1. School of Population and Health Sciences Centre for Health Services Research Using guidelines in healthcare settings Martin Eccles Professor of Clinical Effectiveness University of Newcastle upon Tyne

2. Centre for Health Services Research University of Newcastle upon Tyne Using guidelines in healthcare settings How to think about approaching it Two examples –DVT prophylaxis in an acute trust –X-ray guidelines in primary care

3. Centre for Health Services Research University of Newcastle upon Tyne Grol, Wensing, Eccles Improving Patient Care: The implementation of change in clinical practice. Available from Elsevier Press.

4. Centre for Health Services Research University of Newcastle upon Tyne My starting point Many patients do not receive optimal care –Well-planned programmes are required to implement new or valuable scientific findings, guidelines, protocols, care processes or best practices. –Different approaches to the implementation of change in patient care can be observed, each based on different assumptions and theories of human and organisational behaviour. –A combination Rational, top-down and participative, bottom-up approaches is needed to improve practice successfully.

5. Centre for Health Services Research University of Newcastle upon Tyne Planning models – a selection PRECEED/PROCEED model (Green and Kreuter 1991); Marketing theory (Kotler and Roberto 1989); Continuous improvement, PDSA cycles (Ovretveit 1999; Langley et al. 1996); Stages of change theories (Prochaska and Velicer 1997; Grol 1992; Rogers 1983); Persuasion–communication models (Kok 1987; Rogers 1983; McGuire 1981); Intervention mapping (Bokhoven et al. 2003; Bartholomew et al. 2001); Organisational development (Garside 1998).

6. Centre for Health Services Research University of Newcastle upon Tyne Common features (1) A systematic approach to and good planning of implementation activities is needed most of the time. Focus on the innovation –is it a good product? Subgroups within the target group may be at different stages of the change process and have different needs –allowed for segmentation within the target group Diagnostic analysis of the target group and setting before the start of the implementation. The target group should be involved in the development and adaptation of the innovation, as well as in planning the implementation.

7. Centre for Health Services Research University of Newcastle upon Tyne Common features (2) Implementation activities should link with the results of the diagnostic analysis. Usually, a single method or measure is insufficient (?) –search for a cost-effective mix of methods tailored to the identified obstacles and incentives to change. Make a distinction between the phases of implementation (dissemination, implementation and integration) –different measures and strategies are effective at different stages. Take appropriate measures for each of the various levels –national, local, team, practice and individual professional. Continuous evaluation of both the implementation process and its results. Make implementation an integral part of the existing structures.

8. Centre for Health Services Research University of Newcastle upon Tyne Implementation of change: a model

9. Centre for Health Services Research University of Newcastle upon Tyne Starting point (1) Problems identified, good experiences, knowledge of best practice –What do you and your organisation know about the healthcare you deliver? –What do you and your organisation want/need to know to judge quality of care?

10. Centre for Health Services Research University of Newcastle upon Tyne Starting point (2) Research findings or GUIDELINES –Why develop a guideline? Explicit criteria What is the problem to which your guideline is the answer? –Consider implementation during development Head injury & MRI scanning –Different formats –Wording Michie & Johnston. Changing clinical behaviour by making guidelines specific. BMJ, 2004; 328: 343-5

11. Centre for Health Services Research University of Newcastle upon Tyne Attributes of guidelines Complexity, trialability –Complex 42% v 56% –Trialable 56% v 37% Grilli & Lomas 1994 17% variation in compliance explained by attributes of recommendations –Requiring no change in routines; compatability; concrete, specific and clearly defined Grol 1998, Burgers 2003, Foy 2002

12. Centre for Health Services Research University of Newcastle upon Tyne Planning Clear aims Co-ordination/team –Likely to be complicated & multi-disciplinary Involve target group –Their buy in –Their knowledge Resources –Financial & human Skills – behaviour change, IT, management Timescale

13. Centre for Health Services Research University of Newcastle upon Tyne Next step Develop concrete proposal/targets for improvement or change –Be as specific as possible –How much can you do? Within a guideline Across guidelines

14. Centre for Health Services Research University of Newcastle upon Tyne Diagnostic analysis An analysis of the target group, the setting in which change is planned and the determinants of change –Who is involved? Which interests are relevant? –What is current practice? Which improvements are needed? –What are the barriers and facilitators for change in different subgroups? –Which subgroups can be distinguished in the target group and at what stages of change are these subgroups?

15. Centre for Health Services Research University of Newcastle upon Tyne Diagnostic analysis Barriers and facilitators can relate to: –the individual care provider knowledge, attitude, motivation for change and personal characteristics –the social setting care providers and patients –the organisational and financial system organisation, resources, financial structure, personnel and logistics

16. Centre for Health Services Research University of Newcastle upon Tyne Diagnostic analysis Methods –Multiple Interviews Focus groups Surveys Routinely available data

17. Centre for Health Services Research University of Newcastle upon Tyne Selecting strategies for change Numerous interventions (strategies and measures) can be used to change behaviour or implement innovations: –Professional-oriented strategies –Patient-oriented strategies –Financial measures –Organisational measures –Legal regulations and/or rules

18. Centre for Health Services Research University of Newcastle upon Tyne Selecting strategies for change In selecting interventions consider: –Results of the diagnostic analysis of both the target group and the implementation setting –Existing knowledge of effective implementation –EPOC, –Grimshaw JM et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004 –Wensing, Wollersheim, Grol. Organizational interventions to implement improvements in patient care. Implementation Science 2006:1;2 –Phases in the actual process of implementation and change (a distinction between dissemination, implementation and maintenance of change)

19. Centre for Health Services Research University of Newcastle upon Tyne Organising the implementation Good planning is of great importance –Begin small, test the plan on a small scale using motivated groups and gradually expand In making the plan, consider: –A cost-effective mixture of interventions of proven value –Implementation activities in all phases of the process of change, so the plan is for both dissemination and implementation –Implementation activities at the correct or multiple levels (central, local group, team/department, practice and individual)

20. Centre for Health Services Research University of Newcastle upon Tyne Organising the implementation Good planning & time management; Involve the target group in designing and executing the plan Incorporate the plan into existing activities for communication and teaching of the target group Adequate budgetary and other support Incorporate periodic evaluation in the plan Consider organisational aspects that promote or retard implementation –Leadership, the role of physicians, collaboration, teaching of quality methods and organisation culture

21. Centre for Health Services Research University of Newcastle upon Tyne Context Newcastle and North Tyneside Health Authority established a Clinical Effectiveness Unit –Remit was to provide support to local health-care teams aim of promoting clinical effectiveness encouraging the use of best evidence in daily practice through systematic, evidence based approaches to implementation Three acute hospital trusts in Newcastle upon Tyne

22. Centre for Health Services Research University of Newcastle upon Tyne The hospitals

23. Centre for Health Services Research University of Newcastle upon Tyne Topic selection Venous thrombo-embolism: –Clinical Effectiveness Steering Group agreed criteria to select prevention of venous thromboembolism as a priority area –Given to the Clinical Effectiveness Unit in September 1996

24. Centre for Health Services Research University of Newcastle upon Tyne Local guideline adaptation Guidelines Development Group: –Clinical Effectiveness Unit began working with a local guidelines development group to adapt the recommendations of a national guideline –Produced a local guideline which was widely distributed to local clinicians for review and piloted on four wards at the end of September 1996: Scope of the guidelines: risk assessment and prevention of deep vein thrombosis in hospitalised patients Intended purpose of the guidelines: to standardise procedures within and between local Trusts Staff involved: nursing staff to carry out risk assessment and medical staff to administer appropriate prophylaxis, as necessary

25. Centre for Health Services Research University of Newcastle upon Tyne Implementation Guideline Implementation Group: –Month 4 A multidisciplinary implementation group was convened, to develop the practical aspects of implementing guidelines into routine daily practice Production of guideline pack: –Month 10/11 The implementation group produced a guideline pack A guideline binder, a training resource manual and implementation aids Dissemination and implementation of guidelines: –Month 11-14 A multiple strategy implementation programme was used to introduce the guidelines, initially into Trust 1 and Trust 2. Guidelines were introduced into Trust 3 in Month 20 (1) local change agents and opinion leaders; (2) training and education (3) advertising.

26. Centre for Health Services Research University of Newcastle upon Tyne Evaluation Evaluation of guidelines use: –Month 21 Process evaluation was carried out in Trust 1 and Trust 2, eight to ten months after the introduction of the guidelines Guidelines review: –Month 28 based on feedback and new evidence, additions and changes were made to the guidelines and sent out for review and comments to local health-care professionals

27. Centre for Health Services Research University of Newcastle upon Tyne What happened?

28. Centre for Health Services Research University of Newcastle upon Tyne What happened?

29. Centre for Health Services Research University of Newcastle upon Tyne What happened?

30. Centre for Health Services Research University of Newcastle upon Tyne What happened?

31. Centre for Health Services Research University of Newcastle upon Tyne Prophylaxis

32. Centre for Health Services Research University of Newcastle upon Tyne Prophylaxis

33. Centre for Health Services Research University of Newcastle upon Tyne Prophylaxis

34. Centre for Health Services Research University of Newcastle upon Tyne Implementation research – a question Can we alter the rate of inappropriate requests for X-rays? Are the requests that are made appropriate? –Lumbar spine; knee –Successful outcome: reduction in the number of x- rays requested. Exercise in counting requests - not necessary to identify individual basis Data for evaluation routinely available from radiology department referrals

35. Centre for Health Services Research University of Newcastle upon Tyne Study design Before and after pragmatic randomised controlled trial using a 2 x 2 factorial design –2 x 2 factorial design (4 groups) 1: paper guidelines only 2: paper guidelines + audit 3: paper guidelines + condition-specific reminders 4: paper guidelines + audit + condition-specific reminders –Powered to be able to detect interactions 247 general practices; 6 radiology departments

36. Centre for Health Services Research University of Newcastle upon Tyne Audit and Feedback

37. Centre for Health Services Research University of Newcastle upon Tyne Condition-specific reminders NE X US EDUCATIONAL MESSAGE In either acute (less than 6 weeks) or chronic back pain, without adverse features, x-ray is not routinely indicated In adults with knee pain, without significant locking or restriction in movement, x-ray is not routinely indicated

38. Centre for Health Services Research University of Newcastle upon Tyne What happened?

39. Centre for Health Services Research University of Newcastle upon Tyne Implementation Science Editors Martin Eccles, Brian Mittman Implementationscience.editors@ncl.ac.uk Scope All aspects of research relevant to the scientific study of methods to promote the uptake of research findings into routine healthcare in both clinical and policy contexts www.implementationscience.com

40. Centre for Health Services Research University of Newcastle upon Tyne Conclusions It takes: –Time –Resources –Commitment –Team work –Enthusiasm Buena Suerte!