Open Journal Systems

REVIEW ARTICLES

Received: October 7^th 2014

Accepted: December 16^th 2014

General Strategies for Implementation of Clinical Practice Guidelines

Adriana Abigail Valenzuela-Flores,^a Arturo Viniegra-Osorio,^b Laura del Pilar Torres-Arreola^c

^aÁrea de Implantación y Evaluación de las Guías de Práctica Clínica, Coordinación Técnica de Excelencia Clínica, Coordinación de Unidades Médicas de Alta Especialidad, Unidad de Atención Médica

^bCoordinación Técnica de Excelencia Clínica, Coordinación de Unidades Médicas de Alta Especialidad, Unidad de Atención Médica

^cÁrea de Desarrollo de Guías de Práctica Clínica, Coordinación Técnica de Excelencia Clínica, Coordinación de Unidades Médicas de Alta Especialidad, Unidad de Atención Médica

Instituto Mexicano del Seguro Social, Distrito Federal, México

Communication with: Adriana Abigail Valenzuela-Flores

Telephone: (55) 5653 3589

Email: abigail.valenzuela@imss.gob.mx

The need to use clinical practice guidelines (CPG) arises from the health conditions and problems that public health institutions in the country face. CPG are informative documents that help improve the quality of care processes and patient safety; having among its objectives, to reduce the variability of medical practice. The Instituto Mexicano del Seguro Social designed a strategic plan for the dissemination, implementation, monitoring and control of CPG to establish an applicable model in the medical units in the three levels of care at the Instituto. This paper summarizes some of the strategies of the plan that were made with the knowledge and experience of clinicians and managers, with which they intend to promote the adoption of the key recommendations of the guidelines, to promote a sense of belonging for health personnel, and to encourage changes in organizational culture.

Keywords: Practice guidelines, Implementation, Health care, Mexico.

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The need to use Clinical Practice Guidelines (CPG) as tools for quality improvement stems from the needs faced by health systems, such as: increased demand and high costs of care, more expensive technologies, variations in the provision of services between workers, medical units, and geographic regions, as well as professionals’ desire to offer and patients’ desire to receive the best possible care.¹

In recent years there has been a steady increase in CPG production worldwide, especially across Europe and other countries such as the United States, Canada, and Australia.

Most of these countries now have national programs for the production, dissemination, and implementation of guidelines, aimed at improving the quality of services.²

A CPG is a key tool for the transfer of scientific knowledge into medical practice, representing one of the main challenges for public health institutions in Mexico.

CPGs as components of quality plans can contribute to improved health services, through decision-making for care as well as management of the organization.

The term adoption of good practice refers to the decision, need, or obligation to change professional practice, once the contents of the CPG are known.³ However, the adoption of good practice in professionals’ health decisions is influenced by:

• The perception of proposed changes.
• Knowledge and attitudes of health professionals.
• The context and the organization where they will be applied,⁴ which are determined by the characteristics of the society and its culture, the attributes of the medical units, legal and regulatory aspects, as well as communication systems and information networks, among others.

During adoption, it is necessary for those responsible for the process, both locally and regionally, to identify and control the barriers that may affect the process and strengthen the facilitators that encourage acceptance of the CPG.⁵ Barriers or obstacles mean factors that prevent or hinder the changes that are to be accomplished using the CPG, which can be classified, for example, into:

 

Related to CPG content:

• Problems in interpretation of evidence
• Lack of methodology in development
• Information overload
• Limited access                                              
• Outdated information

Related to the health professional:

• Lack of knowledge of evidence-based medicine
• Difficulty in interpreting recommendations
• Resistance to change
• Lack of integration of the Guide
• Lack of motivation
• Fals concept of limited autonomy for clinical judgment

Related to the organization:

• Lack of support from authorities
• Limited resources
• Organizational structure
• Lack of time

Facilitators are people, factors, and conditions conducive to the implementation process and who promote the adoption of CPG recommendations by stakeholders and persons involved in the care process. The Instituto de Efectividad Clínica y Sanitaria of Argentina described, through a statement, the most important ones:⁶

• CPG development in response to user needs in the clinical setting
• Application of incentives: academic, financial, and administrative
• Medical education programs: medical residency, training, and undergraduate training
• Discussion and consensus by multidisciplinary medical group and opinion leader
• CPG incorporation into daily clinical practice  
• Internet access

 

The Instituto Mexicano de Seguro Social (IMSS) identified the main barriers and facilitators identified by staff of the institution that may affect the adoption process, summarized in Table I.

Once the barriers and facilitators have been identified, the next step for the introduction of CPG is to establish dissemination and implementation strategies.

The strategies, to be effective, must impact the behavior of health professionals particularly.

Dissemination strategies are distributing information to the clinician, that is, distributing the guides by conventional means. Implementation strategies involve all actions aimed at translating the recommendations into professionals’ clinical practice; it involves effective communication and overcoming local barriers or obstacles.

It has been proven that passive measures are less effective than training activities; when these are focused on not just the knowledge, but also on the attitudes and skills of the staff involved, their effectiveness varies from 11-20%. In general, the effectiveness of strategies to implement CPG recommendations for decision-making is variable;^7-10 average improvement for the interventions varies from interactive training sessions with 14.1% for memos, 8.1% for educational materials, 5% for audit and feedback, and 6% for interventions with multiple strategies.

Improvements in clinical practice have been reported at about 10% in specific situations.¹¹ This could represent a moderate improvement; however, this is expected after application of any type of innovation, based on the benefits and costs of implementation. When choosing strategies focused on the main barriers, it is suggested to consider those that combine multiple interventions targeting priority situations, with continuous monitoring, which will result in an effective outcome.

The collaborative group Cochrane EPOC (Effective Practice and Organization of Care Group)¹² proposed a series of strategies with different implementation approaches that can contribute to the dissemination and implementation of CPGs:

 

A) Focused on Health Professionals:

• Distribution of educational materials: dissemination of CPG recommendations in print, electronic, and audiovisual formats, to health personnel in their service area (individual or group)
• Academic sessions: general and clinical sessions, or workshops
• Local consensus processes: to include health professionals in clinical discussions to ensure that they agree that the chosen health problem is important and that the implementation of the proposed recommendations for that problem are appropriate
• Visits from a facilitator: a person with specific training visits health professionals to provide information about CPG, with the intention of changing their clinical practice
• Local opinion leaders: participation of professionals considered and identified by colleagues as (moral) influential leaders for training.  
• Patient-mediated interventions: (new) clinical information gathered directly from patients and provided to health professionals (for example, scores obtained with the application of an instrument to measure depression)
• Audit and feedback: any summary of the performance of health personnel about their professional practice, in a specified period. The summary may include recommendations for clinical decision-making.
• Memos: specific information provided orally, in writing, or electronically, designed to catch the attention of health providers and remind them what to do or what to avoid to help in the care of a specific patient
• Interviews with health providers: individual or group (focus group) meetings or surveys with health professionals, focused on identifying barriers; to then design the strategy, aimed at those barriers or obstacles
• The media: television, radio, newspapers, posters, leaflets, and brochures, either alone or combined with other interventions, aimed at the population.
• Incentives for the professional or institution.

B) Focused on the Organization:

• May include changes in the organizational structure of care units
• Revision of professional roles; creation of multidisciplinary clinical teams, integration of services; professional satisfaction with working conditions; distance communication and discussion of cases between health professionals
• Changes in information systems for patient clinical records
• Changes in the scope of services; existence of internal mechanisms for monitoring the quality of care (complaints and suggestions)
• Accreditation of professionals and certification of units.

 

C) Focused on Leadership:

• Any intervention that aims to change the provision or cost of service via regulation or law
• Changes in the responsibilities of health personnel
• Patient complaints and grievances  
• Licenses

The introduction of CPG involves, therefore, a process of change requiring leadership, effort, and commitment, but above all teamwork at all levels. Once proposed, strategies should be analyzed as to how they will be implemented within the units and what techniques health professionals can use to affect the implementation of CPG. When adopting a Guide, one must account for the resources available, the feasibility of the implementation of its recommendations, and the organizational structure. Some of the recommendations made in the CPG may have to be adapted, while others will not apply to the units.

It is difficult to find a balance between external evidence and one’s own experience, given that without clinical practice experience can be subjugated to evidence and, conversely, practice without evidence runs the risk of becoming obsolete, to the detriment of patients.¹³ The CPG is an option to improve the quality of clinical judgment established by professionals,¹⁴ and herein lies another of the great contributions of the CPG.

The strategies chosen to promote the dissemination and implementation of CPGs should be integrated into a plan, which in turn must be prepared according to the health needs, requirements, and expectations of professionals and disseminated through the local, regional, or national media to ensure their implementation. It is important, from the beginning of CPG implementation, to know the characteristics of the local context where the guideline’s recommendations will be applied, to identify responsibilities, to raise awareness and to involve health professionals who will be the users of the guide, to foster linkage between levels of care involved, and to facilitate the change of clinical practice.

The CPGs published in the Master Catalog are developed according to a methodology agreed upon by institutions in the country.^15,16 The authorities and those jointly responsible for care at IMSS have proposed that CPG be chosen and implemented according to the health needs or demands representing a priority for the population and interest groups. Because of this, the recommendations of the Guidelines will serve the health personnel for decision-making and will help improve the quality of services¹⁷ and patient safety. 

The Instituto Mexicano del Seguro Social designed a comprehensive plan with strategies for dissemination and implementation of CPG,¹⁸ as well as monitoring and control mechanisms, in order to establish an implementation model applicable in the medical units. The plan was drawn up jointly with health personnel and managers of the institution, and it was made available to workers through institutional media. It contains the minimum essential actions that can support CPG implementation, taking into account the characteristics of the organization and the resources available. It was recently updated in order to align the process to the health needs, organizational changes, and rules of the institution.

This plan projected further evaluation activities and monitoring methods which could be used in the units for measuring progress, and find out the adherence (or compliance) of health professionals to the CPG recommendations. This was also to determine when in the process a plan of reaction with corrective actions will have to be implemented.

Before applying the general plan of CPG implementation in the medical units, a local operating plan should be made with the chosen strategies from the plan and local interventions considered relevant by authorities and those jointly responsible for the process. Some of the proposed strategies are summarized here, including several of the matters herein mentioned.

Dissemination strategies

1. Management for CPG distribution:

• Involve senior management and the governing body of the units to promote and facilitate CPG implementation 
• Involving opinion leaders: formal and informal (personnel with prestige in the unit) in local dissemination strategies
• Formalize CPG resources

2. Distribution of CPG:

• Ensure the existence of CPG within units
• Ensure access and availability of the CPG to all family (first-level) medical units, second- and third-level hospitals, as well as all staff involved in the care of insured patients (Table II).

Implementation Strategies

1. Identification of barriers and use of factors:

• Understand the barriers and local needs for the development of strategies
• Identify facilitators and local resources in the unit
• Align the healthcare process with actions for CPG implementation

2. Selection and evaluation of CPG:

• Choose the Guidelines relevant for the population of interest and the mission of the organization, based on the priority conditions and health problems 

3. Adoption of chosen CPG:

• Formalize CPG implementation through the governing bodies of the unit
• Ensure understanding by those responsible for the change and the implications of taking on innovations

4. Adaptation of chosen CPG:

• Adapt recommendations (tests and treatment regimens) of the CPG based on the Basic Institutional Framework for Health and Institutional Regulation

5. Incorporation of CPG contents in educational interventions:

• Effective linking among authorities at different levels
• Choice of educational strategies and spaces used in care units for this purpose
• Using virtual media and available and authorized time for health personnel

6. Planning academic sessions:

• Design a training program on CPG recommendations, considering different types of training and updating (general, group, or individual) for potential users
• Choose through consensus the CPG recommendations to be topics of discussion in academic meetings, considering the processes in which they can intervene for improved care
• Develop educational materials for sessions

7. Sensitization to change:

• Encourage self-reflection for potential users of the CPG.
• Promote development of positive attitudes
• Promote adoption of innovation, confirming the benefits of change

8. Identification of needs for training:

• Design a program to meet those needs, linking the three levels of care, to the extent possible and in accordance with CPG contents

9. Selection of technical group (facilitators) for training:

• Identify facilitators and develop the program or agenda for academic sessions

10. Development of support tools for CPG use:

• Assign responsibility for the design of instruments
• Identify available resources and means for reproducing the material
• Develop the strategy and mechanisms for the distribution and implementation of supporting materials among health personnel and those involved in the care of the specific case (Table III)

Educational interventions

Educational techniques should be designed and adjusted based on the reality of each medical unit to achieve the objectives of the plan. The following methods can be used for CPG implementation:

 

Classroom learning

In classroom learning it is proposed that the academic sessions take place on the days and hours of the work week, to achieve the objectives of training and updating. The number of academic meetings depends on the characteristics of the organization and the size of the unit as well as the number of health professionals and other potential CPG users.

Facilitators use CPG content to advise users during the academic meetings (or sessions). That is, general sessions, department meetings, clinical case reviews, workshops, and counseling in clinic, among others.

Academic meetings can also be held to be attended by personnel from other services of the unit, or meetings inviting professionals from the three levels of care, depending on the content of the CPG and the care needs for improving processes of consultation, hospitalization, surgery, emergency, and patient referrals.

Distance learning

Distance learning facilitates the dissemination and implementation of CPGs, as it is a resource freely accessible to institutional health staff, who can see the content of the CPG at any time.

In the development of educational materials, the following should be considered:

• General framework of the strategic project of CPG development and implementation, and methodology
• Benefits / Impact of CPG
• Structure of CPG (findings and recommendations)
• Contents of CPG
• Clinical Questions
• Goals
• Evidence / Recommendations
• Algorithms

Facilitators

It is the health care professional who serves as an instructor or counselor in training and updating users on the CPG within the primary, secondary, and tertiary care medical units. They are the local technical team.

Facilitators should:

• Be health personnel (doctors, nurses, or other disciplines) directly involved in care activities
• Know the CPG contents of interest
• Have organizational and technical capacity to carry out the program strategies
• Have sufficient public credibility (moral authority) and audience among stakeholders
• Properly handle teaching techniques
• Foster a climate of trust and respect among health professionals
• Have the ability to reduce the impacts of uncertainty and negative attitudes towards CPG

Tips for the facilitator:

• Identify potential CPG users  
• Get to know the program academic sessions
• Identify audience levels of knowledge and skills
• Use concrete, precise, and clear ideas in the academic sessions
• Provide support materials
• Design and implement assessment tools
• Feedback

Information Networks and Communication Systems

It is important to investigate the means available in the units that are accessible to health professionals. The Institute may use:

• General (or academic) meetings
• Governing boards
• Advisory council meetings
• General or departmental sessions
• Press releases and institutional notes
• Video conferences
• Portal CENETEC (access to Master Catalog)
• IMSS Internet portal
• Intranet Portal
• Electronic Health Record
• Print Format: Libraries/newspaper archives, vista Médica del IMSS, Revista de Enfermería del IMSS, posters/leaflets, and others.
• Digital: Compact disc drives, other portable devices

Monitoring, and control

At this stage and according to plan, the activities done in the unit are reviewed to carry out CPG dissemination and implementation, as well as achievements in using them.

It is recommended to conduct internal audits to identify and analyze the difficulties affecting the performance of activities in a timely manner, to then design the actions that help optimize CPG application and reduce the risks in care, for the benefit of the patient's health and to improve services.

It is important during follow-up in units to intentionally check the schedule of meetings for the training of health personnel, according to the modalities chosen to present and discuss the CPG recommendations, always seeking documentary evidence of the actions.

The following diagram summarizes the strategies for CPG dissemination and implementation and the proposed actions for the monitoring process (Figure 1).

Final Thoughts

CPG adoption in the current model of health care is the first step in the acceptance of change in the delivery of health services and towards a path of universality of care. CPGs are quality instruments that help improve the processes of care and patient safety. Institutions must identify and define priorities and health needs of the population, which can affect CPG to improve patient care.

It is essential to structure a plan to ensure the dissemination and implementation of CPG, from prioritizing, identifying the context, barriers, and facilitators; to the specification of strategies and mechanisms for monitoring, including the development of indicators.

The strategies are meant to drive adoption of the key recommendations of the Guidelines and promote ownership by health personnel, and promote changes in organizational culture.

Acknowledgments

The authors specially acknowledge the willingness and cooperation of all health professionals and managers involved in the development of the General Plan for Implementation, Operation, and Control of Clinical Practice Guidelines in the Instituto Mexicano del Seguro Social.

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