Draft Implementation Plan and Pre-testing Guidelines that are simply distributed to the end users without a formal strategy for their implementation are likely to be ineffective.20 In the implementation of any CPGs, the ultimate goal is to ensure that the practice recommendations in the guidelines become part of the routine practice.
Thus, designing a draft implementation plan assigning responsibility for each of the key steps, preferably with a timeline, and testing the feasibility and acceptance with the target users is of value.15 The implementation team may consider circulating such a plan to key stakeholders for review prior to possible pre-testing.
The primary objectives of pre-testing are to verify that all issues have been considered, to identify any unexpected barriers and to assess the estimated impact on the current system and the perceived needs for change in the practice.34 This provides confidence that all issues have been considered at the outset and that the guidelines indeed are applicable to the local practice.
Sometimes, a barrier to change is simply the perception of the new recommendations
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as complex. The practical experience gained by pre-testing may ultimately assist in bringing about positive change in these perceptions.23 Importantly, pre-testing should include data collection. A concise report based on such preliminary outcomes data may be of particular benefit if further resources or budget changes are required.22 This will ultimately facilitate the implementation process and make the benefits more visible to stakeholders.23
The Implementation Plan A detailed, specific implementation plan should follow the stakeholder review of the draft plan and pre-testing.
All feedback and lessons learned at this stage should be carefully considered.
Goals should be carefully constructed and they should bridge the differences between the current practice and the desired practice.
Each goal should be accompanied by the strategies or methods to reach the goal, again preferably assigning responsibility.
Timelines are essential and should be attached to all goals and key steps, which will facilitate progress monitoring.
It is also useful to identify parties essential to success and outline the components that are each party’s responsibility.
In addition, key organisational issues need to be considered in an implementation plan and efforts made to tying in to existing structures, processes and goals.8 Lack of specificity has been identified as a possible barrier to change.
Hence, it follows that for implementation to be successful it is necessary that the plan is clear and everyone understands the goals and strategies.
Ideally, a budget should be attached to an implementation plan.
It may be worth planning for sustainability from the outset, as the change is likely to continue past the current fiscal year and the project can stall or stop if not adequately resourced.22 Data to support start-up, implementation and ongoing evaluation must be credible and persuasive to those who influence budget decisions.22 Finally, the plan should include a section on monitoring, maintenance and reinforcement of change.
The resulting implementation plan should be a living document and should be updated as and when its core elements, such as the strategies and goals, require.
Communication For any project to gain support and succeed, feedback and communication is vital.
Ideally, all stakeholders should endorse the implementation plan and be kept informed of the progress, as this is important to sustain the process.
Communication should be brief, relevant, easily accessible and preferably in a form familiar to the target audience.12 For stakeholder buy-in, the focus of information should be on improving quality of patient care and how the guideline will help achieve this.25 Effective communication has been shown to be best achieved using existing communication systems.12 This could be in the form of a newsletter, email, a Web site or a hotline.
Meetings should be kept to an absolute minimum, as they require finding time in an already overloaded timetable and could be seen as an addition to an already heavy workload.
Education Education and training are essential when implementing national guidelines at a local level. Interactive, targeted education interventions can be effective in developing practitioners’
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knowledge, skills and attitudes in relation to guideline recommendations.8 It is important to understand the gap between current and intended roles and practices before designing indi- vidual training schedules.
The degree of training required is dependent on the level of change required.
Ideally, education can be integrated in a meaningful and professionally supportive way.
In addition to the health care professionals, education and training should include support staff, as a lack of involvement on all levels may lead to delays and uneven implementation of the new practice guidelines.25 Raising the awareness of the guidelines in new staff members through induction programs can be a useful way to promote good practice.35 Successful adoption is more likely if the intended adopters have sufficient training and support on task issues (e.g. fitting the changes into the daily work schedule).23
Monitoring and Collection of Outcomes Data Guidelines that are simply distributed to the end users without regular review are likely to be ineffective.20 Monitoring is essential to review progress against the established goals.
Thus, any systematic approach to implementation of new CPGs and therefore changing professional practice should include plans to monitor and evaluate as well as to maintain and reinforce any change.12 Different processes exist to monitor progress and outcomes.
Identification of what needs to be measured and the means of capturing relevant data should be considered at an early stage in the planning process.12 Simple user and target group surveys could be used, or more formal clinical audits may be performed.
Audit and feedback are useful to measure adherence to guideline recommendations and may also provide a mechanism by which health care profes- sionals can be made accountable for clinical implementation.
Importantly, the process of audit will detect if aspects of the guidelines prove impracticable in local practice, and appropriate modifications can subsequently be made.20 This importance of an audit to enable modifications or create new support systems should be emphasised.
Audit results may be used as positive reinforcement if they are fed back in a constructive manner to participants.8
CONCLUSION Whilst a guideline may be developed by experts, using a comprehensive and rigorous evidence base, it may still lack the necessary tools and recommendations to facilitate implementation.
The guidelines selection and implementation process is fractured, and there is clearly a need for much attention to be given to the appropriate implementation strategies to accompany a guideline.
Shortcomings exist in the appraisal of available guidelines and most lack a pilot test period prior to issuance.
This suggests that the guidelines are being developed without their developers having the specific circumstances and problems of their implementation in mind.
This lack of pre-testing of CPGs by their developers prior to the dissemination of the guidelines may be a major reason why to date only limited evidence is available in the literature concerning those factors that are instrumental in achieving successful implementation of CPGs.
The failure to pre-test may not be surprising as the mindset, skills, expertise and experience of developers of CPGs are often different than those who would implement CPGs in an organisation.
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A successful facilitator of CPGs implementation is logically someone who is a project management, or change management, specialist or at a minimum has project management or change management skills, expertise and experience as well as the ability to be the ‘translator’ of the guidelines into daily clinical practice.
Such specialists are not common in the primary care setting.
If it is desired that CPGs be successfully implemented into primary care, the sector needs to have access to such specialists.
In addition, in an ideal world, the teams of developers of CPGs would also include individuals who have the above-mentioned project or change management experience.
In light of the distinct lack of robust evidence concerning the delivery of CPGs into the primary sector, this chapter should be viewed as a presentation of recommendations and sug- gestions rather than as a definitive checklist for realising best practice in CPG delivery and translation.
Our presentation of the subject has been based on a combination of not only the information available in the literature but the authors’ own project and change management experience.
Finally, it is hoped that this chapter will at least to a small extent assist in the ultimate implementation of CPGs and prevent them from becoming ‘lost in translation’.
ACKNOWLEDGEMENTS The authors wish to express their appreciation to Professor Patricia Price, Director Wound Healing Research Unit (WHRU), Cardiff University, Wales, for her review of this chapter and valuable comments. The authors also thank Professor Patricia Price and Elizabeth Mudge, Research Fellow WHRU, for their participation in the guidelines appraisal using the AGREE instrument.