45%)), patient mediated interventions (9/26 (35%)), and patient specific reminders (8/26 (31%)). CONCLUSIONS: Most senior hospital staff have a favourable attitude towards clinical guidelines. Most hospitals are undertaking some guideline activity, but few seem to be doing so within a locally agreed hospital wide strategy in which guideline development, dissemination, implementation, and evaluation are systematically considered. Many of the current methods used to validate guidelines locally are inadequate. Evidence-based clinical guidelines should be developed nationally, leaving hospitals to focus their energies on the local adaptation, dissemination, implementation, and evaluation of such guidelines. Only in this way will local guidelines achieve their full potential to improve clinical care and patient outcomes.     

Facilitators and barriers to implementing task shifting: Expanding the scope of practice of clinical technologists in the Netherlands

Despite recent studies confirming task shifting is both safe and effective, its implementation has proven difficult in practice. So too in the Netherlands, where legal barriers enforcing strict professional boundaries have historically limited task shifting. In recent years, Dutch policymakers have experimented with temporary expanded scopes of practice (ESP) for several professional groups, with the aim to facilitate task shifting in order to increase the overall effectiveness and efficiency of health care. The Clinical Technologist (CT), is an emerging new professional group that has received such a temporary ESP pending an evaluation. This paper reports the qualitative findings of the implementation process of providing CTs with an temporary ESP. Data collection consisted of 69 semi-structured interviews, 3 focus group interviews and 9 participant observations, conducted between September 2015 and October 2017. Analysis was conducted through an ‘editing analysis style’ whereby data were categorized using the conceptual framework of Grol & Wensing’s implementation model. The study suggests that social features are of great importance when implementing task shifting. In situations with few social barriers, organizational and administrative barriers seem to be less dominant, thereby expediting the overall implementation process. Consequently, we recommend that policymakers should prioritize social features over organizational features when implementing task shifting.