By: David A. Ganz, MD, PhD
Have you ever wondered how to implement a guideline that you find in the National Guideline Clearinghouse into your care setting? We have too. It turns out that putting guidelines into practice is not a simple thing at all. The VA QUERI Center for Implementation Practice and Research Support (CIPRS) focuses on implementation studies and we have observed that even when there is evidence that a particular healthcare screening tool or treatment can be beneficial, healthcare providers are not always sure whether it is good for their patients, or whether it will work in their environment (1). We have also determined that sometimes these "naysayers" are actually your best friends in disguise; they are sentinels of potential problems you will encounter during the implementation process.
Although we don't have a universal recipe for successfully implementing guidelines, we do have some key questions you may want to ask yourself before and during the implementation process, along with potential homework to assist the decision making process:
- What are the motivations for implementation?
Are you considering implementing a guideline because of external pressures (for example, pay-for-performance, accreditation), an internal problem (you became aware that patient care in your organization needs improvement), or some other reason?
Homework: Before implementing any practice or procedure, it is important to make sure the reasons for doing so are robust. For example, if you suspect there is a need for improvement in care, have you evaluated how well your organization is complying with what the guideline recommends? (See question 7 for details.)
- What is the political climate surrounding implementation?
In your organization, who wants the guideline implemented and why? Is this something everyone already agrees should be implemented, or are just a few people leading the charge? Is it your leaders who want the guideline implemented, or a few staff who really care about the topic?
Homework: Map out the political climate of your organization, as you may encounter resistance to implementing a guideline depending on how much buy-in there is and at what levels of your organization that interest exists. If there is too much resistance, do not start your project until you have established a sufficient sense of urgency to move the project forward.
- What is the culture of your workplace?
Are people generally compliant when something new comes down the pike? Or is it hard to get people to adapt to new situations? Reflect on the last time a change occurred within your organization. How did it go? What were the problems? And what was the ultimate outcome?
Homework: Use the information you have gathered about your organization's culture to anticipate challenges and opportunities surrounding implementation of the guideline. Your organization's readiness to change will determine the amount and type of resources you need to employ for implementation.
- Do you have the resources to move forward?
Homework: Assess the availability of resources needed for a successful implementation experience. Depending on your plan, you may require money as well as staff release time and enthusiasm, to differing degrees. In many cases, you will need to create a formal budget for approval by your leadership. Make sure you have sufficient resources to proceed. If not, go back to question 1.
- Assuming that your answers to the first four questions above support moving forward with guideline implementation, have you considered how you will introduce practice changes based on the guideline into your organization?
Homework: Think about who you will need on your implementation team; teams are slower but more effective in the long run (2). The team should include anybody whose work is potentially affected by the guideline, i.e., clinicians. These people should be given release time to participate in team meetings (if you can't secure release time, circle back to questions 1 and 4 – re: political buy-in and budget – do not continue until buy-in and resources are secured). A good topic to start a series of team meetings with is how team members perceive the current state of care delivery with respect to the guideline of interest; you can even map it out using a flow diagram (see the Resources section below). If you want to better understand team function, consider using the Team Development Measure (see the Resources section below).
- What are your aims with respect to guideline implementation?
Homework: Develop an aim statement (see the Resources section below for guidance on how to do this), which succinctly summarizes your goals in terms of what you want to improve with respect to the guideline, to what degree, and within what timeframe. In order to have a good aim statement, you need to have a way of measuring achievement of that aim.
- How will you measure your guideline implementation progress?
Homework: The guideline you seek to implement may have predefined measures for tracking improvement, or you may have to develop these yourself. Depending on the guideline, you may need to complete a chart audit, review administrative data, or survey patients to determine your progress with respect to the measures that you choose. Once you have aims (see question 6) and measures, you can develop an action plan with milestones to keep you and your team on track.
- Does the guideline tell you anything about how it should be implemented?
Homework: The best way to implement a guideline may not be clear from reading the guideline itself. That is because there is no one "cookbook" way to implement recommendations: it depends on the specifics of your organization (3). In order to gather ideas, therefore, it is beneficial to perform a literature review to explore whether other organizations similar to yours have tried to implement a guideline, and if so, how they went about it. Recommended common search engines include PubMed and Google Scholar; it is worth looking into the many articles that are available in full text for free. Make sure, however, that the resources and guidance you find contain some patient data to support them. The article's authors should be able to show that some aspect of patient care improved and that benefits outweighed harms.
- Does a small test of guideline implementation work?
Homework: Even after conducting a literature search, you probably will not have a complete solution for how to implement a guideline. For this reason, and to avoid big mistakes, it is very important to test your implementation on a small scale before fully committing to it. With this small-scale test, you will want to develop a mechanism for evaluating whether implementation efforts are positive and productive. Go back to question 7 if you are unsure.
- If answers to questions 1-9 are supportive of guideline implementation, how will you roll out that initiative more broadly in your organization?
Homework: There are a variety of different ways to roll out change in an organization. There is no single recipe, given that organizations have different sizes, cultures, and needs. But there are frameworks to help think through a roll-out. One such example is the Model for Improvement (see the Resources section below). The Model for Improvement covers many of the items discussed above but goes into greater depth.
We hope this brief overview of guideline implementation will encourage you to learn more. Some detailed resources that you might find helpful are listed below.
General discussion about implementing guidelines:
- VA Quality Enhancement Research Initiative (QUERI): http://www.queri.research.va.gov/implementation/
- RAND Monograph: Putting Practice Guidelines to Work in the Department of Defense Medical System: A Guide for Action: http://www.rand.org/pubs/monograph_reports/MR1267.html
- Humphris D, Littlejohns P. Implementing clinical guidelines: a practical guide. London (UK): Radcliffe Medical Press; 1999. 200 p.
- Margolis CZ, Cretin S. Implementing clinical practice guidelines. Chicago (IL): AHA Press; 1999.
- National Health and Medical Research Council. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra (Australia): National Health and Medical Research Council; 1999. 88 p.
Framework for thinking about organizational change:
- Lukas CV, Holmes SK, Cohen AC, Restuccia J, Cramer IE, Shwartz M, et al. Transformational change in health care systems: an organizational model. Health Care Manage Rev. 2007;32(4):309-20.
David A. Ganz, MD, PhD
Research Physician/Associate Professor
VA QUERI Center for Implementation Practice and Research Support
VA Greater Los Angeles Healthcare System
Los Angeles, California
The views and opinions expressed are those of the author and do not necessarily state or reflect those of the National Guideline Clearinghouse™ (NGC), the Agency for Healthcare Research and Quality (AHRQ), or its contractor ECRI Institute.
Potential Conflicts of Interest
In addition to the VA Greater Los Angeles Healthcare System, Dr. Ganz is also affiliated with the David Geffen School of Medicine at UCLA and the RAND Corporation. Dr. Ganz declares no financial or personal conflicts of interest with respect to this commentary.
- Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65.
- Shortell SM, Marsteller JA, Lin M, et al. The role of perceived team effectiveness in improving chronic illness care. Med Care. 2004 Nov;42(11):1040-8.
- Rycroft-Malone J. The PARIHS framework--a framework for guiding the implementation of evidence-based practice. Journal of nursing care quality. Oct-Dec 2004;19(4):297-304.
Pat Ridgely, MD
Disclosure/Conflict of Interest: None stated
Sheldon Ball, PhD, MD
Humana, San Diego, California
Disclosure/Conflict of Interest: None
Kelly Kruse Nelles, RN MS APRN-BC
National RN Case Manager Training Center, Blue Mounds, Wisconsin
Disclosure/Conflict of Interest: None
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