Dr Philip Cotton, Dr Liz Duncan and Professor Frank Sullivan describe Lanarkshire Health Board's strategy for translating national guidelines into local protocols
While the science of guideline development has been keenly pursued, the art of guideline implementation has lagged behind.1 Yet without implementation, guidelines are only a pipe dream.
A guideline produced at a national level is implemented by a variety of individuals in a range of settings. Transferring a guideline into varying environments therefore requires careful planning. Primary healthcare teams (PHCTs) will require skills that enable them to translate guidelines into protocols for use in their unique contexts.
While most clinicians will welcome a more evidence-based approach to clinical practice, the pace of guideline adoption is likely to be influenced by factors outside the medical profession. Government legislation, technology, and patient expectations all influence the process, as does the new commissioning and purchasing culture. These factors may also account for the feelings of imposition that clinicians often associate with guidelines.
There is very little experience on which to base a strategy for guideline implementation, yet implementation has been made urgent by the arrival of the Scottish Intercollegiate Guideline Network (SIGN) guidelines. This article describes Lanarkshire Health Board's experience with guideline implementation over the past 2 years.
Consultations with healthcare professionals in Lanarkshire, by a ostal questionnaire, meetings and interviews, have addressed some of the implications of guideline implementation.
A postal questionnaire was developed by a multidisciplinary panel and piloted in hospitals and general practices. The experiences and attitudes of 591 healthcare professionals (309 GPs, 74 practice nurses, 178 hospital consultants and 30 senior hospital nurses) were assessed; 437 (74%) returned completed questionnaires.
Invitations to attend two evening meetings to explore guideline implementation were sent to all practices, primary care audit facilitators and public health consultants. Forty-seven professionals attended each meeting. The first meeting dealt with factors influencing the implementation of disease-specific guidelines (asthma, diabetes, epilepsy, dyspepsia and rheumatoid arthritis). Hospital pecialists were invited to facilitate the small group work. At the second meeting a presentation on the economic implications of H. pylori eradication was followed by a discussion.
Individual interviews were held with five GPs and five practice nurses.
Common themes found were:
|The different perceptions of healthcare workers|
|Issues around evidence|
|Research and the dissemination of information|
|Standard setting in terms of objectives and outcomes|
|Time and money concerns|
|The problems of sustaining guideline recommendations over time|
|Local ownership and strategies for guideline implementation.|
There have been several surveys of GPs' perceptions of clinical guidelines,2,3 but little is known about those held by other PHCT members.
The perceptions of practice nurses' in this study reflect differences in role, gender, decision making, responsibility and training.4 They regard guidelines as important in improving the quality of care, the rational use of resources, and facilitating clinical decision making.
Common concerns, several of which are reflected in the literature, were:
|Guidelines involve more work and will lead to data overload in practice|
|The medico-legal implications of failure to comply with a guideline5|
|The threat to clinical freedom, arising from fears that guidelines will become rigid protocols3|
Guidelines are Government driven or imposed from outside.
The experiences of professionals can help to anticipate problems with implementation, assist in the transfer of research information to wider stakeholder audiences and promote acceptance for change.6 Their concerns about guideline implementation could be addressed nationally through published material, meetings with opinion leaders and local workshops on practical skills.
Guidelines often reveal gaps in existing knowledge, which may cause confusion in some practitioners. Clinicians in this study wanted to understand not only the nature and sources of the scientific evidence but also the rationale for guidelines. More work is needed on the dissemination of research information to practitioners and the cumulative clinical and financial effects of decisions.7
Mailing guidelines and publishing research findings in major journals were not seen as effective ways of disseminating information, and information and guidelines for patients were needed. Training in critical appraisal and IT skills, specifically accessing the internet, was requested.
Professionals felt that the broad objectives of guideline implementation were 'getting effective care into practice' or 'delivering consistent and predictable care at reasonable costs'.
More detailed objectives, specific to particular conditions, must be clear. The criteria used, e.g. 'potential for health gain', are not always familiar to everyone.
Outcomes must be relevant, easily measurable and fed back to the users, who should be equipped to act on the information received.8
It was agreed that early evaluation might be useful, as it would be encouraging to demonstrate an improvement in patient care during the process of implementation.
Feedback, although considered a poor implementation strategy by the paricipants in this study, is part of the process of reinforcement, and it was felt that the recognition of positive outcomes by stakeholders would help to maintain change.
Implementation is the most commonly rushed stage of the process of change, and will almost certainly fail if the full impact of change is not realised before this stage.9
Valid guidelines can take a great deal of time and resources to develop, yet it is often not appreciated how long implementation can take.
All stages from development to evaluation of guidelines should be scheduled well in advance. The involvement of practising clinicians at health board/authority level in guideline coordination groups is essential if the time and pace of introduction is to be appropriate. The existing workload and time pressures in practice mean that unrealistic time scales will generate resistance.
Account has to be taken of the time needed to develop new skills; protected time and accreditation for practice-based education were suggested. Coordination and consultation both locally and nationally is time consuming, and remuneration should be given for travel expenses and locum cover.
Guideline recommendations may result in more costly management options shifted into primary care without a shift in funding. Implementation may well be costly in time and money and needs adequate funding for audit and evaluation, reconfiguring practices, employing new staff and training existing staff.
Collaboration has a pivotal role in the implementation of guidelines. Teams at practice, health board/ authority and national levels should be multidisciplinary,10 with primary and secondary care, public health, management, audit, research and consumer groups all represented when appropriate.
In Lanarkshire, a guideline coordination group has been set up with trust, board and primary care representation.
Difficulties may arise from strong personalities and unequal relationships. One way round this is for the lead person to change for each guideline. Effective leadership and good communication are essential if inter- professional and inter-organisational barriers are to be broken down.LA participative, non-directive, non-paternalistic approach was called for.
Increasingly, SIGN working groups are involving patient and carer representatives in guideline development. This could be extended to implementation.
Guideline implementation is not just about introducing change, but also about continuing predicted improvements. Many people feel that guidelines are poorly sustained over time. Lack of peer support, both within practice, particularly for nurses, and locally, was cited as a major factor.
Likely predictors of compliance with guidelines include workload, the target area of work, and the complexity of a recommended procedure.11 Sustainability may therefore require analysis of guideline compliance linked with guideline usability and, above all, matching the guidelines to practitioners and patients.
Reinforcement and reiteration are elements of sustainability, and while guidelines will not disappear, incentives and support services might.
Local commitment is vital for effective implementation and long-term maintenance of guidelines.12 The economic and political climate both creates opportunities and threatens commitment.
Priorities for guideline implementation should be set at health board/ authority level through multidisciplinary consultation involving lead groups such as the area clinical audit committees and drug and therapeutics committees. Local priorities may not necessarily accord with those set elsewhere or nationally.13
The Scottish Council of the RCGP has compiled a 'talent list' to link interested professionals. Talent lists may be a useful means of progressing guideline implementation locally.
A local guidelines support agency Ùould serve as a clearing house for guidelines currently being produced by a series of agencies. Guideline facilitators could carry out literature searches, offer technical support for practitioners, coordinate the distribution of guideline updates and judge the suitability of guidelines for local implementation.
In some health boards/authorities, an alliance of primary care professionals deals with issues of implementation in practice.
Local implementation strategies capitalise on predisposing physicians to change behaviour by enabling and reinforcing desired change.14
The literature seems clear about the strategies to aid guideline implementation: those operating within a consultation work better than those outside,15 and those operating closer to the end users and those integrated into the process of healthcare delivery are more likely to be effective.16 It is possible to use a combination of inter-ventions aimed at specific barriers.17
Selection of an appropriate format in which to present guidelines was seen as more important than strategies. Algorithms received little support, while concise text with summary points was favoured most strongly.
It is unlikely that any one strategy or combination of strategies will work in all settings. It is essential to create environments that enhance and encourage change and optimise physician cooperation.18
What guidelines are prone to manipulation by sanction or incentive could be regarded as a threat. However, incentives could be linked to resource allocation, e.g. full reimbursement for practice nurses and free asthma training for nurses.
Successful translation of nationally derived evidence-based guidelines into local protocols demands that guideline developers and implementers remain responsive to local circumstances as much as they do to new evidence.
Uncertainty may arise from the speed of development of the guideline process, and the lack of experience of implementation on which to reflect, but there is a need to move beyond the barriers. Achieving a balance between positively encouraging acceptance of guidelines as syntheses of current knowledge and vectors of change, and being too proscriptive about their use, is difficult and needs carefully planned and executed programmes.
The mnemonic 'protocols' (see below) combines all of the themes arising from the questionnaire, meetings and interviews. It describes the components that practitioners consider paramount to the implementation of national guidelines into local protocols. It highlights the most important aspects of guideline implementation; in some cases it is a checklist for implementation of national guidelines and can be used as a checklist for practice-derived guidelines.
|The mnemonic 'Protocols'|
|Perceptions of stakeholders|
|Time and money|
|Strategies for guidelines implementation|
Checklists alone do not guarantee successful implementation: there needs to be some element of preference base reflected in our evidence base. Implementing guidelines is as much about putting the knowledge and experience of practice into protocols (without changing the evidence) as of putting protocols into practice.
Changes in practice are more likely to occur if the process of implementation is participative, consultative and collaborative. Practice-based implementation workshops and special interest practitioner groups may be one way forward.19
The impact of implementation may be greater than the sum of its components. Moving from guidelines to protocols is easier if each component is identified and addressed. The mnemonic 'protocols' may help to remind us of that.
- Delamonthe T. Wanted: guidelines that doctors will follow. Br Med J 1993; 307: 218.
- Siriwardena AN. Clinical guidelines in primary care: a survey of general practitioners' attitudes and behaviour. Br J Gen Pract 1995; 45: 643-7.
- Newton J, Knight D, Woolhead G. General practitioners and clinical guidelines: a survey of knowledge, use and beliefs. Br J Gen Pract 1996; 46: 513-17.
- Cotton P, Ross S, Sullivan F. Protocol development: attitudes among GPs and practice nurses. Pract Nurs 1997; 8(6): 21-24.
- Hurwitz B. Clinical guidelines and the law: advice, guidance or regulation? J Eval Clin Pract 1995; 1: 49-60.
- Charles C et al (1994). Involving stakeholders in health services research – developing Alberta resident classification system for long-term care facilities. Int J Health Serv 1994; 24(4): 749-61.
- Lomas J. Retailing Research – Increasing the role of evidence in clinical services for childbirth. Milbank Q 1993; 71(3): 439-75.
- Greco P, Eisenberg JM. Changing physicians' practices. N Engl J Med 1993; 329(17): 1271-4.
- McCalman J, Paton RA. In: Change Management: A guide to effective implementation. London: PCP, 1992.
- Kitson A. The multi-professional agenda and clinical effectiveness. In: Deighan M, Hitch S (Eds). Clinical Effectiveness from Guidelines to Cost-Effective Practice. London: Earlybrave, 1995.
- Grilli R, Lomas J. Evaluating the message – the relationship between compliance rate and the subject of a practice guideline. Med Care, 1994 ; 2(3): 202-13.
- Flynn BS. Measuring community leaders perceived ownership of health education programmes: initial tests of reliability and validity. Health Educ Res 1995; 10(1): 27-36.
- Cotton P, Duncan E, Sullivan F. Whose priorities? Do those of primary care professionals match national ones? Poster presented at AUDGP Conference, Dublin, July 1997.
- Lomas J et al. Diffusion, dissemination and implementation. Who should do what? Ann NY Acad Sci 1993; 703: 226-37.
- Grimshaw JM, Russell IT. Achieving health gain through clinical guidelines II: ensuring guidelines change medical practice. Qual Health Care 1994; 3: 45-52.
- Grol R. Implementing guidelines in general practice care. Qual Health Care 1992; 1(3): 184-91.
- Wensing M, Grol R. Single and combined strategies for implementing changes in primary care: a literature review. Int J Qual Health Care 1994; 6(2): 115-32.
- Bula CJ et al. Community physicians cooperation with a programme of in-home comprehensive geriatric assessment. J Am Geriatr Soc 1995; 43(9):1016-20.
- Davis DA et al. Changing physician performance – a review of the effect of CME strategies. JAMA 1995; 274(9):700-5.