National Guidelines Update Process: Key Steps

2 Objectives Identify guideline components Share best practices in the guidelines development and dissemination

3 What are Guidelines ? Guidelines may include several components: Service delivery policies Service delivery standards Clinical guidelines and protocols Clinical management plans

4 Why Develop National Guidelines ? Guidelines are key to improving access to high quality service delivery: Provide the foundation on which high quality services can be built or strengthened Reduce medical and access barriers Standardize provider practices Guide the content for inservice training and preservice education programs Guide supervisory and management systems Provide standards for monitoring and evaluating quality of care

5 “MAQ: From Guidelines…to Action Conference”, May 1998 Steps in the Guidelines Process

6 Review data Collect existing documentation –national level –service delivery points Conduct needs assessment −include compliance issues Step 1: Establish Need Indonesia Example Variety of service delivery guidelines −national government −professional organizations −project specific documents −NGO materials Confusion among providers and managers

7 Solicit opinion of all stakeholders Solicit policy level support through strategic and frequent meetings with senior officials Prepare a plan and obtain commitment and approval to participate in plan Form a broad-based committee to steer process Step 2: Ensure Broad Scope and Commitment Indonesia Example STARH program identified key/influential stakeholder: YBP-NGO led by providers Convinced and empowered YBP to lead the service delivery guidelines development Provided resources −technical assistance −implementation −printing and dissemination

8 Step 2: Ensure Broad Scope and Commitment Expert Committee in Turkey’s National Guidelines Development Representatives of: Ministry of Health University Service providers, trainers, and their professional associations Local NGOs, FP associations UNFPA and USAID cooperating agencies Expert Committee in Indonesia’s National FP Service Delivery Guidelines Development Representatives of: Ministry of Health Nat’l FP Coordinating Board Service providers, clinical trainers, and their professional associations Medical & Midwifery faculty representatives Local NGOs, FP associations

9 Get input from all levels of the health service system pyramid Identify practices that are positive Conduct broad discourse on proposed guidelines Utilize national and international resources Step 3: Develop Outline and Content Indonesia Example Identify the target audience −providers at the PusKesMas Need to know clear, updated Information −clinical −program Compact and affordable to be in the hands of all providers

10 Step 3: Technical Resources WHO 2008 Eligibility Criteria WHO 2008 Selected Practices Recommendations Family Planning Global Handbook for Providers, 2007 JHPIEGO Infection Prevention reference manual, 2004 CPI guidance documents Reference documents and resources guide the formulation of up-to-date guidelines:

11 Step 4: Testing and Revising Field testing done by a variety of providers Review for technical accuracy, user- friendliness, internal consistency Revisions should reflect client perspectives Review and revise with sanctioning authorities Indonesia Example Feedback from −editors and stakeholders- internal −NGOs and CAs including UNFPA and WHO - external −providers during Contraceptive Technology Update workshops Iterative review process

12 Step 5: Preparing For Dissemination Host country plans strategy and ensure adequate funding Formulate clear and flexible workplan Plan to use a wide variety of formats Go beyond distribution to ensure application in plan

13 Involve and reach all organizations concerned Plan series of workshops for different groups at different levels of service Issue an official letter validating the guidelines and use other opportunities to broadcast them officially Promote using creative mechanisms Step 6: Dissemination Strategies for Success Indonesia Example Secure documented official endorsements Plan national launch in a high profile event Print starter copies for distribution Develop target distribution list Encourage use of the material during training of providers Encourage use in supervision tools

14 Radio dramas Dissemination workshops Flyers Internet Hotlines Audio cassettes Posters and logos Modeling by respected colleagues Step 6: Dissemination and Promotion Strategies

15 Step 7: Hit All the Targets Service delivery points Training programs Education programs Program planning Community linkages Source: Population Reports, Series J, Number 47, 1998.

16 vs. Pregnancy safely ruled out by checklist in 90% of women typically sent home if not menstruating at a time of their visit Of those pregnancies ruled out by checklist only <0.5% where found pregnant by pregnancy test Dipstick  Pregnancy Test Pregnancy Checklist Step 7:Kenya Service Delivery Example

17 Use positive, team- based approaches that make providers partners in promoting guidelines use and solving problems in their application! Source: Population Reports, Series J, Number 47, Step 8: Ownership Encourages Adherence

18 Identify focus of responsibility for adherence and authority for ensuring it Ensure orientation and training around guidelines Look beyond the guidelines for causes of lack of adherence Step 8: Build Adherence Into The System Indonesia Example Dissemination activities led by team of national & local providers Shared results of on- going survey on compliance issues during dissemination Invited both providers and program managers

19 Ecuador Sustainability Study Before: CEMOPLAF policy on IUDs required 4 revisits Study: on impact of reducing mandatory IUD follow-up visits to 1 Results: actual revisits reduced 36% while only detecting 7% less serious medical complications Savings: $23,000 for clients, $10,000 for CEMOPLAF, 1800 provider hours annually Step 8: Explore Reasons for Non- Adherence

20 Send periodic content pieces reinforcing guidelines--especially problem-solving tips and solutions found by practicing colleagues Develop/use job aids and coaching Step 8: Provide The Tools for Adherence

21 Methods to monitor compliance: Self assessment (with checklist) Supervision and training Follow-up Peer review Medical monitoring Record review Client surveys Action research Step 8: Monitor Compliance Source: Population Reports, Series J, Number 47, 1998.

22 Plan for periodic review early in process Provide content and program updates to steering committee Plan for host country self-reliance for guidelines revisions and updates Establish mechanisms for providing technical professionals in the field with up- to-date scientific information Step 9: Plan for Updates

23 Evaluate the integration of guidelines in daily service provision practices Evaluate the impact on access to and quality of care, and accordingly take initiatives to strengthen these Apply results of evaluation to new initiatives to strengthen quality and access Integrate indicators into existing data collection systems Step 10: Evaluate

24 REFERENCE STEPS IN GUIDELINES PROCESS, 1998 MAQ EXCHANGE POWERPOINT PRESENTATIONS BP3K GUIDELINES DEVELOPMENT PRESENTATION, 2002