using guidelines in healthcare settings

School of Population and Health Sciences

Centre for Health Services Research

Using guidelinesin healthcare settingsMartin EcclesProfessor of Clinical EffectivenessUniversity of Newcastle upon Tyne

Centre for Health Services Research University of Newcastle upon Tyne

Using guidelinesin healthcare settings

• How to think about approaching it

• Two examples– DVT prophylaxis in an acute trust– X-ray guidelines in primary care


Grol, Wensing, Eccles

Improving Patient Care: The implementation of change in clinical practice.

Available from Elsevier Press.


My starting point

• Many patients do not receive optimal care – Well-planned programmes

• are required to implement new or valuable scientific findings, guidelines, protocols, care processes or best practices.

– Different approaches • to the implementation of change in patient care can be

observed, each based on different assumptions and theories of human and organisational behaviour.

– A combination• Rational, top-down and participative, bottom-up

approaches is needed to improve practice successfully.


Planning models – a selection

• PRECEED/PROCEED model (Green and Kreuter 1991);

• Marketing theory (Kotler and Roberto 1989);• Continuous improvement, PDSA cycles (Ovretveit

1999; Langley et al. 1996);• Stages of change theories (Prochaska and Velicer

1997; Grol 1992; Rogers 1983);• Persuasion–communication models (Kok 1987;

Rogers 1983; McGuire 1981);• Intervention mapping (Bokhoven et al. 2003;

Bartholomew et al. 2001);• Organisational development (Garside 1998).


Common features (1)

• A systematic approach to and good planning of implementation activities is needed most of the time.

• Focus on the innovation– is it a ‘good product’?

• Subgroups within the target group may be at different stages of the change process and have different needs– allowed for segmentation within the target group

• Diagnostic analysis of the target group and setting before the start of the implementation.

• The target group should be involved in the development and adaptation of the innovation, as well as in planning the implementation.


Common features (2)

• Implementation activities should link with the results of the diagnostic analysis.

• Usually, a single method or measure is insufficient (?)– search for a cost-effective mix of methods tailored to the identified

obstacles and incentives to change.• Make a distinction between the phases of implementation

(dissemination, implementation and integration) – different measures and strategies are effective at different stages.

• Take appropriate measures for each of the various levels – national, local, team, practice and individual professional.

• Continuous evaluation of both the implementation process and its results.

• Make implementation an integral part of the existing structures.


Implementation of change: a model


Starting point (1)

• Problems identified, good experiences, knowledge of best practice– What do you and your organisation know

about the healthcare you deliver?– What do you and your organisation

want/need to know to judge quality of care?


Starting point (2)

• Research findings or GUIDELINES– Why develop a guideline?

• Explicit criteria• What is the problem to which your guideline is the

answer?

– Consider implementation during development• Head injury & MRI scanning

– Different formats– Wording

• Michie & Johnston. Changing clinical behaviour by making guidelines specific. BMJ, 2004; 328: 343-5


Attributes of guidelines

• Complexity, trialability – Complex 42% v 56%– Trialable 56% v 37%

• Grilli & Lomas 1994

• 17% variation in compliance explained by attributes of recommendations– Requiring no change in routines; compatability;

concrete, specific and clearly defined• Grol 1998, Burgers 2003, Foy 2002


Planning

• Clear aims• Co-ordination/team

– Likely to be complicated & multi-disciplinary• Involve target group

– Their “buy in”– Their knowledge

• Resources– Financial & human

• Skills – behaviour change, IT, management

• Timescale


Next step

• Develop concrete proposal/targets for improvement or change– Be as specific as possible– How much can you do?

• Within a guideline• Across guidelines


Diagnostic analysis

• An analysis of the target group, the setting in which change is planned and the determinants of change– Who is involved? Which interests are relevant?– What is current practice? Which improvements are

needed?– What are the barriers and facilitators for change in

different subgroups?– Which subgroups can be distinguished in the

target group and at what stages of change are these subgroups?


Diagnostic analysis

• Barriers and facilitators can relate to:– the individual care provider

• knowledge, attitude, motivation for change and personal characteristics

– the social setting • care providers and patients

– the organisational and financial system • organisation, resources, financial structure,

personnel and logistics


Diagnostic analysis

• Methods– Multiple

• Interviews• Focus groups• Surveys• Routinely available data


Selecting strategies for change

• Numerous interventions (strategies and measures) can be used to change behaviour or implement innovations:– Professional-oriented strategies– Patient-oriented strategies– Financial measures– Organisational measures– Legal regulations and/or rules


Selecting strategies for change

• In selecting interventions consider:– Results of the ‘diagnostic analysis’ of both the

target group and the implementation setting– Existing knowledge of effective implementation

– EPOC, – Grimshaw JM et al. Effectiveness and efficiency of

guideline dissemination and implementation strategies. Health Technol Assess 2004

– Wensing, Wollersheim, Grol. Organizational interventions to implement improvements in patient care. Implementation Science 2006:1;2

– Phases in the actual process of implementation and change (a distinction between dissemination, implementation and maintenance of change)


Organising the implementation

• Good planning is of great importance – Begin small, test the plan on a small scale using

motivated groups and gradually expand• In making the plan, consider:

– A cost-effective mixture of interventions of proven value

– Implementation activities in all phases of the process of change, so the plan is for both dissemination and implementation

– Implementation activities at the correct or multiple levels (central, local group, team/department, practice and individual)


Organising the implementation

• Good planning & time management;• Involve the target group in designing and executing

the plan• Incorporate the plan into existing activities for

communication and teaching of the target group• Adequate budgetary and other support• Incorporate periodic evaluation in the plan• Consider organisational aspects that promote or

retard implementation– Leadership, the role of physicians, collaboration, teaching of

quality methods and organisation culture


Context

• Newcastle and North Tyneside Health Authority established a Clinical Effectiveness Unit– Remit was to provide support to local health-care

teams• aim of promoting clinical effectiveness• encouraging the use of best evidence in daily practice

through systematic, evidence based approaches to implementation

• Three acute hospital trusts in Newcastle upon Tyne


The hospitals


Topic selection

• Venous thrombo-embolism:– Clinical Effectiveness Steering Group

agreed criteria to select prevention of venous thromboembolism as a priority area

– Given to the Clinical Effectiveness Unit in September 1996


Local guideline adaptation

• Guidelines Development Group:– Clinical Effectiveness Unit began working with a local

guidelines development group to adapt the recommendations of a national guideline

– Produced a local guideline which was widely distributed to local clinicians for review and piloted on four wards at the end of September 1996:

• Scope of the guidelines: risk assessment and prevention of deep vein thrombosis in hospitalised patients

• Intended purpose of the guidelines: to standardise procedures within and between local Trusts

• Staff involved: nursing staff to carry out risk assessment and medical staff to administer appropriate prophylaxis, as necessary


Implementation

• Guideline Implementation Group:– Month 4 A multidisciplinary implementation group was convened, to

develop the practical aspects of implementing guidelines into routine daily practice

• Production of “guideline pack”:– Month 10/11 The implementation group produced a “guideline

pack” • A guideline binder, a training resource manual and implementation aids

• Dissemination and implementation of guidelines:– Month 11-14 A multiple strategy implementation programme was

used to introduce the guidelines, initially into Trust 1 and Trust 2. Guidelines were introduced into Trust 3 in Month 20

• (1) local change agents and opinion leaders;• (2) training and education• (3) advertising.


Evaluation

• Evaluation of guidelines use:– Month 21 Process evaluation was carried out in

Trust 1 and Trust 2, eight to ten months after the introduction of the guidelines

• Guidelines review:– Month 28 based on feedback and new evidence,

additions and changes were made to the guidelines and sent out for review and comments to local health-care professionals


What happened?


Prophylaxis


Implementation research – a question

• Can we alter the rate of inappropriate requests for X-rays?

• Are the requests that are made appropriate?– Lumbar spine; knee– Successful outcome: reduction in the number of x-

rays requested. • Exercise in counting requests - not necessary to identify

individual basis• Data for evaluation routinely available from radiology

department referrals


Study design

• Before and after pragmatic randomised controlled trial using a 2 x 2 factorial design– 2 x 2 factorial design (4 groups)

1: paper guidelines only2: paper guidelines + audit3: paper guidelines + condition-specific reminders4: paper guidelines + audit + condition-specific reminders

– Powered to be able to detect interactions

• 247 general practices; 6 radiology departments


Audit and Feedback

Requests per 1000 patients

85.080.0

75.070.0

65.060.0

55.050.0

45.040.0

35.030.0

25.020.0

15.010.0

5.00.0

Requests for knee x-raysN

um

be

r o

f pra

ctic

es

60

50

40

30

20

10

0

Std. Dev = 16.93

Mean = 15.8

N = 247.00

Your practice


Condition-specific reminders

• NEXUS EDUCATIONAL MESSAGEIn either acute (less than 6 weeks) or chronic

back pain, without adverse features, x-ray is not routinely indicated

In adults with knee pain, without significant locking or restriction in movement, x-ray is not routinely indicated


What happened?

6262 6161 6161 6262N =

Condition

SpinesKnees

Ch

an

ge

in r

eq

ue

sts

pe

r 1

00

0 p

atie

nts

20

10

0

-10

-20

-30

Intervention

No intervention

Audit only

Reminder only

Audit & reminder

11111

1

1

1

42

1

41

1

1

7

2

51

1

1

7

2

233

1121

3


Implementation Science

EditorsMartin Eccles, Brian [email protected]

ScopeAll aspects of research relevant to

the scientific study of methods to promote the uptake of research findings into routine healthcare in both clinical and policy contexts

www.implementationscience.com


Conclusions

• It takes:– Time – Resources – Commitment– Team work– Enthusiasm

Buena Suerte!

using guidelines in healthcare settings

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