required for implementation.
It is worth noting that health care professionals as stakeholders include, in addition to the members of the multidisciplinary team, all groups of professionals who may be affected by or who may influence the new guidelines in practice.12 These health care professionals are likely to play different roles at different times throughout the implementation process.
Recognising their roles will allow members of the health care team to engage in a more focused manner at the relevant time, and therefore avoid imposing on their limited time more than necessary.
Whilst the practice nurse’s role in the care of persons with diabetes has substantially grown, physicians remain a key group.
They need to be involved early on, and a determination of the level of support of key physicians who influence clinical practice is essential.11 Among the documented physician-related barriers are changes to standards of practice such as usual routines; opinion leaders not agreeing with the evidence; insufficient medical training; or obsolete knowledge.27 If the new practice is compatible with the practitioners’ individual or professional values, norms and perceived needs, it will be more readily adopted.23 Identifying and involving the key players acknowledges their importance and sets up a transparent process for identification of issues that need to be addressed to ensure success of the implementation.11 Requiring others to change necessitates an understanding of the problems they face.12 Innovations that are compatible with the intended adopters’ values, norms and perceived needs are more readily adopted.28 It is recognised that a person can play both a negative and a positive role in effecting change and implementing guidelines, and inviting them to provide input on their individual concerns about the recommendations and engaging in the adaptation process may have a positive influence on implementation.8 Rather than being passive recipients, people tend to a greater or lesser extent to find (or fail to find) meaning in new recommendations, develop feelings (positive or negative) about them, challenge them, worry about them, complain about them, ‘work around’ them, gain experience with them, modify them to fit particular tasks and try to improve or redesign them , often through dialogue with other users.23 Strategies for change should provide mechanisms that reinforce desired behaviour and as such, incentives for change may be required.
Such incentives can include financial reward, resource reallocation, education and training, performance feedback and empowerment.12 If the changes are likely to be widespread, securing support of a strong coalition of key players is essential for the implementation process to succeed.12 Until this important step has been completed, it is not advisable to commence a project, which otherwise may only disrupt practice and fail, due to lack of necessary support, resources and time.
The patients
In chronic illness, day-to-day care responsibilities fall most heavily on patients and their families.29 Patients’ adherence to recommended treatment protocols is vital to successful dis- ease management. Therefore, recognising that patients are key stakeholders will encourage their participation and ultimately serve to improve care.10
The referral practice
The particular collaboration between primary and secondary care should be carefully consid- ered and taken into account and included at the outset, as this will inevitably be affected by the change. Success is much harder to achieve if the new recommendations require complex
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changes in clinical practice, improved collaboration between disciplines or better organisation of care.27 Failure often relates to a lack of realisation of the extent of commitment required and to the wide scope of activities needing change. Managing diabetic foot complications effectively requires seamless collaboration between the primary and secondary care teams responsible for the provision of care for this patient group, and one of the great barriers to change is the difficulty in ensuring that the right groups and individuals work together.24
The Implementation Team
Implementation ensuring the sustainability of the new practice guidelines is the main respon- sibility of the implementation team.
This team sets key priorities and timelines for the change agenda.
Because of its central role, the team requires dedicated members and ideally some form of representation by all the key groups and individuals affected by the upcoming implementa- tion process.
Resources are invariably limited and any implementation strategies that exhaust these limited resources are unlikely to be sustainable in the long term.26 Membership is likely to require a substantial amount of work and impose greatly on the individual team member’s workload and time; therefore, it is vital that all the members of the core team are committed to the project.
Key people leading the change, as well as continuity of leadership, has been associated positively with receptivity to change.21 Success also requires that the team members have the appropriate support and, equally important, the required knowledge and skills.12 Successful management of the implementation project may require a full-time lead person for a duration that depends on the size and complexity of the project.
In all cases, a dedicated project champion committed to the project should head up the team.
Dedicated clinical leaders and champions are critical to a successful implementation process.22 Therefore, it may be worthwhile to consider engaging opinion leaders and/or well- respected leaders committed to the required changes, as mentors and champions for support.
A dedicated facilitator, or opinion leader, who works with individuals and teams in the practice context may help facilitate the adoption of new guidelines into practice; however, it is worth noting that this strategy can turn out to be resource intensive.8
Diagnostic Analysis and Adapting Guidelines Any process to bring about change should begin by identifying and analysing factors likely to influence the proposed change.12 This will facilitate a better understanding of the scope of required changes in practice and allow identification of and planning around barriers to implementation.
Analysis of barriers to doctors’ willingness to change their routines have shown that obstacles to change in practice can arise at different levels in the health care system.27 To understand the extent of the change requirements, a thorough so-called diagnostic analysis, i.e. an analysis of how the current practice compares to the practice outlined in the CPGs, is recommended.12 An algorithm can be an important tool accompanying the CPGs to be implemented.
Produc- ing detailed algorithms for the key elements in the organisation as a whole, the health care team and the individual professionals, of both current practice and the practice to be implemented, may facilitate comparisons and the subsequent identification of key issues.
It is important to examine these key elements, and when recording and considering the required changes in
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practice, it is important to identify the steps needed to address any particular barriers and to tailor strategies to overcome them.
It is very likely that the adaptation of national CPGs will require modifications of the guideline recommendations to suit the local circumstances.
Analysing and modifying a CPG to ensure local relevance has been shown to be a positive factor influencing change.8 Successful implementation is more likely if the intended adopters have sufficient opportunity, autonomy and support to adapt and refine or otherwise modify the innovation to suit their own needs and to improve its fitness for purpose.23 Subsequently, it is important to review the adapted CPGs to gain a good understanding of facilitators and possible obstacles, and for developing required interventions.30 It is critical to ensure that the final CPGs and recommendations, in addition to being relevant to local practitioners and practice, are clear and specific.
Unless guidelines are limited to the major decision points, they are likely to be too unwieldy to use in practice.31 The preferred format of the guideline may vary between professional groups, and this may be influenced by whether the professional group considers the topic to be of relevance or priority to them.32 Presenting the guideline at the implementation stage as an algorithm has been suggested to be an acceptable format for practitioners and may contribute to its successful implementation.8
Baseline Data Collection
For the purpose of evaluating project impact, baseline data should be secured.
Naturally, this must take place before implementing any of the new recommendations.
Without access to baseline data it is impossible to obtain an accurate view of the true impact of the new practice.
It is expected that CPGs will reduce inappropriate variations in practice and promote delivery of high-quality, evidence-based health care.33 Verifying expectations such as these and credibly evaluating the impact of the project, reporting progress and building a better case for the local relevance of the guidelines are clearly not possible without relevant baseline data.
Furthermore, having credible data may be of crucial importance when seeking sustained support for the new practice in terms of resources and financing.
It is worth ensuring that the current records and database support this activity; if not, further resources and financial support may be required in order to obtain the baseline data.