Ali El-Ghorr (left), Roberta James, and Sara Twaddle explain how SIGN, with stakeholder input, has developed astrategy for supporting guideline implementation

The Scottish Intercollegiate Guidelines Network (SIGN) was formed in 1993 with the objective of improving the quality of healthcare for patients in Scotland by producing national clinical guidelines containing recommendations for effective practice that are based on the best available evidence.

SIGN has become a world leading organisation in guideline development with an international reputation for producing high-quality evidence-based guidelines as a result of the robust methodology used to produce its guidance.1 To date, SIGN has published over 120 clinical guidelines and delivers training to guideline developers all over the world.

Implementing guidelines

The implementation of guidelines is the remit of local NHS Boards, but in 2009, SIGN initiated a transformation to become an organisation that not only develops high-quality clinical guidelines, but also supports their implementation. The process of guideline implementation is complex as it involves understanding different user needs and tailoring support to those needs. Difficulties in implementation often centre on the need for personal, organisational, or cultural change.2 SIGN aims to take published evidence on the effectiveness of different implementation strategies into account when developing resources for support: ‘Evidence based medicine requires evidence based implementation.’3

A meta-synthesis of GPs’ attitudes to clinical practice guidelines indicated that their reasons for not following guidelines differ according to whether the guideline in question encouraged a certain intervention or discouraged certain treatments or behaviours.4 The purpose of the guideline and the way it is written may therefore influence if and how it is received and implemented.5

An overview of systematic reviews on professional behavioural change strategies published in 1999 identified 44 reviews covering a wide range of activities and interventions.6 The authors concluded that:6

  • passive dissemination is generally ineffective and is unlikely to result in behaviour change when used alone; however, it may be useful for raising awareness of the desired behaviour change
  • active approaches are more likely to be effective, but also likely to be more costly
  • multi-faceted interventions targeting different barriers to change are more likely to be effective than single interventions.

A health technology assessment (HTA), published in 2004, reported that educational materials may have an effect on guideline implementation, but this is short lived.7 This HTA suggested that multiple-intervention strategies have a modest effect on implementation, especially when targeted at prescribing behaviours. The combination of educational meetings and reminders appears to be more effective than educational meetings alone. Any activities supporting implementation should always take into account local circumstances.7

A number of criteria for success in quality improvement and implementation work in healthcare have been identified:8

  • Provision of practical and human resources to enable quality improvement
  • Active engagement of healthcare professionals, particularly doctors
  • Sustained managerial focus and attention
  • Use of multi-faceted interventions
  • Coordinated action at all levels of the healthcare system
  • Substantial investment in training and development
  • Availability of robust and timely data through supported IT systems.

In the absence of a strong evidence base, a multi-faceted strategy that includes educational outreach, audit, and feedback is the pragmatic approach to implementation. Further research is needed to establish the best strategies for guideline implementation.

Research on implementation activities

In order to devise an implementation support approach for SIGN, a number of stakeholders were approached during late 2009. The aim was to find out what implementation support SIGN guideline users would value. Stakeholder opinion was sought using structured interviews aimed at generating a large number of ideas on the topic ‘What implementation support activities do guideline developers and users think are most appropriate for SIGN to provide?’ The interviews were focused around evidence-based interventions, but extended to include any other ideas and suggestions for supporting implementation. A total of 43 participants took part in the interviews (see Table 1).

The participants were chosen by SIGN staff based on:

  • involvement with SIGN
  • experience in guideline implementation
  • current involvement or interest in guideline implementation.

The structured interviews resulted in a large number of innovative ideas on how SIGN can better support guideline implementation. The responses varied in emphasis depending on interviewee roles:

  • Internal stakeholders made more practical suggestions (based on their experience of what can currently be delivered)
  • Guideline users were more aspirational
  • Patient representatives focused on patient power to make change happen.

Despite these differences, the implementation support ideas that emerged from the structured interviews fell into four main categories (see Table 2).

Survey feedback
The main ideas generated by the structured interviews were listed in a questionnaire survey conducted through SurveyMonkey. The survey was sent to over 3000 guideline users who had also been involved in the development of SIGN guidelines. Respondents were asked to rate each of the suggestions on a four-point scale:

  • No benefit (1)
  • Not much benefit (2)
  • Some benefit (3)
  • Much benefit (4).

This scale forced participants to decide whether each suggestion was of benefit or not as they could not choose a neutral category. The questionnaire also elicited the respondent’s clinical or work background and asked them to suggest alternative implementation support activities.

A total of 746 people completed the survey (25% response), 269 people suggested other implementation support activities for SIGN to consider, and 407 respondents said that they would be happy to be involved in further work with SIGN. The full results of this survey will be published elsewhere.9

Guideline users prioritised implementation support activities in the following order:

  1. Developing algorithms and care pathways to accompany guidelines.
  2. Organising awareness-raising activities and supporting local clinical champions.
  3. Linking with existing professional networks to support implementation.
  4. Producing and distributing audit tools.

The key SIGN implementation support activities, and recent examples, are summarised in Table 3.

Table 1: SIGN stakeholders who took part in the structured interviews
Internal stakeholders n=8 External stakeholders n=35
  • SIGN staff (6)
  • Healthcare Improvement Scotland staff (2).
  • Guideline users (doctors, nurses, allied health professionals) (21)
  • NHS managers (2)
  • Scottish Government representatives (2)
  • Patient and lay representatives (10).
Table 2: The main themes of SIGN implementation support activities as suggested by stakeholders
Processes Awareness raising and education
  • Robust dissemination process
  • More interactive website.
  • Local clinical champions professionals
  • Awareness-raising activities
  • Patients as champions for change
  • Training modules linked to continuous professional development
  • Tailored support for primary care.
Networking Implementation support resources
  • Linking with professional networks
  • Linking with existing Scottish Government projects
  • Meetings with NHS Boards.
  • Algorithms and care pathways
  • Resource implications calculator
  • Audit tools and datasets
  • Electronic decision support tools development
  • Slide sets
  • Documentation templates.
Table 3: Key SIGN implementation support activities
Activity Rationale Recent examples
Algorithms and care pathways rithms and care pathways describe the typical journey of care and provide a visual representation of a group of recommendations. They can be a useful tool for people wishing to implement a change in practice and can be used for educational purposes. The SIGN depression guideline is closely linked with the depression care pathways that every NHS Board in Scotland is currently developing. Building relationships with people in local NHS Boards who are leading on this work helps to ensure that this happens.


Awareness-raising activities SIGN staff, lay representatives, and Guideline Development Group members are taking a more active role in making people aware of new guideline recommendations by giving presentations at conferences, workshops, and educational events.

Awareness-raising events have been held recently for guidelines on depression, diabetes, gastrointestinal bleeding, head injury, obesity, and stroke. Summaries of SIGN guidelines are now frequently published in medical journals,10–12 ensuring a much wider audience is made aware of SIGN and its latest recommendations.

Raising awareness in primary care The evidence base shows that the barriers to implementation in primary care are distinct and require a tailored implementation approach.4,5
  • Targeting information for primary care, particularly in Quick Reference Guides and on the SIGN website (e.g. Rockets:
  • Integrating recommendations into primary care IT systems to allow easy access to the latest information (e.g. an electronic decision support module has been developed for the asthma guideline)
  • Linking certain recommendations to the quality and outcomes framework
  • Delivering training and awareness-raising sessions on guideline recommendations at Community Health Partnership protected-learning events (e.g. for skin-related guidelines).
Education and training modules In collaboration with NHS Education Scotland and the Royal Colleges, SIGN is developing training modules based on its guidelines. Linking modules to Continuous Professional Development, gives front-line staff a genuine incentive to complete them. Training modules developed in collaboration with NHS Education Scotland accompany the SIGN headache and sore throat guidelines (
Local clinical champions Designating a powerful clinical champion is an effective way to raise awareness of a guideline. Clinical champions have a high profile, are widely respected, have a good understanding of policy, and have local contacts. SIGN supports clinical champions to take a leading role in promoting the implementation of specific guidelines in their locality. Over 400 NHS Scotland staff expressed an interest in being SIGN clinical champions when the prioritisation survey was conducted.9
Patients as champions for change
  • If patients are aware of a guideline, they can ask for their care to be in line with the latest recommendations. This is a very powerful agent for change in the health service. SIGN is increasingly raising awareness of published guidelines with patient groups and voluntary organisations. This is supplemented by publishing and distributing a patient version of many guidelines (e.g. stroke, diabetes, depression)
  • Lay representatives on Guideline Development Groups are also being supported to raise awareness at conferences and other events.
SIGN is working closely with Psoriasis Scotland, Arthritis Link Volunteers, and the Skin Care Campaign Scotland to support the implementation of recent dermatology guidelines.
Linking with existing networks and projects


Professional networks and/or national projects exist in many clinical areas to improve the quality of care and to put evidence into practice. These include Managed Clinical Networks for cancer, coronary heart disease, and epilepsy and the national Mental Health Collaborative. Relationships have been established with these professional networks, the Scottish Government, NHS Education Scotland, and others as part of a wider awareness-raising strategy that results in SIGN taking a more proactive role.
  • The stroke guideline was developed and launched in coordination with the revision of the clinical standards, the production of key performance indicators, and an interactive tool to identify resource implications
  • Joint working is taking place with stroke Managed Clinical Networks to support implementation and improve care.
Audit tools and datasets
  • SIGN is working with a group of doctors and dentists in training to develop audit tools that can be used by cohorts of healthcare professionals in training to conduct audits of guideline implementation during their rotations
  • SIGN is also working with other agencies to support the incorporation of key recommendations in national datasets and audits.
An increasing number of audit tools are now available online (


Recent web-access statistics show that high numbers of these audit tools are downloaded by guideline users. In April 2011, there were:

  • 524 downloads of the post-operative assessment audit tool
  • 498 downloads of the depression audit tool
  • over 300 downloads each of the hip fracture, head injury, and venous thromboembolism audit tools.

Strategy for change

Based on the structured interviews with stakeholders and the views of survey respondents, a SIGN implementation support strategy was developed, which included the following:

  • Improved internal processes and standard operating procedures
  • Reliable distribution to ensure that evidence-based recommendations reach the target audience
  • Development of:
    • formats to suit different guideline users (e.g. quick reference guides, mobile phone SIGN Apps)
    • educational resources
  • Development and distribution of a range of implementation support resources to accompany guidelines
    (e.g. care pathways, costing reports, audit tools, electronic decision support tools, slide sets, patient information)
  • Support for local champions to deliver awareness-raising events
  • Networking with clinical and other interest groups to coordinate implementation activities
  • Engagement with the Scottish Government to promote key messages.

The SIGN implementation support strategy was adopted in 2010 and has been applied to recently published guidelines as demonstrated in Table 3. Good progress has been achieved in:

  • setting and communicating the SIGN vision
  • building implementation support into the guideline development process
  • creating individual guideline implementation subgroups that develop a targeted implementation strategy for a specific guideline
    (e.g. psoriasis:
  • delivering implementation support for guidelines
  • building an evaluation model for analysing the impact of implementation support activities based on logic models13
  • encouraging the development of structured improvement programmes collecting continuous data14
  • building relationships with partners in Healthcare Improvement Scotland, local NHS Boards, education bodies, professional bodies, and the Scottish Government in order to work collaboratively on guideline implementation.

Next steps

SIGN implementation support has evolved over the last few years and now relies on each Guideline Development Group considering implementation throughout the development process. The group is guided to develop an implementation strategy that is unique and tailored to that guideline. This strategy will always be multi-faceted and will include care pathways, awareness-raising activities, and linking with professional networks. The aim is not to produce every tool for every guideline, but to undertake a range of activities that are aimed at helping local clinicians implement a specific guideline.

Going into the second decade of the 21st century, and with SIGN coming up to its 20th anniversary, we aim to be a leading player in guideline implementation support, building on being a world-leading organisation in guideline development.

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