Tool for implementation of guidelines

1. Introduction

Implementing recommendations in guidelines is a process in which a certain number of phases can be distinguished. Besides the guideline’s development and the drafting of recommendations, a guideline will usually be published and distributed (dissemination), will actually be used in practice (implementation) and will become clear whether the guideline is feasible in practice (evaluation). Finally, working with the guideline could become part of the daily routine (continuation). Based on the literature, there are a number of relevant factors that contribute to (or hinder) the proper implementation of guideline recommendations. Problems related to implementation can be reduced or prevented by considering aspects that promote the application of the recommendations in practice. These should be taken into account before, during and after the guideline development process.

Because implementation is not a linear process, it is important that guideline developers consider the applicability and implementation of a guideline’s recommendations during the development phase. They can promote implementation by creating a number of conditions for implementation during the development phase. This tool includes a number of short and concise conditions. Guideline developers’ involvement and responsibility in the guideline process usually ends after the development and dissemination of the guidelines. They are not usually involved with or responsible for the implementation of the guideline’s recommendations. Therefore, this tool focuses on the specific attention that should be paid to the implementation of a guideline’s recommendations. Recommendations for the choice of an implementation strategy are not part of this tool. In general, the chosen strategies should be linked to the findings from the problem analysis, which looked at specific facilitating and obstructing factors for implementation of one or more of the guideline’s recommendations. An overall comprehensive strategy (‘magic bullet’) for implementation does not exist.

2. Objective of this tool

This tool includes a list of attention points to structurally consider aspects during the guideline development process that will help with later implementation of the guideline recommendations in practice.

3. Content of the tool

Below are a number of attention points for implementation during the guideline development process and the distribution of guidelines. These attention points are based on and ranked according to the eight themes on the checklist for implementation activities by Grol and Ouwens in Chapter 19 of ‘Implementatie, effectieve verbetering van de patiëntenzorg [Implementation, effective improvement of patient care] by Grol and Wensing, Reed Business 2011.’

  1. Implementation objectives
    • Is there a clear description of the recommendations that are being implemented?
    • Is there a clear description of the target groups on which the implementation is focused?
    • Are the target groups involved in formulating the recommendations and objectives for improvement?
  2. Tool kit
    Have specific aids been developed to help with implementation?
    • Aids for professionals (summaries, decision trees, decision support systems)?
    • Aids for patients (leaflets, internet applications, videos)?
    • Aids for organisations (care pathways, protocols, collaboration models, best practices)?
  3. Dissemination or distribution plan
    Have specific plans been made to inform target groups about proposed changes in response to the guideline’s recommendations?
    • Does a clear description of the target groups exist?
    • Have different approaches been planned for different segments in the target groups?
    • Is there a concrete description of the channels through which information will be distributed? (e.g. through websites, social media, guidelines sent to users, publication of the guideline in scientific, association or professional journals, regional (organisational) structures, PR campaigns). Link the media coverage to communication channels that the target group is currently focused on and be clear about what changes the new guideline entails in practice. Connect to and make use of existing regional structures such as medical coordination centres, professional education organisations, care groups and regional support structures.
    • Is there a concrete description of who is responsible for distribution?
    • Is repeated attention paid to promoting the guideline by adapting it based on feedback on the distribution and the actual use of the guideline in practice?
  4. Indicators and measures
    A systematic approach will be applied to the development of indicators, measures and feedback.
    • Is there a limited set of selected core recommendations that people would like to see made measurable?
    • Have valid and reliable indicators been developed for these core recommendations?
    • Has a measurement of the actual care been conducted to determine the most important problems?
    • Have the results of the measurement been used to select a few concrete objectives for improvement?
  5. Problem analysis
    A systematic approach will be applied to factors that positively or negatively influence the implementation of a guideline’s recommendations.
    • Has an analysis been carried out of all the parties in the implementation process (who is important, who plays what role)?
    • Have the factors that hinder or facilitate change been charted (preferably by a planned change target):
      • by professionals;
      • by patients;
      • by teams in care processes;
      • in an organisational context (staff, resources, culture, leaders, etc.);
      • in a political, economic and legal context?
    • Have the factors that play a role in the implementation plan been prioritised?
  6. Carrying out the implementation plan
    A systematic approach will be applied to the change in practice.
    • Have interventions and measures been selected that are connected with the results of the problem analysis?
    • Has a plan been made for when each part of the intervention takes place?
    • Has a division of tasks been made (who does what)?
    • Is the target group involved in the change plan?
    • Have measures been foreseen to preserve and anchor the preferred new method, even after completion of the project?
  7. Evaluating the result
    • Have the methods been determined for collecting, analysing and providing feedback about the (indicator) data?
    • Has a plan been made for which evaluations will take place when over the course of time?
  8. Organising the plan
    • Is there a project team with a suitable leader and sufficient expertise?
    • Have a budget and other resources/personnel been determined?
    • Has the current and long-term support of management (also at a higher level) been obtained?
    • Is the target group sufficiently involved in the project at all important moments?
    • Has a concrete plan with all the steps for the implementation project been clearly defined?

Below are some additional attention points from experienced guideline developers:

  • Ensure agreement in the development group about review questions that align with care gaps in clinical practice. Where necessary, pay attention to heterogeneity in patient characteristics.
    (Tool for the analysis of clinical care gaps, Tool for developing population-specific recommendations, Tool for considering sex differences in guideline development)
  • Involve implementation expertise in the development phase.
  • Under the heading ‘other considerations’, report any major consequences of the recommendations, subdivided into financial, organisational, political and otherwise.
  • Ensure that the guideline is readable by providing a clear and compact structure, an attractive layout and a summary.
  • Where possible, analyse the implications to costs and revenues of applying the guideline (e.g. by performing a budget impact analysis). A clear view of the concrete financial consequences facilitates implementation.
  • Reserve some of the budget for carrying out a problem analysis that will identify factors that may positively or negatively affect implementation and for preparing an implementation strategy; do this through a trial implementation.
  • Map out the preconditions for applying the guideline’s recommendations (practice management aspects, people and resources).
  • Ensure broad acceptance by the target groups (client and user) by carefully selecting a committee, asking for many stakeholders’ comments and establishing ownership of the guideline. Sometimes it is necessary to create a separate committee or board.

4. Literature

  1. Barneveld T.A. van, Broek L. van den, Burgers J.S., Schouten L.M.T., Steeg H.C. van de. Implementeren van richtlijnen. Een leidraad voor adviseurs CBO 2006.
  2. Broerse A., Fleuren M.A.H., Kamphuis M., Dommelen P. van. Effectonderzoek proefimplementatie JGZ-richtlijn secundaire preventie kindermishandeling TNO 2009.
  3. Burgers J., Grol R., Zaat J. Richtlijnen en protocollen als hulpmiddel bij de verbetering van de zorg. In: Grol, R, Wensing, M. Implementatie, effectieve verandering in de patiëntenzorg. Elsevier Gezondheidszorg, Maarssen, 2001.
  4. Burgers JS Quality of clinical practice guidelines [ proefschrift]. Nijmegen 2002.
  5. Chong, C.A, Chen, I., Naglie, G. & Krahn, M.D. (2009). How Well Do Guidelines Incorporate Evidence on Patient Preferences? J Gen Intern Med 24(8): 977–82.
  6. Conroy, M. & Shannon, W. (1995). Clinical guidelines: their implementation in general practice. British Journal of General Practice, 45, 371-375.
  7. Fleuren MAH. Essentiële activiteiten en infrastructuur voor de landelijke invoering en monitoring van het gebruik van de JGZ-richtlijnen. TNO Kwaliteit van Leven, 2010.
  8. Fleuren MAH, Wiefferink CH, Paulussen TGWM. Determinanten van innovaties in gezondheidszorgorganisaties; systematische literatuurreview. Tijdschrift voor Gezondheidswetenschappen (TSG), 2006; 160-167.
  9. Fleuren MAH, Wiefferink CH, Paulussen TGWM. Determinants of innovation within health care organizations: Literature review and Delphi-study. International Journal for Quality in Health Care, 2004; 16, 107-123.
  10. Foy, R., MacLennan, G., Grimshaw, J., Penney, G., Campbell, M. & Grol, R. (2002). Attributes of clinical recommendations that influence change in practice following audit and feedback. Journal of Clinical Epidemiology 55: 717–722.
  11. Francke, A.L., Smit, M.C., De Veer, A.J.E. & Mistiaen, P. (2008). Factors influencing the implementation of clinical guidelines for health care professionals: A systematic meta-review. BMC Medical informatics and decision making. 8:38 doi 10.1186/1472-6947-8-38.
  12. Grol, R, Wensing, M. Implementatie, effectieve verandering in de patiëntenzorg. Reed Business, Amsterdam, 2011.
  13. Grol, R. (2001). Successes and Failures in the Implementation of Evidence-Based Guidelines for Clinical Practice. Medical Care Volume 39, Number 8, Supplement 2, pp II-46–II-54.
  14. Grol, R., Wensing, M., Laurant, M. & Harmsen, M. Implementatie van kennis in de praktijk. Het richtlijnen implementatieprogramma. Maastricht/ Nijmegen: WOK, UMC St Radboud. Mogelijk gemaakt door het Ministerie van VWS. 2003.
  15. Grol, R.P.T.M. & Wensing, M.J.P. Implementatie: effectieve verbetering van de patiëntenzorg. Amsterdam: Reed Business, 2011.
  16. Grunberg, S.M. (2009). Obstacles to the Implementation of Antiemetic Guidelines. Journal of the National Comprehensive Cancer Network, 7(5) 601-605.
  17. Harmsen M., Wensing M. en Grol R.P.T.M.. Implementatie van richtlijnen en innovaties. Lessen uit de praktijk, Nijmegen: Centre for Quality of Care Research (WOK) 2002.
  18. Koot j., Pos S., Rietveld S. Focus op Implementatie van Richtlijnen ontwikkeling van een checklist en een meetinstrument. Regieraad, Kwaliteit van Zorg 2010.
  19. Moriss, R. (2008). Implementing clinical guidelines for bipolar disorder. Psychology and Psychotherapy: Theory, Research and Practice, 81: 437–458.
  20. NHMRC. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra: National Health and Medical Research Council 1998.
  21. Richtlijn voor Richtlijnen. Den Haag, Regieraad 2010.
  22. The Agree Collaboration. Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument. www.agreecollaboration.org.
  23. Van Everdingen JJE, Burgers JS, Assendelft WJJ, Swinkels JA, Van Barneveld TA, Van de Klundert JLM (redactie). Evidence-Based Richtlijnontwikkeling. Een leidraad voor de praktijk. Houten: Bohn Stafleu Van Loghum; 2004.
  24. Zuiderent-Jerak T, Jerak-Zuiderent, S, Bal R. Veiligheidsnormen in richtlijnen: kansen en valkuilen voor het besturen van kwaliteit. Rotterdam: Instituut Beleid & Management Gezondheidszorg, 2009.