Janine Margarita R. Dizon, PhD Research Supervisor Center for Health Research and Movement Science University of Santo Tomas, Philippines

Objectives Lecture –To present strategies to assess the impact of disseminating, implementing and evaluating the guidelines into practice Practical work –To identify the following which are relevant to the disease condition identified in the workshop methods of dissemination and evaluation of the impact of the contextualised guidelines for a larger roll out in practice enablers and barriers in guideline dissemination and implementation 2

Evidence into Practice The implementation of guidelines is one strategy to get evidence into practice “Globalise the evidence, localise the decision” (Eisenberg 2002, Globalize the evidence, localize the decision: evidence-based medicine and international diversity) 3

Evidence based healthcare Patient Values Clinical Expertise Best research evidence EBP Local context

Who and what are to be involved??? Hospital director Hospital departments Department heads Medical residents/ Registrars Allied health practitioners Patient’s families Change champions Hospitals? Clinics? Community? 5

Enablers Access to hospital departments/ peers Membership in professional organisations Good leadership 6

Barriers Knowledge management barriers Structural Organisational Peer group Professional Professional-patient interaction barriers 7

8 Why is there a need to disseminate and implement guidelines?? –So much time has been devoted to developing guidelines –Not sure if these guidelines are utilised to underpin practice –Changing ‘usual practice’ takes time –Consider ‘intention-behavior’ gap Dissemination and implementation

Dissemination of guidelines Consider ‘spreading’ the guidelines in the form of: –Publications –Conferences/ workshops –Trainings –Educational meetings –Journal clubs –Posters in hospitals Multi faceted dissemination strategies better than single component strategy 9

Implementation of guidelines Consider factors that impact guideline implementation –Practical and easy to understand guideline recommendations –Multifaceted strategies (multiple components) are more effective –Guideline interventions are considered as complex interventions (consider local context setting, practice setting and patient and clinician behavior) 10

To assess if the principles of evidence based practice are applied in real life practice –Evidence based guidelines provide information to guide/assist clinicians in making informed decisions regarding patients To identify if implementation strategies are effective –Not all implementation strategies are effective; general and context specific strategies are needed to make sure that guidelines are implemented and utilised in practice To achieve better patient outcomes –Evidence based guidelines provide recommendations which are known to result to effective outcomes, thus expecting better patient outcomes To achieve efficiency in the health system –Guidelines provide recommendations for best patient management known to result to effective outcomes, thus improving efficiency in the health system 11 Evaluation of guideline dissemination and implementation strategies

Evaluation methods 12 Conduct audit studies –Descriptive audits –Benchmarking audits Conduct surveys Conduct practice visits Semi-structured interviews Focus group interviews

The dissemination and implementation plan One day training –Morning Lectures on concepts of underpinning practice with best evidence Contextualisation of the guidelines Key recommendations –Afternoon Workshop on implementing the key recommendations Development of forms to use for documentation Collaboration with other hospital departments Posters in the department (patient journey, key recommendations) Per hospital orientation Inclusion of the guideline recommendations in the examinations of the trainees involved (Refer to implementation protocol) 14

The dissemination and implementation plan Stroke and low back pain caravan 2 day training for health professionals for the purpose of: –Introducing the importance of using evidence to guide practice –Presenting the key recommendations of the contextualised guidelines –Training to implement the key recommendations 15

What and who we involved Factors to consider Target Setting Rehabilitation Wards and Neurology wards of the training institution  Philippine OrthopedicCenter  Philippine General Hospital  University of Santo Tomas Hospital  Veterans Memorial Medical Center Main islands of the Philippines (National Capital Region, Luzon, Visayas and Mindanao) Health professionals Medical Internists/Neurologists (Consultants/ interns/ residents) Physiatrists Physical Therapists Occupational Therapists Nurses Masters students in our Physical Therapy program ConsumersPatients who have been confined because of stroke Caregivers of the patients 16

Our Identified enablers Access to hospitals Vision of the professional organisation Passion and commitment of the group 17

Our identified barriers Misconception about guidelines Hierarchy in place Unavailable records for assessment 18

Our experience – Evaluation methods Descriptive audit of acute in-patient stroke practices (nationwide audit -43 hospitals) Post implementation audit (3 training institutions involved in the implementation project) Focus group interviews with health professionals involved –Perspective regarding the implementation –Facilitators and barriers –Recommendations for improvement (Refer to clinical audit protocol) 19

Preliminary findings Gaps in practice identified The forms developed for documentation are already being used Health professionals involved perceive the implementation useful especially in standardising practice 20