Introducing a guideline is a bit like putting on a village play: someone needs to get the ball rolling. Roles have to be assigned, and not always because someone has a natural talent for acting. All those involved have to agree a script, and arrangements have to be made according to a plan.
The first task is to identify the key players involved in implementing your guideline. The four key groups or individuals are shown in Table 1.
Earlier articles in the series have considered the desirable characteristics of the group that developed the guideline. The development team lends legitimacy to the recommendations and provides a solid technical and professional bedrock for the proposed change in practice.
An advocate is very important: you need an enthusiast to get things going. Bear in mind, however, that the sort of person who initiates projects is not likely to be well suited to keeping them going in the long term.
The implementation team will need to represent key stakeholders. Some of these may represent a key group (e.g. a practice nurse to ensure that the team takes account of the views of practice nurses) to act as a channel of communication with that group.
Others may be there in a personal capacity: the advocate will almost certainly be a member of the team, as may the opinion leader who commands the respect of local clinicians.
Non-clinical staff may also need to be involved: this may include operational staff (e.g. practice managers) or others, such as local health authority managers or trust managers who can contribute their management expertise and speak for and communicate with the organisations from which they come.
Finally, a patient representative may be invaluable.
A balanced implementation team, then, is made up of:
- The product champion
- An opinion leader
- Representatives of relevant clinical staff groups
- Representatives of relevant non-clinical staff groups involved in supporting the care
- Non-clinical staff such as local trust or health authority managers
- Patient representatives.
Apply three golden rules to your group:
- Directly or indirectly involve everyone who has an interest in applying the guideline and dealing with the consequences of change.
- Have a good chairperson, who will make sure that all points of view are acknowledged and that people feel valued.
- Keep the group to no more than about 10.
Finally, there are the clinical and non-clinical staff who are going to make the guideline work or not. As the rest of this series makes clear, implementation is a matter of understanding the target audience and creating situations that make people feel comfortable with change and committed to it.
The guidelines industry has been too product-focused in the past: it needs to become more customer-focused. Customer focus reflects the way the target audience thinks, not the way experts think, or the way experts think they should think.
A good implementation team is a secure foundation for a successful implementation plan. At the core of a good implementation team are people who understand how their group thinks and feels, and can suggest ways in which the plan can meet their needs.
Time spent planning is always time well spent, unless it is used as an excuse for procrastination. You will find a clear idea of your goals, and the steps you intend to take to get there, invaluable. Much better to make your mistakes and correct them at the planning stage than later on.
At the planning stage, use your local knowledge to identify barriers and opportunities. Select methods that capitalise on opportunities and overcome barriers. Opportunities are often overlooked: what is obvious is not always apparent. Barriers are often best overcome by avoiding them rather than confronting them.
1. Secure local support
This means making sure that the organisation (e.g. the practice manager, the PCG board) understands what is proposed and is able and willing to take steps (such as reorganising the layout of a health centre, or the way in which records are kept, or employing staff with new skills) to support the plan.
You also need to get key opinion leaders (e.g. the practice nurse who has the respect of her colleagues, the GP whose views count for a lot at local meetings) on board. If they are not committed to your goals, colleagues will assume that your work is not really worth supporting.
Professional committees are also important, in that they lend your proposal the authority it needs to succeed when dealing with people who are reluctant to change.
2. Disseminate the guideline
You need to plan to disseminate the guideline in a way that is likely to make the proposals clear to your colleagues and persuade them of the need for change.
Dissemination is not a technical term for posting or circulating printed material, although you could be forgiven for thinking so. Dissemination means communicating knowledge about the guideline to potential users in an effective way. Posting material out when it comes back from the printer does not change behaviour which is why guidelines and audit so often fail to deliver what is expected of them.
Key things to remember about dissemination are:
- The initial information should be presented personally, to give you an opportunity to explain what is proposed and listen to the responses.
- There is no single effective way to ensure the use of guidelines in practice, and you should therefore use a selected range of interventions that suit the circumstances in which you work.
- Reminders should be simple, be presented, where possible, at the time the clinician is making the decision, and be specific to the patient. For example, a red sticker reminding a GP to take the blood pressure of a middle-aged patient next time he/she visits the surgery for any reason is more likely to be successful than a general reminder in the health authority's parish newsletter about the need to screen all middle-aged patients for hypertension.
3. Introduce mechanisms
Key points here are:
- Feedback of information should be active rather than passive. Active feedback involves judgment and intervention; passive involves neither. Sending out a table of #ercentage of middle-aged patients ácreened for hypertension by practice 'for information' will be less effective than a discussion of the results between the clinical governance lead and practice staff. This discussion not only serves as a reminder, but also allows people to explain any problems they may have in making the guideline work as intended
- Organisational changes, where appropriate, are powerful ways of altering behaviour and maintaining new patterns of care. A practice computer system that prominently displays a prompt reminding a GP that a patient has not had a blood pressure "easurement for more than 5 years, and can only be overridden with some effort, is more likely to be successful than a general appeal to think about the need to watch for cardiovascular risk factors.
- Don't neglect incentives. These may be financial or non-financial and positive or negative. In general, positive incentives work better than negative ones. Very often, incentives in the NHS are not financial, but you should still look for opportunities to reward people for making the effort to change. For example, there may be an opportunity for the practice to gain recognition under the 'Beacon' initiative, a piece of work can be published in a medical journal, or the project may contribute to a higher degree.
- Link continuing education with the needs revealed in the course of implementing your guideline. Remember that this may not always involve simple knowledge transfer (an update on current best practice etc.); for some, personal development (learning to work better in a team or better communication skills etc.) may be more relevant.
- Interventions based on assessment of potential barriers are more likely to be effective.
4. Monitoring progress
Finally, you need to monitor implementation. Although this is the subject of the next article, a few words are appropriate here.
Monitoring is essential to successful implementation. However sound yourìplanning and earnest your efforts, you cannot assume success and must be prepared to adjust the plan in the light of changing or unexpected circumstances.
Implementing guidelines successfully is difficult not because it is technically complicated, but because it requires patience, sensitivity, attention to detail, flexibility and, above all, tenacity.
Good planning will raise the chances of achieving your goals. Predicting problems makes them much easier to deal with, and identifying opportunities means that you don't fail to get the support you will need.
Eve R, Golton I, Hodgkin P, Munro J, Musson G. Learning from Facts: Lessons from the Framework for Appropriate Care Through Sheffield (Facts) Project. Occasional paper no. 97/4. School of Health And Related Research (ScHARR), University of Sheffield, May 1997.
Getting Evidence into Practice. Effective Health Care Bulletin, NHS Centre for Reviews and Dissemination, University of York, February 1999. ISSN: 0965-0288.