Best practice guidelines can only be successfully implemented if there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. The Registered Nurses' Association of Ontario (RNAO), through a panel of nurses, researchers, and administrators, has developed a Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a healthcare organization.
The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating guideline implementation. Specifically, the Toolkit addresses the following key steps:
- Identifying a well-developed, evidence-based clinical practice guideline
- Identification, assessment, and engagement of stakeholders
- Assessment of environmental readiness for guideline implementation
- Identifying and planning evidence-based implementation strategies
- Planning and implementing an evaluation
- Identifying and securing required resources for implementation and evaluation
Implementing practice guidelines that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.
Evaluation and Monitoring
It is suggested that organizations implementing the recommendations in this nursing best practice guideline consider how the implementation and its impact will be monitored and evaluated. Whereas outcome evaluations possess several quantitative indicators driven largely by the literature base upon which this guideline was developed, implementation evaluations will often be more qualitative in nature and will focus on a sufficient allotment of resources (financial, personnel, subjects, etc.) required to support successful implementation/maintenance of the recommendations in the guideline.
To this end, several factors must be taken into consideration when implementing recommendations. It is essential that implementation proceed in a manner that is consistent with the circumstances, setting, and population investigated in the scientific literature upon which the recommendation is based, otherwise it is impossible to evaluate a departure of actual results from the expected outcomes. For example, the multifactorial intervention recommendation requires that the components of the intervention be tailored to the individual's needs. If the facility implementing the recommendation decides instead to structure the multifactorial interventions based on client group (for example, amputees vs. stroke patients), then the desired outcome of fall reduction may not be achieved. In this case, it is impossible to determine whether the desired outcome failed to be achieved because the intervention was ineffective, or whether the intervention was applied inappropriately. In addition, proper implementation ensures consistency across different facilities where multiple sites are involved.
It is recommended that any implementation of recommendations proceed with respect to the objectives of the implementation program. For each objective, administrative and personnel support must be sufficient for the objective to be achieved. In the absence of sufficient resources to both implement and ensure the sustainability of a program, the presence of a population of interest is of little value. The following factors for consideration will assist in ensuring the recommendations from this guideline have been implemented properly and will provide the foundation for a rigorous evaluation of its outcomes.
- What are the objectives of the implementation program?
- What are the imposed timelines for achievement of objectives/interim goals?
- Is there sufficient budget in place to cover expenses of the program? What time period is covered by funds?
- What are the major costs? What are the capital/start-up/maintenance expenses?
- What is the "per patient" cost of the program?
- Are there contractual obligations in implementing the program? Will they be met?
- What costs associated with the program will be borne by the facility's operating budget?
- What are the internal/external reporting relationships associated with the program?
- Will there be interim reviews of the program's effectiveness? What resources will be required?
- Has an individual/committee been tasked with ongoing oversight of the program?
- How many clinical/administrative/support staff will be required to implement the program?
- Has staff been provided with a clear description of their roles/responsibilities?
- What specialty staff is required?
- What resources are required to train staff?
- How will adequacy of training be evaluated?
- What is staff turnover like on the unit? Has succession planning been considered in the work plan?
- Are any external resources required to support the program?
- For what population was the program designed (age, patient classification, level of function, etc.)?
- What is the typical length of stay? Will it provide for sufficient data collection?
- On what basis are participants selected for recruitment? What resources (clinical assessment, evaluation instruments, etc.) will be required to determine appropriateness for inclusion?
- How have participants been grouped? i.e., if experimental and controls groups are desired, how are they to be randomized (individually, by room, by unit, etc.)?
- Are there any systematic differences between experimental and controls groups (e.g., age, co-morbidities, functional capacity, disease state, etc.) that may affect the outcome of the program evaluation?
- Has a contingency plan been prepared to account for patient drop-out? Poor compliance?
- Will participants be actively involved in program? If so, how will program goals, and interim results be communicated to participants?
- What other programs/guidelines have been/will be implemented during the course of the program?
- What are their objectives?
- Will programs conflict (i.e., staffing demands, resources)?
Shanley (2003) notes that systems for monitoring falls and associated fall injuries need to be comprehensive, easy to use and well integrated with other systems in the facility that includes a feedback and action process on results, such as with quality and risk management processes within organizations.
Both AMDA (1998) and Queensland Health (2003) recommend use of existing quality improvement and or risk management systems for monitoring review of falls and the use of minimum data set (MDS) as a system source for complex continuing care clinical data, for evaluation of contributing factors associated with falls. As well, these guidelines recommend the monitoring of specific factors such as the incidence of injuries associated with falls, and associated clinical conditions such as functional ability.
A table in the original guideline document, based on the framework outlined in the RNAO Toolkit: Implementation of Clinical Practice Guidelines, illustrates some suggested indicators for monitoring and evaluation.
The RNAO and the guideline development panel have compiled a list of implementation strategies to assist healthcare organizations or healthcare disciplines who are interested in implementing this guideline. A summary of these strategies follows:
Have a dedicated person such as an advanced practice nurse or a clinical resource nurse who will provide support, clinical expertise and leadership. The individual should also have good interpersonal, facilitation and project management skills.
Establish a steering committee comprised of key stakeholders and members committed to leading the initiative. Keep a work plan to track activities, responsibilities and timelines.
Provide educational sessions and ongoing support for implementation. The education sessions may consist of presentations, facilitator's guide, handouts, and case studies. Binders, posters and pocket cards may be used as ongoing reminders of the training. Plan education sessions that are interactive, include problem solving, address issues of immediate concern and offer opportunities to practice new skills.
Provide organizational support such as having the structures in place to facilitate the implementation. For example, hiring replacement staff so participants will not be distracted by concerns about work and having an organizational philosophy that reflects the value of best practices through policies and procedures. Develop new assessment and documentation tools.
Identify and support designated best practice champions on each unit to promote and support implementation. Celebrate milestones and achievements, acknowledging work well done.
Organizations implementing this guideline should look at a range of self-learning, group learning, mentorship and reinforcement strategies that will over time, build the knowledge and confidence of nurses in implementing this guideline.
Beyond skilled nurses, the infrastructure required to implement this guideline includes access to specialized equipment and treatment materials. Orientation of the staff to the use of specific products must be provided and regular refresher training planned.
RNAO's Advanced/Clinical Practice Fellowships (ACPF) Project is another way that registered nurses in Ontario may apply for a fellowship and have an opportunity to work with a mentor who has expertise in the clinical area described in this guideline. With the ACPF, the nurse fellow will have the opportunity to hone their skills in prevention of falls and fall injuries in the older adult.
Champions – Identify, develop and support Best Practice Champions and include people who have expertise in the topic area, facilitation skills, and knowledge of adult education principles in order to support, develop, mentor, and train other nurses within organizations to ensure knowledge transfer.
In addition to the strategies mentioned above, the RNAO has developed resources that are available on the website. A Toolkit for implementing guidelines can be helpful if used appropriately. A brief description of this Toolkit can be found in Appendix F of the original guideline. A full version of the document in PDF format is also available at the RNAO website, www.rnao.org/bestpractices .