Figure 1 Diagram of strategies for dissemination, implementation and evaluation of clinical practice guidelines
How to cite this article: Valenzuela-Flores AA, Viniegra-Osorio A,Torres-Arreola LP. General Strategies for Implementation of Clinical Practice Guidelines. Rev Med Inst Mex Seguro Soc. 2015 Nov-Dec;53(6):774-83.
REVIEW ARTICLES
Received: October 7th 2014
Accepted: December 16th 2014
Adriana Abigail Valenzuela-Flores,a Arturo Viniegra-Osorio,b Laura del Pilar Torres-Arreolac
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.mxThe 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.
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:
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:
Related to the health professional:
Related to the organization:
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
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:
| Table I Barriers and facilitators | |
| Barriers | Facilitators |
| Health personnel •Lack of awareness of existence of CPG •Resistance to change •Lack of awareness of usefulness of CPG •Lack of awareness of methodology for CPG creation •Heterogeneous training of facilitators •Insufficient staff for CPG implementation •Negative attitude •Lack of support and recognition •Lack of motivation •Inadequate training programs •High staff turnover •Time of workday |
Health personnel •Opportunity to detect moral leaders ofunits •Willingness and positive attitude •Active participation in CPG elaboration •Specialist staff with recognition and leadershipamong colleagues •Existence of clinics for complex diseases formed by various specialists with experience •Staff in training •Availability of leaders to provide training courses •Institutional expertise for implementation of certain top-level CPG |
| Organization •Lack of support from authorities •Limited institutional resources •Lack of coordination and participation amongmedical and administrative areas •Poor personnel structure for CPG implementation and supervision •Need to make assessment before and after CPG application •Lack of awareness of regulations •Limited operational templates •Poor coverage of bothscheduled and unscheduled absenteeism •Structural differences between levels of care •Lack of connection between clinical and research areas |
Organization •Scheduled general and academic sessions for health staff •Support from senior authorities •Leadership capacity of managers •Regulations available for CPG implementation •Access to and availability of guides |
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.| Table II Key points for CPG dissemination |
| •Involve users in development and dissemination of guidelines |
| •Request collaboration of clinical leaders to promote CPG use |
| •Use media and medical journals, both institutional and national |
| •Incorporate CPG within routine procedures: quality improvement activities andcontinuing medical education activities |
| •Discuss CPG at conferences, congresses, seminars, and other academic meetings |
| •Visit users in their clinical setting individually for guidance on CPG use |
| Table III Key points for implementation |
| •All users involved in implementation of the Guide should be trained for skills required in implementation of recommendations, techniques, and skills involved in the CPG in daily clinical practice |
| •Training allows appropriate interpretation of evidence and appropriate use of key CPG recommendations |
| •Reduce resistance to change, providing appropriate training to carry out activities to beimplemented |
| •Develop instruments of support for CPG use and design mechanisms to distribute these among health staff |
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:
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:
It is important to investigate the means available in the units that are accessible to health professionals. The Institute may use:
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).
Figure 1 Diagram of strategies for dissemination, implementation and evaluation of clinical practice guidelines
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.
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.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.