- Large NHS trusts can benefit from a robust implementation framework
- Some guideline recommendations are too difficult or resource intensive for individual clinicians to manage alone
- Any governance process must demonstrate clear benefits if staff are to be engaged
- Applying change-management theory can resolve common barriers to implementation
- The governance team has a pivotal role in supporting clinicians to get guidelines into practice.
Although individual clinicians have a responsibility to consider and implement clinical practice guidelines where possible, in large NHS trusts some guideline recommendations are simply too difficult or resource intensive to manage alone. This is where having a systematic approach to implementation, and support from the governance team, can really make the difference between paper and practice.
Department of Health (DH) reforms have led to major restructuring throughout the NHS, resulting in fewer NHS trusts serving a larger geographical area. The Transforming Community Services1 initiative has brought significant changes to the size and spread of community trusts. Lancashire Care NHS Foundation Trust (LCFT), the author’s workplace, now provides a range of services from dentistry to inpatient mental health facilities, and such diversity of services means many more clinical guidelines are applicable, all of which need reviewing.
Governance teams often have some responsibility for monitoring and reporting on the uptake of clinical guidelines, and so have the advantage of a bird’s-eye view of practice across a trust. Having a carefully managed, trust-wide approach to guideline implementation provides an opportunity to share good practices, and can enable individuals to flag up when a recommendation is difficult to get into practice; for example where a guideline recommends a new service or costly therapy.
This article outlines the framework for implementation of NICE guidelines—a set of steps that were developed to manage implementation in a large trust following significant restructuring. This framework, as adopted in the LCFT, draws upon change-management theory to break down common barriers to implementation.
Barriers and enablers
Changes in practice usually have to occur before implementation of a guideline becomes routine, and such changes need to be carefully managed in order to be effective.2 An understanding of what barriers to implementation may exist is therefore essential for anyone taking a lead on guideline implementation (either in a governance team or as an individual).3 ‘Barriers’ are discussed in this article in broad terms (i.e. not in relation to specific guidelines, but rather to implementation in general). Once identified, measures can be put in place to try and overcome such barriers.
Barriers to guideline implementation are discussed in two published systematic reviews undertaken by Cabana M et al in the USA4 and by NICE and The King’s Fund.5 These reviews were considered alongside potential intervention strategies on effective guideline implementation (as identified from published research6–9) during the development of the LCFT framework.
Lancashire Care NHS Foundation Trust was established in April 2002 and authorised as a Foundation Trust on 1 December 2007. It covers the whole county and provides health and wellbeing services for a population of around 1.5 million people, employing over 7000 members of staff across more than 400 sites.10 The trust specialises in inpatient and community mental health services,10 and provides community nursing, health visiting, and a range of therapy services including physiotherapy, podiatry, and speech and language support.
The NICE implementation framework described here (see Figure 1, p.56) has been in place at LCFT for 2 years, with a designated post funded to support it—the NICE Guidelines Lead. One of the key aims of publishing this framework here is to share and offer it as an idea that could be adapted to work in other trusts.
The rationale for each step in the framework is described in detail below. As with any governance-related activity, it is important to know why you are asking staff to do something extra on top of their day-to-day clinical practice. Any process must demonstrate clear benefits or it is unlikely to receive support or to be sustainable.11
The key stages in this framework are as follows:
- register as a stakeholder
- circulate to teams once published
- complete a baseline assessment
Register as a stakeholder
At LCFT, draft versions of NICE guidelines are circulated at each stage of their development, and clinicians are encouraged to submit comments via the NICE Guidelines Lead (contributors will then receive acknowledgment from the trust for their input). This process is important because:
- NICE does not always get it right first time—the greater the input into a guideline, the more robust the end result is likely to be
- there is a considerable barrier to implementation when a clinician makes a conscious decision not to implement a guideline because he or she disagrees with it.4,12
Ensuring that key staff are included in conversations about draft versions can help increase receptiveness to the guideline post publication. Staff who have taken the time to comment on a draft guideline tend to be more senior opinion leaders,11 with influence over their peers;13 it is therefore worth investing time and effort in this stage of the process.
Being acknowledged as a contributor in the final version of the guideline can be very satisfying for the individual clinician, and for board level managers if the trust is perceived as being at the forefront of advancing practice.
Circulate to teams once published
Clinicians need to know about the existence of guidelines for them to be able to put the recommendations into practice. In research literature about guideline uptake, the most commonly cited reason for poor implementation is a general lack of awareness of its existence by clinicians.4,5,14,15
Therefore when NICE sends an email announcing the publication of new guidelines in that month, two processes take place at LCFT:
- a notification is placed in a weekly e-bulletin (‘NICE News’) with a hyperlink to the NICE website
- team leaders and/or service managers in LCFT are sent details of that month’s guidance, and asked to identify (within 4 weeks) if a guideline is applicable; these staff check the guidelines and email back one of the following responses:
- ‘not applicable’
- ‘to be circulated for information’
- ‘to be implemented’.
This regular communication with teams ensures that NICE guidelines become part of the culture of LCFT. The ‘drip-drip’ effect of monthly emails and bulletins means that consideration of guidelines becomes routine, and they are therefore more likely to be embedded in systems; for example, including them in policies, care pathways, and strategic development.
The main outcome of this part of the process, though, is that teams and managers are fully aware when a relevant guideline is published and know they need to familiarise themselves with the content. This lays the foundations for the next stage in the process, the baseline assessment.
Complete a baseline assessment
The systematic review by Cabana4 identified ‘a lack of familiarity’ with a guideline as a significant barrier to implementation (i.e. knowing a guideline exists, but not fully understanding all the recommendations). One implementation tool that NICE produces to support clinical guideline implementation is an Excel ‘baseline assessment’ (e.g. www.nice.org.uk/guidance/CG137/BaselineAssessment/xls/English [for the NICE guideline on epilepsy]). Once a team identifies a guideline as applicable to their work, they are asked (and given support) to complete this baseline assessment. As a result of this process, each team will understand the recommendations and can assess their current level of implementation against the guideline. It is only by completing the baseline assessment that they can identify if there is anything they need to change, or request support for. This process will also allow teams to identify their strengths, and gives them an opportunity to share good practice. For example, if one team has an excellent patient leaflet or useful template document that would be useful in supporting guideline implementation, this can be acknowledged and shared with other teams in a different part of a trust.
Completion of the baseline assessment also enables individuals, managers, and teams to identify whether they need additional resources to implement the guideline or if a guideline recommends something not within their ability to put into practice (e.g. the establishment of a new service, training programme, or provision of new therapies).
As part of the framework, baseline assessments are completed with support from the NICE Guidelines Lead. A key function of this post is to facilitate and share any areas of good practice identified through the baseline assessment process, and to report upwards if any additional resources are required. Completed baseline assessments are discussed at governance business meetings, which are held by each network within the LCFT. If implementation cannot be managed at a local level or within existing resources, members of the governance group can initiate conversations with the executive team and/or commissioners.
A 6-monthly report is forwarded to the LCFT Board to inform them of the level of implementation against each guideline. Senior level support is invaluable in ensuring the LCFT framework works in practice; although this is not surprising given the wealth of evidence on top-down support in organisational development theory.11,16
Lancashire Care NHS Foundation Trust takes the pragmatic view that while every endeavour is made to implement guidelines, if barriers still exist (e.g. because of a lack of resources), then highlighting these via governance processes at least makes the decision-making process transparent.
Implementation, of course, takes place at each stage of the process. General awareness of the guideline, understanding that it has been developed in collaboration with LCFT staff, and familiarity with the recommendations, is likely to have already influenced practice. However clinical guidelines do not usually leap from paper into practice without at least some conscious effort, and with any new guideline it is unlikely every recommendation will already be embedded in practice. Common barriers here include a lack of training, time,16 resources,4,5,17,18 and IT capabilities (e.g. not being able to record or link data to a patient digitally).
Large NHS trusts have corporate departments (i.e. information management and technology teams, training teams, pharmacy department) that can be considered a resource when attempting to implement more strategic aspects of guidelines. Some changes cannot be made by individual clinicians, for example, clinical system changes, including training in the mandatory training programme, aligning care pathways to NICE guidance, or revising the prescribing formulary. By working with these corporate services, the governance team and/or designated NICE Guidelines Lead can help coordinate implementation across a trust.
Finally, ensuring staff are aware when a guideline has been successfully implemented is critical to engagement. Trying to implement NICE guidelines in a recession is challenging, and we all need short-term wins10 to keep us going.11
It is not easy to get guidelines into practice, particularly across teams in a large NHS trust; therefore having a robust implementation framework and support from the governance team/designated NICE Guidelines Lead can make the difference between paper and practice. Other trusts can of course apply some or all of this framework to national non-NICE guidance provided that drafts are available, and open to consultation.
The framework operational in LCFT, now in place for 2 years, is based upon a sound understanding of the barriers to achieving implementation and how these barriers are addressed by following change-management principles.
- Department of Health. Transforming community services: enabling new patterns of provision. London: DH, 2009. Available at www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093196.pdf
- Davis D, Taylor-Vaisey A. Translating guidelines into practice: a systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 1997; 157 (4): 408–416.
- Grol R, Grimshaw J. Evidence-based implementation of evidence-based medicine. Jt Comm J Qual Improv 1999; 25 (10): 503–513.
- Cabana M, Rand C, Powe N et al. Why don’t physicians follow clinical practice guidelines? JAMA 1999; 282 (15): 1458–1465.
- Robertson R, Jochelson K. Interventions that change clinician behaviour: mapping the literature. NICE: London, 2007. Available at: www.nice.org.uk/media/AF1/42/HowToGuideKingsFundLiteratureReview.pdf
- Grimshaw J, Shirran L, Thomas R et al. Changing physician behaviour: an overview of systematic reviews of interventions. Med Care 2001; 39 (8 Suppl 2): II2–45.
- Grimshaw J, Thomas, R, MacLennan G et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004; 8 (6): iii–iv, 1–72. Available at: www.hta.ac.uk/fullmono/mon806.pdf
- Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003; 362 (9391): 1225–1230.
- NHS Centre for Reviews and Dissemination. Getting evidence into practice. Effective Health Care 1999; 5 (1).
- Lancashire NHS Foundation Trust website. About us. www.lancashirecare.nhs.uk/about-us.php (accessed 28 February 2013).
- Kotter J. Leading change. Boston: Harvard Business School Press, 1996.
- Tufnell D. Why clinical guidelines? A medical perspective. In: Tingle J, Foster C. Clinical guidelines: law, policy and practice. London: Cavendish, 2002.
- Doumit D, Gattellari M, Grimshaw J, O’Brien M. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2007; 24 (1): CD000125.
- Fedder G, Eccles M, Grol R et al. Using clinical guidelines. BMJ 1999; 318 (7185): 728–730.
- Rhodes L, Genders R, Owen R et al. Investigating barriers to implementation of the NICE guidelines for depression: a staff survey with community mental health teams. J Psychiatr Ment Health Nurs 2010; 17 (2): 147–151.
- Mullins L. Management and organisational behaviour. 8th ed. London: Pitman Publishing, 2008.
- Riley A, Byng R, White C, Smith S. Utilising theories of change to understand the engagement of general practitioners in service improvement: a formative evaluation of the Lewisham Depression Programme. Qual Prim Care 2008; 16 (1): 17–26.
- Audit Commission. Managing the financial implications of NICE guidance. Health national report. London: Audit Commission, 2005. Available at: www.nice.org.uk/niceMedia/pdf/financial_implications_NICE_guidance.pdf G