Implementation of clinical practice guidelines, from theory to practice.
Jaime Hernán Rodríguez Moreno
Md, MGSIG. PhDPH. DBA (c)
Health Systems Consultant
"We must be creative when we make inventions, but we must be disciplined while implementing them." Amit kalantri
The health care process is based on knowledge, that is, on taking the content of the lessons learned through time and making them available to the patient, the family and the community, in the different fields and branches of health .
However, this process is not linear, which means that different situations of each of the people and organizations that intervene in the health care process must be analyzed and that will be in charge of implementing the best recommendations, derived from the review of the best available evidence (National Academies of Sciences, Engineering, and Medicine, 2018).
For the development of this process, the following stages must be met:
1. Analysis of the recommendations in a specific context: this means that the capacity of people, institutions and health systems to put the recommendation into practice must be evaluated, in this the following elements are analyzed (Peters, Tran, & Adam , 2013):
- Human talent: at this stage, the type of professional who should put the recommendation into practice is identified, identifying whether it is a person with technical, professional or specialized training, the person's profession (nursing, medicine, physical therapy, nutrition) and the degree of specialization, professional with general or specialized training such as a surgeon, a gynecologist, an electrophysiologist among others.
- Infrastructure and equipment: in this section the necessary environmental and location conditions are analyzed, as well as the required equipment and the skill level of the people to carry out the recommendations.
In this regard, the performance and maintenance of the equipment and infrastructure, the learning curves of the people and the need for interaction between the areas, the equipment and the people (including the patient) during the moment of care must also be considered. .
- Supplies and medicines: the availability of the supplies and medicines necessary during the time of care, the interaction between the process medicines, with those coexisting in the patients, the storage and dispensing conditions, as well as the care that must have people.
- Processes and procedures: during this analysis, the activities to be developed, the times necessary for the consultation or the execution of the recommendation, the levels of interaction between organizations within the health system, the characteristics of the financing, and the coverage are reviewed. by health systems.
2. Construction of implementation plans: once the analysis of the requirements in each of the components of point number 1 is done, those situations that the institution already has implemented and those that it must consider to put into practice must be identified, that is, , those that, since they are not developing, require a greater degree of work to ensure compliance (World Health Organization, 2018).
In this sense, the first element that must be considered is the need for the appropriation of knowledge by the different people who are part of the patient's care, including health professionals and administrative support people of the institution.
To ensure that this knowledge can be appropriate and used more effectively during the care process, support tools such as:
- Evidence sheets: these tools are summaries of evidence that allow you to easily emphasize the reasons behind the recommendations.
- Management flow charts: these are tools much closer to decision-making, they help to identify the route in the care process, at the time of putting the recommendations into practice (Rodriguez, et al., 2017).
- Electronic reminders: these can be of two types like this (Proctor, Powell, & McMillen, 2013):
- Active: they are support systems articulated with electronic clinical records, in these, alerts are generated in relation to patient safety, pharmacovigilance alerts, drug interactions, control tests in certain pathologies or with special medications, alarm signs for the patient.
- Liabilities: these are messages that are sent periodically via email or cell phone messages to ensure that the evidence is fixed in the best possible way.
It is important to indicate that within the implementation plans classic continuing education activities should be included, which allow institutional staff to consolidate knowledge and make a fundamental element that is to unlearn old personal and institutional practices.
The development of the implementation plan must also include the analysis of elements and activities not available and their concordance with the availability of time and resources that the organization has, in order to ensure the success of the implementation process.
One of the important activities of the implementation of the guidelines at the institutional level is the articulation with the existing processes, among which are patient safety, technology management and continuous quality improvement.
3. Follow-up to the implementation plan: for this activity, measurement and follow-up actions must be established, based on two types of indicators as follows:
- Follow-up on the execution of the plan: these are process indicators that allow to know the progress in the realization of the content of the implementation plan.
- Adherence and impact: the generation of this type of indicators will allow the institution to know if the actions developed allow the recommendations to reach the patient (National Academies of Sciences, Engineering, and Medicine., 2018).
- Adherence: the measurement of adherence is the production of a series of indicators that should focus on the fact that the patient actually received the recommendation, not only on the doctor or nurse who performs it, for example, if one talks about taking a medication, it is not enough to measure that the doctor prescribed it, it must be measured that it has been delivered and ideally that the patient consumes it.
- Impact, these types of indicators are late and are related to the change in health outcomes, as a result of the implementation of the recommendations, for example, decrease in hospital stay, decrease in adverse events, among others.
In conclusion, implementation is a complex process that must be worked on in an articulated, planned and strategic manner, which must involve the entire organization and not only health professionals, it must consider the new knowledge and the specific context where it will be put into practice the recommendations of the CPGs.
– We appreciate the participation of Dr Jaime Hernán Rodríguez as a guest writer to the NeuroEconomix blog.
– NeuroEconomix has extensive experience in the adoption and adaptation of clinical practice guidelines. If you want to know more about this service you can consult HERE
1. National Academies of Sciences, Engineering, and Medicine. (2018). Crossing the global quality chasm: Improving health care worldwide. Washington: National Academies Press.
2. National Academies of Sciences, Engineering, and Medicine. (2018). Implementing quality measures for accountability in community-based care for people with serious illness: Proceedings of a workshop. Washington: The National Academies Press.
3. Peters, D., Tran, N., & Adam, T. (2013). Implementation research in health: a practical guide. Geneva: Alliance for Health Policy and Systems Research, World Health Organization.
4. Proctor, E., Powell, B., & McMillen, C. (2013). Implementation strategies: recommendations for specifying and reporting. Implementation Science, 2-11.
5. Rodriguez, J., Romero, A., De Alba, D., Jaramillo, H., Diaz, C., & Ciapponi, A. (2017). Evaluation of tools for the implementation of the Clinical Practice Guide for sexually transmitted infections. Rev Panam Salud Publica, 41: e49.
6. World Health Organization. (2018). Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care. Geneva: World Health Organization.