Implementation Guide and Toolkit for Naonal Clinical Guidelines N ati o na l Pati ent Safet y Of f i ce Oifig Náisiúnta um Shábháilteacht Othar Feasibility Capacity Outcomes Impact Reach Fit Leadership Adherence Fidelity Enablers Adoption Cost Implementation planning Organisational culture Intervention readiness Stakeholder engagement Implementation Science Knowledge translation Situation analysis Capacity building Behaviour change Needs assessment Appropriateness Evidence-based Effectiveness Acceptability Communication Dissemination Maintenance Logic model Competency Sustainability
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Implementation Guide and Toolkitfor National Clinical Guidelines
National Patient Safety OfficeOifig Náisiúnta um Shábháilteacht Othar
Feasibility
Capacity
OutcomesImpact
ReachFitLeadership
AdherenceFidelityEnablers
Adoption
Cost
Implementation planning
Organisational culture
Intervention readiness
Stakeholder engagement
Implementation Science
Knowledge translation
Situation analysis
Capacity building
Behaviour change
Needs assessment
Appropriateness
Evidence-based
Effectiveness
Acceptability
Communication
Dissemination
Maintenance
Logic model
Competency
Sustainability
The National Clinical Effectiveness Committee (NCEC) is a Ministerial committee of stakeholders, including patient representatives, that was established to oversee a National Framework for Clinical Effectiveness. Its Terms of Reference are:
1. Provide strategic leadership for the national clinical effectiveness agenda.
2. Contribute to national patient safety and quality improvement agendas.
3. Publish standards for clinical practice guidance.
4. Publish guidance for National Clinical Guidelines and National Clinical Audit.
5. Prioritise and quality assure National Clinical Guidelines and National Clinical Audit.
6. Commission National Clinical Guidelines and National Clinical Audit.
7. Align National Clinical Guidelines and National Clinical Audit with implementation levers.
8. Report periodically on the implementation and impact of National Clinical Guidelines andthe performance of National Clinical Audit.
9. Establish sub-committees for NCEC workstreams.
10. Publish an Annual Report.
Published by:The Department of HealthBlock 1, Miesian Plaza, 50-58 Lower Baggot St, Dublin 2, D02 XW14, Ireland Tel: +353 (1) 6354000https://health.gov.ie/ [email protected]
Citation text: Department of Health (2018). NCEC Implementation Guide and Toolkit. Available at: https://health.gov.ie/national-patient-safety-office/ncec/In text citation: (Department of Health 2018)
2 Implementation Guide and Toolkit for National Clinical Guidelines
Development of the GuideThe development of this Implementation Guide was informed by Implementation ScienceliteratureandresourcesandconsultationandinteractionswiththeClinicalEffectivenessUnitintheDepartmentofHealthandmembersofGuidelineDevelopmentGroups.
FundingTheprocessfordevelopingthisguidefortheNCECwasfundedbytheDepartmentofHealthandoverseen by the Clinical Effectiveness Unit of the National Patient Safety Office, Department ofHealth.
AcknowledgementsThe Clinical EffectivenessUnitwould like to thank the following peoplewho contributed to thedevelopmentoftheGuideinvariousways,includingtheprovisionofworkedexamplesoftoolsandprovidingfeedbackonearlierdraftsofthisGuide:
PermissionsPermission has been granted by the National Implementation Research Network (NIRN) foradaptationoftheirHexagonToolinthisGuide.PermissionhasalsobeenobtainedtoincludeProctoretal.’s(2010)TaxonomyofOutcomes[28] andimagesfromtheIHIFrameworkforLeadershipforImprovementandtheBehaviourChangeWheel.
3Implementation Guide and Toolkit for National Clinical Guidelines
How to use this Guide
Who is this guide for?The purpose of this Implementation Guideis primarily to support those involved in thedevelopment and implementation of NationalClinical Guidelines, for planning implementationactivities. Throughout this guide we refer to‘guidelines’astheinterventionforimplementation.However, it will also be of interest to thoseinvolved in the development and implementationof other evidence-based interventions, such asclinical practice guidance; policies, procedures,protocols and guidelines (PPPGs), and auditrecommendations.
ThroughoutthisGuide,werefer to ‘GuidelineGroups’.This refers toboththe initialGuidelineDevelopment Group and the post-publication implementation team(s). There will be someoverlap between the initial Guideline Development Group and the implementation team(s).The implementation team isgenerallyanational team,butadditional local teamscanalsobeestablished as required. The implementation team(s) take the guideline forward through theimplementationstages,inpartnershipwiththewiderhealthserviceorganisation.
When will it be used?ThisImplementationGuideprovidesthetheory,stepsandtoolsforeachstageofimplementation.WhilstitisrecommendedthattheImplementationGuidebeusedfromtheoutsetinguidelinedevelopment, existing Guideline Development Groups will also find the various tools useful,regardlessofwhatstageofdevelopmenttheyareat.
What needs to be included in the guideline?NCECGuidelinesalreadyincludeaplanforimplementation.NewGuidelineDevelopmentGroupswill beexpected to include the following implementation components in their submission forQualityAssuranceandinthefinalpublishedguideline:
for implementation at various stages of the guideline development and implementationprocess.
ThisGuidebuildsoninformationdeliveredbytheCentreforEffectiveServicesfortheNationalClinicalEffectivenessCommittee (NCEC) in the Department of Health ata two-day Introductory Training in ImplementationScience and a series of three additional workshops onspecific implementation topics delivered to healthcarepractitioners, healthcare staff and other stakeholders.However,itisdesignedinsuchawaythatitcanbereadandusedbystakeholderswhowerenotattheseeventsorwhohaveabroaderscope.
The first section of this Guide is intended as a source of evidence for why implementation ofclinicalguidelinesisanimportantandusefultopic.Followingthat,thereisabriefoverviewofthemain theories and concepts put forward in Implementation Science. This will serve as a usefulintroductionforthosewhoarenewtoImplementationScience,orasarefresherforthosewhoarefamiliarwith thedisciplineand/orwhohaveattended relevant training sessionsandworkshops.ReferencesareprovidedwithhyperlinksattheendofthisGuide,whereavailable,andthereisalsoalistoffurtherresources,forthosewhowouldliketoreadfurther.
The remaining sections provide information, tools and resources for the most relevant andimportantimplementationconsiderationsthroughoutguidelinedevelopmentandimplementation.Implementation stages are discussed in somedetail in thisGuide, and it is especially helpful toidentify which stage a guideline/project is at in the implementation process. ImplementationplanningisalsodiscussedindetailinthisGuideandatemplateforcreatinganimplementationplanisincludedinTool4.
However, it is important to note that “implementing research evidence is not just a matter of following procedural steps” [2,p.4].Accordingly,thisGuideisnotastep-by-stepguideorchecklistfor implementing clinical guidelines. Rather, it provides a package of information, tools andresourcestohelpguidediscussions,thinkingandplanningaroundimplementation.ItwillbeuptoGuidelineDevelopmentGroups,implementationteamsandotherrelevantstakeholderstoidentifyimplementation activities, given the context in which they are implementing and the nature ofwhatisbeingimplemented.Naturally,thesewillvaryonacase-by-casebasis,andwebelievethatthisGuidewillbecomeincreasinglyusefulaspeoplegainexperienceandknowledgeofboththetheoryofImplementationScienceandthepracticeofimplementingintherealworld.
5Implementation Guide and Toolkit for National Clinical Guidelines
Implementation of Clinical GuidelinesIn Ireland, clinical guidelines that meet specific prioritisation and quality-assurance criteria setforthbytheNCECareendorsedbytheMinister forHealthandaretitled ‘NCEC National Clinical Guidelines’. This is in line with evidence indicating that the quality assurance and evaluationprocessesusedindevelopingclinicalguidelinesinternationallyhasimprovedsincethe1990s[3]
However, there is little international evidence ofconsistent improvements in the dissemination,implementationandclinicaluseofclinicalguidelines.Forexample, studieshaveshown thatup to50%ofpatients can fail to receive clinical interventions inaccordancewiththebestclinicalevidenceandlatestclinicalguidelines[4,5]
Guidelines have often been found to contain alargevolumeofclinical information,andhavebeendescribedvariouslyas ‘cumbersome’ [6]and‘unmanageable’ [7]. Thishas left thoseusing theguidelines “frustrated with the vast number of guidelines and uncertain about how to implement them” [8,p.1].Evenwhencliniciansareawareof and in agreementwith clinical guidelines, adoptionandadherence canbe low, and cliniciansindicateadesireformoreguidanceandsupporttoimplementthem[9]
Not only is this a sub-optimal return on considerable investment of public money [10], it alsoindicatesasignificantlossinpotentialhealthgainsforpatientsandpopulations[5].InIreland,thisisadrivingfactorbehindtheproductionofthisGuideandtheincreasingfocusonimplementationofclinicalguidelines.
Thereisanopportunityforguidelinedevelopersandstakeholderstodomoretotranslateclinicalguidelinesintousablematerialsforpractitionerswithlittletimeandresources.“Merely circulating guidelines or other documents to health professionals has only a small effect on practice” [3,p 276]–healthprofessionalsalsorequiredisseminationand implementationactivities,toolsandresources thatwillhelp tomaximiseusageofguidelines [10].Guidelinesshouldbepresented inamanner that is clear, precise and usable, for example in summary documents, ‘Plain English’versions,orpoint-ofcarechecklistsandforms[11]
Prioritisation occurs at the beginning of the guideline development process. Key aspects ofimplementationwhichareassessedbytheNCECduringtheguidelineprioritisationstage include[12,p.12]:
• Whatisthefeasibilityofimplementationoftheclinicalguideline?• Whatarethefacilitatorstotheguidelineapplication?• Arethereanysignificantbarrierstoimplementationoftheclinicalguideline?• Whatistheresourceimpactforimplementationoftheclinicalguideline?• How acceptable will the clinical guideline be to relevant stakeholders (consumers and
6 Implementation Guide and Toolkit for National Clinical Guidelines
• DidtheGuidelineDevelopmentGroupincludeindividualsfromalltherelevantprofessionalgroups,methodological experts and intended users, for example healthcare professionals,hospitalmanagersetc.?
ThisguideandthetoolsareavailableontheDepartment of Health NCEC website:http://health.gov.ie/national-patient-safety-office/ncec/
Other resources relating to National Clinical Guidelines, National Clinical Audit and ClinicalPracticeGuidancearealsoavailableonthe Department of Health NCEC website linkedabove.Thisincludesresourcesonguidelineprioritisationandqualityassuranceprocesses,suchasthe:
• Preliminary Prioritisation Process for National Clinical Guidelines• National Quality Assurance Criteria for Clinical Guidelines• Guideline Developers Manual
Trainingmaterials, including videos and e-learning are available on theDepartment ofHealth National Patient Safety Office Learning Zone: https://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/
8 Implementation Guide and Toolkit for National Clinical Guidelines
Introduction to Implementation Science
What is Implementation Science?Implementationfocusesonoperationalisingaplan–itisabout‘How’somethingwillbecarriedout,aswellas‘What’willbecarriedout[14].Itisbothanartandascience,harnessingknowledgefromacademicresearchandpracticewisdom,withtheaimofsuccessfully incorporating interventionsinto typical service settings, in order to improve outcomes for service users (children, adults,families,communitiesandsociety)[15]
Diffusionlettingithappen
Disseminationhelpingithappen
Implementationmakingithappen
Implementation is conceptually distinctfrom diffusion and dissemination. Diffusionis a passive process, described as ‘letting ithappen’, meaning the intervention follows anunpredictable, unprogrammed, emergent andself-organising path. Dissemination is a moreactive, negotiated and influenced means ofdelivering an intervention (‘helping it happen’).Implementation is the most active form ofdelivering interventions – it involves ‘making ithappen’,throughscientific,orderly,plannedandmanagedactivities[16]
Implementation Science is linked to and builds on a number of related disciplines includingImprovement Science, Quality Improvement, Project Management, Change Management,KnowledgeTranslationandOrganisationalDevelopment.
ItisworthnotingwhatImplementationScienceisnot:ûA magic formula – ImplementationScienceisnottheanswertoallImplementationproblems
ûA mystical and inaccessible language – while some Implementation Science literature cancontainjargon,itbuildson‘commonsense’andknowledgefromarangeofrelateddisciplines.
ûA way of proving an evidence-based intervention – Implementation Sciencewill not provewhetheraninterventioniseffectiveornotandusingImplementationSciencewillnotturnabadinterventionintoagoodone.
9Implementation Guide and Toolkit for National Clinical Guidelines
Asafieldofstudy,ImplementationSciencehasgrowninpopularityoverthelastdecade,andthereisnowaconsiderablebodyofresearchfromawiderangeofsectorsindicatingsomeofthemostimportantfactorsindeterminingwhetherimplementationwillbesuccessfulornot.Implementationisanotachallengeuniquetothehealthsector.Rather,itisauniversalphenomenon,andlessonsinImplementationSciencehavebeenobtainedfromfieldsasdisparateaseducationandtraining;manufacturing and engineering; agriculture and forestry; business and information technology;andmore.
Effective Interventions
The “WHAT”
Effective Implementation
Methods The “HOW”
Socially Significant Outcomes
Enabling Contexts
Enabling Contexts
Having an effective intervention is just one part (albeit an important one) of getting to positiveoutcomes.ImplementationSciencehelpsustoidentifytheeffectiveimplementationmethodsandenabling contexts that form the remaining parts of the equation and improve the likelihood ofreachingtheintendedoutcomes[15]
Implementation FrameworksImplementation frameworks provide a conceptual modelofimplementation,servingtodescribespecificstepsintheplanningandexecutionofimplementation,andhighlightingpotentialpitfalls.
The past decade has seen an increase in the number offrameworksappearinginImplementationScienceresearch.In2012,thecountwasatmorethan60frameworks[17];in2017, itwas100ormore[18].Theseframeworksdiffer intermsofassumptions,aims,context(policy,practice,etc.),andsectors(publichealth,childwelfare,etc.).
• Websites such as the ‘Dissemination & Implementation Models in Health Research & Practice’arenowbeingcreatedtohelpresearchers,policymakersandpractitionersdeterminewhich framework, or elements of a particular framework,will bemost relevant for theirimplementationproblem.
To access this website, click here:http://www.dissemination-implementation.org/
• Forthoseinterestedinreadingfurther,theCentre for Effective Services has created a short document summarising several implementation frameworks withlinksforfurtherreading.
To access the Summary of Implementation Science Frameworks, click here or see Appendix A.
10 Implementation Guide and Toolkit for National Clinical Guidelines
While Implementation Science is producing growing evidence of generalisable lessons formoreeffective implementation, the evidence for any individual implementation framework is limited.There is also significantoverlapamongmanyof the frameworks.Asa result, there is a growingemphasis on combining and improving existing frameworks, and on using the most relevantelementsofanyoneormoreframeworksgivenaspecificcontext.
Implementation StagesImplementation frameworks almost unanimously conceptualise the implementation of anyinterventionaspassingthroughagivennumberofstages.Thenumberofstagesvariesbetweenframeworks(usually3-5),asdoesthenamesprovidedforeachofthestages.
Key messages from Implementation Stages:• Youcannot skip any stageof implementation.Eachstagerequiresstakeholders’timeand
12 Implementation Guide and Toolkit for National Clinical Guidelines
Assessing Implementation StageIt is very useful for Guideline Groups to assess what stage of implementation their guidelineis at. This allows groups to get a sense of how far along the implementation process they are,and consider the most appropriate activities for them, given their stage. Strictly speaking, thisassessment could occur at any stage of guideline development and implementation, but isparticularlyusefulinstages1and2,forthepurposesofplanningandresourcing.
The Implementation Stages – Key Activities Tooloutlinesthefourstagesofimplementationandprovidesexamplesofkeyactivitiesateachstage.Italsoprovidesatemplateforstakeholderstoanalysetheirownprogressonthekeyactivitiessuggested,aswellasanyadditionalactionstheyidentifyspecificallyfortheirintervention(s).
Click here to access the tool on the Centre for Effective Services’ website:http://effectiveservices.org/resources/article/implementation-stages-key-activities
Enablers and BarriersImplementation Science has highlighted a number of factors which increase the probability ofanyinterventionbeingsuccessfullyimplemented.Thediagrambelowindicatestenofthesemostcommonly-seenfactorsandindicatesatwhichstageofimplementationtheyrequiremostattention.Thesefactorsaregivenavarietyofnamesintheliterature,includingdriversandfacilitators,butforsimplicity,thisGuidewillrefertothemasimplementation ‘enablers’
13Implementation Guide and Toolkit for National Clinical Guidelines
Context for ImplementationImplementationScience indicatesthe importanceofthecontext inwhich interventionsare implementedand used [19]. Examples of factors that influencecontextinclude:
By nature, implementation is inseparable from context. This means that contextual influencesexplain a lot of the variation in implementation success [19]. For example, if an interventionrequires thepurchaseofnewequipment,but theexternal contextmeans funding isnot readilyavailable,thechancesofsuccessfulimplementationarereduced.
14 Implementation Guide and Toolkit for National Clinical Guidelines
Strategies for ImplementationFor some time, there has been evidence that tailored implementation strategies improveimplementation success [22]. Implementation Science is now identifying what strategies andactivitiesmaybeusedtotargetspecificenablersandbarriersofimplementation.Thesestrategiescanbeeithertop-downorbottom-up:
The recent Expert Recommendations for ImplementingChange (ERIC) project has sought to gather togetherimplementationstrategiescommonlyusedbythosetryingto successfully implement an intervention [23]. This canbeusedbyimplementersasa‘menu’ofoptions,wherebythey can choose strategies and activities based on whatwould be most suitable and effective in their specificcontext.
16 Implementation Guide and Toolkit for National Clinical Guidelines
Stage 1: Exploring and Preparing
In stage 1 of implementation, the needs of stakeholders are assessed, the reason/rationale for developing the guideline is clarified, and the scope of the guideline is determined. It involvesexploring thecontext inwhich implementationwill takeplace,andtherangeofpossibleactionsthatwillsuitthiscontext.Forguidelinedevelopment,thisstagetypicallyinvolvesdecidingontherangeofclinicalquestionstobeincludedintheguideline,i.e.thescopeoftheguideline.Specificactivitiestobecarriedoutinthisstageare:
The pyramid shown overleaf indicates four potential levels of engagement with stakeholders.GuidelineGroupsshouldconsideratwhichleveltoengagewithkeystakeholders.Theupperlevelsof thepyramidaremore likely to achieve true levelsof engagement,whereby stakeholders feeladequatelyconsultedandarewillingtobuy-intotheintervention.However,theupperlevelsofthepyramidalsohaveahigherresourcerequirementintermsofeffortandcost.
The Stakeholder Engagement Tool,developedbytheCentreforEffectiveServices,helpsthoseimplementingapolicyorprogrammetoplanforandmanagetheprocessofengagingwithkeystakeholders.Itsetsouttasksandquestionsforstakeholderidentification,analysisandmapping.Italsoprovidesatemplateandchecklisttohelpdevelopastakeholderengagementplan.
Click here to access the Stakeholder Engagement Tool on the Centre for Effective Services website: http://effectiveservices.org/resources/article/stakeholder-engagement-tool
Public InvolvementTheNCEChaspublishedaFrameworkandToolkit forPublic Involvement inClinicalEffectivenessProcesses in2018,which is availableon theNCECwebsite:http://health.gov.ie/national-patient-safety-office/ncec/public-involvement-framework/. The term ‘public’ includes a wide range andvarietyof individuals, aswell as groups and/ororganisations. These includepeoplewhouse, orhaveusedhealthcareservices,carersandfamilymembers,parents,organisationswhorepresentpatients, patient support groups, charities that represent specific health conditions, individualswithaninterestinatopic,andmembersofthegeneralpublic[26]
The public are partners in the use of clinical guidelines. Their involvement at all stages of theplanninganddevelopmentprocessisintegraltothefeasibility,needsassessmentandsustainabilityof the intervention. Public involvement in clinical effectiveness processes strengthens publicparticipationinhealthcaredecision-makingandbringspublicknowledgeandexperiencetotheseprocesses.
18 Implementation Guide and Toolkit for National Clinical Guidelines
The NCEC Framework and Toolkit for Public Involvement inClinical EffectivenessProcessesoutlines thepractices thatmaybeundertakento involvethepublic inclinicaleffectivenessprocessesand includes theNCECvalues forpublic involvement,whichapplytoengagementwithallstakeholders:
Needs AssessmentPrior toguidelinedevelopmentand implementation,aneedsassessmentshouldbecarriedouttoidentifythegapbetweenwhatiscurrentlyinplaceandwhatisdesirabletohaveinplace,inadditiontoanyvariation inpractice.Thesegapsshouldbeassessed at multiple levels (patient, provider, organisation,system).Needsshouldalsobeassessedfromtheperspectiveof the stakeholders (both individuals and organisations)whowillbedirectlyinvolvedinimplementation.
“Clearly, improving the health and wellbeing of patients is the mission of all healthcare entities, and many calls have gone out for organisations to be more patient centred… Consideration of patients’ needs and resources must be integral to any implementation that seeks to improve patient outcomes” [20, p.7].
A needs assessment should come very early in the guideline development and implementationprocess,anditissometimesconsideredapre-implementationactivityoranecessaryfirststep.
The Hexagon Tool is a planning tool used to conduct a needs assessment and evaluateimplementation readiness for interventions during the initial stages of implementation. It helpsguidelinedevelopersandimplementerstobroadlyconsidersixfactorsthathelptodeterminelevelsofneedandindicatewhereinitialimplementationeffortswouldbemostimpactful.Thesixfactorsare:Need; Fit; Resource Availability; Evidence; Intervention Readiness; and Capacity to Implement.
To access the Hexagon Tool, click here or see Tool 1.
A Needs assessmentclarifiestheextenttowhichneeds,aswellasbarriersandfacilitatorstomeetthoseneeds,areaccuratelyknownandprioritisedbyanorganisationorgroupofpeople.
19Implementation Guide and Toolkit for National Clinical Guidelines
Identifying OutcomesImplementation outcomes are changes resulting fromdeliberate and purposive actions to implement newtreatments, practices, and services. They are distinct fromserviceoutcomesandpatient/clientoutcomes,andtheyservethreemainpurposes:
a) Theyareindicatorsofimplementationsuccessb) Theyhighlightimplementationprocessesc) They can serve as intermediate outcomes for desired
• Frame and label outcomes in the correct language. They should indicate a change from acurrentposition,ratherthanjustanactivity,outputordecision.Thediagramoverleafprovidessomeexamples of incorrectly labelledoutcomes andhow they canbemore appropriatelyframed.
21Implementation Guide and Toolkit for National Clinical Guidelines
Developing a Logic Model The potential usefulness of guidelines shouldbe determined with reference to a clearlyarticulated description of how theywill bringabout a change. A Theory of Change makesthisexplicit,by indicatingwhyproviding inputXshouldleadtoachangeinoutcomeZ,bywayof output Y. This theory should be evidence-based,andtracehowthe inputs,outputsandoutcomes are conceptually and practicallylinked.
AnexampleofaTheoryofChangefortheMobilisationofVulnerableAdults,Ontario(MOVE-ON) [29] study is provided below. This clearly details a number of steps and expected relationships,whereby investment intrainingand infrastructurecaneventually leadto improvedoutcomesforclientsandservices.
Managementandstaffvalue
mobilisationamongpatients
Staffaregiventhetoolstoincreasepatientmobility
Patientsareassessedfortheirmobility
needs
Staffdeveloplocalised
mobilisationstrategies
Patientsgetexerciseduringtheir
hospitalisation
↓Lossofmusclestrength
↓Depression
↓Delirium
↑Rateofdischarge
↑Independentfunctioning
↓Hospitalcosts
Investmentintrainingandinfrastructure
If – Then If – Then If – Then If – Then If – Then
Theory of Change for the Mobilisation of Vulnerable Elders, Ontario (MOVE-ON) study (created by CES based on [29])
22 Implementation Guide and Toolkit for National Clinical Guidelines
Guidelinesdesignedusingalogicmodelcanhelptoachievedesired results by encouraging a focus onoutcomes fromthestart,makingtheconnectionsexplicitandensuringthatthereisevidencetosupporttheconnections.
It is important to remember that using a logic modeldoes not take away from the need for flexibility orresponsiveness.Alogicmodelisastatementofintentanddevelops through a live and iterative process rather thana one-off event. This means it can adapt to unexpectedevents, takeadvantageofemergingopportunities,andbecreativeinmeetingchallenges.
1. Situation Analysis: Consider the context andwhat the opportunities, problems and needsin relation to theguidelineare.The informationcontained in thisboxcandrawheavilyontheneedsassessment.Answering the followingquestionswillhelp todescribe thecurrentsituation:• Whyistheguidelineneeded?• Whatisthesituationandissue(s)?• Whataretheneedsofpopulationandtargetgroups?• Whatarethestrengthsandweaknessesofcurrentprovision?• Wherearethegaps?
Benefits of using a Logic Model:• Provides coherence across
complextasks• Helps differentiate between
‘what we do’ (outputs) and‘results/changes’(outcomes)
Itisusefultobeasclearaspossibleaboutyourthinkingregardingthechoiceofactivitiesandinclude specific targets for numbers to be reached and frequency of activities, wherepossible.
4. Inputs:Thisinvolvesbeingclearaboutwhatresourcesareneededtocarryouttheactivities/outputs identified. As such, inputs essentially enable outputs. Examples of resources thatcanbeemployed include staff,equipment,buildings, technology, informationsystems,andsupportstructures.Thelimitednatureofresourcesmeansit is importanttotrytoleverageorre-organiseexistingresourcesasmuchaspossibleandincludeanyadditionalcostsintheguideline’sBudgetImpactAnalysisandeconomicevaluation.Ifcostsareconsideredunrealisticornotcosteffective,thentheactivities/outputssectionmayhavetoberevisitedandrevisedaccordingly.
5. Monitoring and Evaluation: This involves assessing the extent towhich an intervention isworking towards theoutcomes stated. In the logicmodel, it is important to consider howinformationwillbecollected,interpretedandreported.Itisalsoimportanttoconsidertargets,metrics,andKeyPerformanceIndicators(KPIs),aswellasbaselinesandbenchmarks,whichcanprovidesignsofprogress.
Itisimportanttoconsidermultipleformsofevidencehere,includingpeer-reviewedresearch,independentreports,casestudies,greyliterature,auditdataandpracticewisdom.Informationcontained inthe logicmodelcanbeunderpinnedbyanyoftheseformsofevidence, if theevidenceisofhighquality.
Tips for developing a logic model: • Whilealogicmodelshouldbereadfromlefttorightoncecompleted,itismostlydeveloped
from right to left, beginning with outcomes (after completing the situation analysis) andworkingbackthroughactivities/outputsandinputs.
• Thoughitisoftendifficulttobeprecise,being as concrete as possible,intermsoffiguresandtargetslisted,isbetterforplanning,implementation,accountabilityandevaluationpurposes.
• Outcomes inserted into a logic model can be clearly grouped bywhethertheyarerelatedtoimplementationoutcomes,serviceoutcomesorclientoutcomes
• List any anticipated inputs and discuss any issues arising. If you are intending to workin partnership, for example, what would you need to consider in terms of planning orimplementation?
• Workalreadydoneonthe Hexagon Tool and outcomes can form the basis for development of a logic model
Toaccessablank version of the Logic Model Tool,whichGuidelineGroupscaneditandfillinfortheirownguidelines,click here or see Tool 2.
Whenan intervention is particularly complex, itmaybeuseful forGuidelineGroups to createaseriesoflogicmodels.Thismayhelptobreakdowntheoveralllogicmodelintoamoremanageable,clear,conciseandrelevantwayforthoseresponsibleforimplementingspecificrecommendationsorworkinginspecificcontexts.Logicmodelscanbebrokendowninthefollowingways:
25Implementation Guide and Toolkit for National Clinical Guidelines
Macro level, e.g. National
Institution level, e.g. Hospital
Unit level, e.g. Service
The following page contains a worked example of a logic model, created by the GuidelineDevelopmentGroupresponsiblefortheupdateoftheNational Clinical Guideline No. 6: Sepsis Management in 2018.
26 Implementation Guide and Toolkit for National Clinical Guidelines
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Stage 2: Planning and Resourcing
28 Implementation Guide and Toolkit for National Clinical Guidelines28 Implementation Guide and Toolkit for National Clinical Guidelines
Stage 2: Planning and ResourcingIn stage 2 of implementation, the foundation is laid for effective implementation. This stageinvolvesplanningforimplementationinmoredetail,anticipatingpotentialimplementationissues,costing the implementation plan and submitting the Budget Impact Assessment as part of theannualserviceplanningprocess.Specificactivitiestobecarriedoutinthisstageare:
• Assessingimplementationreadiness• Assessingenablersandbarriers• Implementationplanning• Expandingthe initialGuidelineDevelopmentGroupto include implementationteam(s)and
Assessing Implementation ReadinessEvidence shows that attempts to implement newinterventions often fail because those leading theimplementationfailtoestablishsufficientreadinessforthechange[30]
Implementation readiness in healthcare settings isdependentonanumberofkeyfactors:[20, 31,32]
• Psychological and behavioural readiness inindividuals,teamsandorganisations–staffshouldbeindividuallyandcollectivelyprimed,motivated,andtechnicallycapableofexecutingchange.
• General organisational/structural capacitytosuccessfullyimplementanyinnovation–existingstaff,ICTinfrastructure,humanresourcesandproceduresetc.
• Organisational/structural capacity that is intervention-specific – specific training, resourcesandpoliciesetc.
• Securingaccess to resourcesneededtoimplementguidelines–theimplementationplanmustbecosted,andaBudgetImpactAssessmentcarriedout,tobesubmittedthroughtheserviceplanningprocess.
29Implementation Guide and Toolkit for National Clinical Guidelines 29Implementation Guide and Toolkit for National Clinical Guidelines
Assessingandunderstandingimplementationreadinesscanhelpidentifybarriersandfacilitatorstochangeandinformimplementationplanning.However,readinessatonestageofimplementationdoes not ensure readiness for the next. Thismeans that assessing readiness is an ongoing anditerativeprocess, that shouldconsidernewchallengesandaddress themas theyarise [32] This requiresfeedbackandinputfromstakeholdersatlocallevelstogetanaccuratepictureofchangingcontextsandcircumstances.
Resources and strategies to help assess and build implementation readiness:• The Hexagon Toolisusefulforassessingneedsandreadiness,andimplementationplanning:
ClickhereorseeTool1
• Normalization Process Theory (NPT):o Toolkitforthinkingthroughpotentialimplementationproblems: http://www.normalizationprocess.org/npt-toolkit/o Murray et al. (2010) paper, titled ‘Normalisation Process Theory: A framework for
Communication Ongoingandopencommunicationwithandbetweenstaffiscrucialinsuccessfulimplementationforseveralreasons:ithelpsmotivatestaffandovercomeresistance;providesamechanismforfeedbackanddealingwithconcerns;andhelpstobuildtrustandmorale.
32 Implementation Guide and Toolkit for National Clinical Guidelines32 Implementation Guide and Toolkit for National Clinical Guidelines
Implementation Enablers and Barriers: Assessment ToolTheCentreforEffectiveServiceshascreatedabespoketoolforstakeholdersinvolvedindesigningand implementing clinical guidelines and other policies, procedures, protocols and guidelines(PPPGs),toassessenablersandbarriers.ThistoolisbasedontheConsolidatedFrameworkforImplementationResearchandtheBehaviourChangeWheel.Thetoolgeneratesconsiderationofstructuralandpsychologicalenablersandbarrierstoimplementationinahealthcontext.
To access the tool, click here or see Tool 3.
Implementation PlanningAllowingadequateandappropriatetimeforplanninghowclinicalguidelineswillbeimplementedis a crucial implementation enabler. Devising an implementation plan enables those driving thechangetomapouttheimplementationprocessandprovideacourseofactionforanychallenges.Research shows that implementation is likely to be more successful if this planning is doneconcurrentlywiththedevelopmentofguidelines,ratherthanaftertheyhavebeendeveloped[9]
The following steps help to prepare the implementation plan and should be retained by thosedeveloping/implementingguidelines:
A comprehensive Implementation Plan should [8]:üDetailtheimplementationobjectivesüOutlinetasks and activities necessaryforimplementationüIdentifywho is responsibleforthedeliveryofactivitiesüOutlinetime-frames and milestonesüConsiderrisks andstrategiestomanagethese risksüIdentifymonitoring and reporting processes.
It is importantthat implementationplanningshould includepublic involvementandengagementwithmultiplestakeholderstosecurebuy-inandensurethattheplanconsidersmultipleviewpoints.The plan should also remain live throughout the implementation process and be revisited andrevisedregularlythroughoutallimplementationstages.
AnimplementationplanmustbeincludedinpublishedNCECguidelines.Thetemplateprovidesanexampleofatoolthatcanbeusedforimplementationplanning,promptingGuidelineGroupstolayouttheimplementationtasks(in the form of specific actions);whichguidelinerecommendation(s)thesetasksreferto;whichgroup/unit/organisationhasleadresponsibilityforthetask;anindicative
33Implementation Guide and Toolkit for National Clinical Guidelines 33Implementation Guide and Toolkit for National Clinical Guidelines
NCEC guidelines must include an implementation plan.Thetoolalsohelpsstakeholderstoconsider implementation team processes; dissemination and communication strategies;anddevelopmentofspecificimplementationtoolsandresources.
To access the Implementation Planning Tool, click here or see Tool 4
• Click here to access aGagliardi et al. (2015) paper ‘Developing a checklist for Guideline Implementation Planning’ whichcontainsauseful checklist to help stakeholders consider different aspects of implementation planningforclinicalguidelines[9,pp.5-6]
37Implementation Guide and Toolkit for National Clinical Guidelines 37Implementation Guide and Toolkit for National Clinical Guidelines
Establishing Implementation TeamsImplementation teams are groups of stakeholdersthatoverseeandattendtomovingguidelinesthroughthe stages of implementation. They are establishedto make it happen, i.e. actively use strategies andsupportstofacilitateimplementation.
Implementationteamsaretypicallymadeupof3-12people,andthecompositionofthegroupisextremelyimportant. It is possible to repurpose existingGuidelineDevelopmentGroupswhenformingapost-publication implementation team, but the followingpointsshouldbeconsidered:
• Decision-making authority – the implementation team should containmemberswho havetheirowndecision-makingauthorityorhavedirectaccess todecision-makingauthority, sothatdecisionscanbemadeinatimelymanner
Itisimportantthatthereis somedegreeofoverlapinmembershipbetweenGuidelineDevelopmentGroups and implementation teams, as implementation needs to be considered throughout allstagesofguidelinedevelopment.Itisrecommendedthatthereisan‘ImplementationLead’ontheGuidelineDevelopmentGroupfromthebeginning,toensurethatguidelinerecommendationsareimplementableandtocoordinatethedevelopmentoftheimplementationplan.
It is worth noting that one implementationteam may not be sufficient to implementguidelines at a national level. In this case,it might be appropriate to establish aninfrastructure of linked implementation teams to encourage greater integration andcoherenceinlargesystems.Teamscanoperateat different levels (e.g. national, hospitalgroup, individual hospital, community) orteams can work to implement differentrecommendations contained in clinicalguidelines.
Key implementation team functions: üMove guidelines through the stages of
withinguidelinesüIdentifybarriersandfindsolutionswhereneededüIdentify enablers and leverage themifpossibleüEnsureBudget Impact Assessmentissubmittedtotheserviceplanningprocess
38 Implementation Guide and Toolkit for National Clinical Guidelines38 Implementation Guide and Toolkit for National Clinical Guidelines
üPutimplementation infrastructureinplaceüEngagewithstakeholdersandcommunitiesüBuild cross-sector collaboration to ensure service partners are aligned with new ways of
workingüWorkwithotherteamstomonitor progress üUse data tomakedecisionsandsupportimplementationcapacityüEnsuredecisionsarepurposefulandplanned
Developing Leadership for ImplementationThereisbroadconsensusontheimportanceofleadershipforeffectiveimplementation.Thisisduetothepotentialforleadershiptoinspireandmotivatestafftoadoptandsustaintheattitudesandbehaviouralchangesnecessaryforeffectiveimplementation[33]
• If leaders and implementers create positive, supportive environments for all practitioners,thosepractitionersthencreatecaring,supportiveenvironmentsforpatients
While individual members of Guideline Groups may not be in high-level leadership positionsthemselves, they can seek to influence those who are, and be champions for the guidelinesthemselves.
39Implementation Guide and Toolkit for National Clinical Guidelines 39Implementation Guide and Toolkit for National Clinical Guidelines
Monitoring and Evaluation PlanningNationalClinicalGuidelinesendorsedbytheMinisterforHealtharemandatedforimplementationinthe Irishhealth system.Accordingly,theNCECguidelinedevelopmentprocessrequiresmonitoringandauditcriteria,includingKeyPerformanceIndicators(KPIs),tobeincludedineachguideline.
• Clinical or Healthcare Audit is aprocess to improvepatient careandoutcomes involvingadocumented,structuredandsystematicreviewandevaluation,againstclinicalstandards,orclinicalguidelines,and,wherenecessary,actionstoimproveclinicalcare.
Clinicalauditispartoftheclinicalgovernanceagendaandisintendedtoprovidetheevidencefor assuring the quality of clinical care and helping to bring about improvements wherenecessary.
Clinicalauditisacyclicalprocess,recognisedashavingthefollowingelements:• acommitmenttoqualityimprovementandlearning• measurement–measuringaspecificelementofclinicalpractice• comparison – comparing results with an accepted benchmark, these are national or
Information and toolstohelpguidelinedevelopersthinkaboutmonitoringandauditcriteriaareavailablefrom:
• The National Clinical Effectiveness Committee guideline development manual http://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/ncec-
processes-and-templates/
• The National Clinical Effectiveness Committee website http://health.gov.ie/national-patient-safety-office/ncec/
• The HSE Quality Improvement Division website https://www.hse.ie/eng/about/who/qid/measurementquality/clinical-audit/
For implementationtobemeasuredaccurately,all threeof theabovemechanismsmaybeusedwithdifferentlevelsofemphasis,dependingonthecontext.Thereisnosinglemeasurementtypethatcomprehensivelymeasuresallelementsofimplementation,andahybridmethodologymayberequired.Currently, implementationofNCECNationalClinicalGuidelinesismonitored through theHSE Performance Assurance Reports, compliance with the National Standards for Safer BetterHealthcareand alignmentwith the clinical indemnity scheme[36]
ThepurposeofthissectionisnottofocusonmethodologiesorKPIsformonitoring,evaluationandaudit.Instead,theremainderofthissectionwillfocusonplanningformonitoringandevaluation,particularly when considering how to monitor whether the guideline has been successfully implemented. Accordingly, the table overleaf provides a series of prompts and questions thatguidelinegroupscanusetoguideplanningformonitoring,evaluationandaudit.
Monitoring and Evaluation of Implementation: Planning Tool TheCentreforEffectiveServiceshascreatedabespoketooltohelpGuidelineGroupstothinkaboutandplan for monitoring and evaluation of the implementation process.Thistoolshouldbeusedatanearlystageofguidelinedevelopmenttoensurethatmonitoringandevaluationareembeddedintotheimplementationprocess.
To access the Monitoring and Evaluation of Implementation Planning Tool, click here or see Tool 5.
Involving relevant stakeholders is a crucialpartof themonitoringandevaluationprocess– theyshould be consulted with at all stages of developing and implementing clinical guidelines. Thisis toensure that specific responsibilitiesofall those involvedcanbeclarifiedandagreedbefore
41Implementation Guide and Toolkit for National Clinical Guidelines 41Implementation Guide and Toolkit for National Clinical Guidelines
IndicatorsItisalsoimportanttoconsiderwhatindicatorscanbefeasiblyandaccuratelyusedtomonitorandevaluateimplementationoutcomes.Toensurethateffortstocollectdataarestreamlinedandthatthedataisrelevant,theseindicatorsshouldbeaction-focused, important, measurable and simple.
A number ofQuality andPatientSafetyPerformanceIndicatorsthatmeasureimplementationandthe impact of NationalClinicalGuidelinesalreadyexistandarespecifiedintheHSEServicePlan:https://www.hse.ie/eng/services/publications/serviceplans/national-service-plan-2018.pdf
When deciding how to monitor and evaluate implementation of clinical guidelines, existingindicators and data collectionmechanisms should be used where available. Other useful typesof data collection methods may also already be in place, such as patient satisfaction/patientexperiencesurveys,evaluation,qualityindicators,auditandresearch.
The HSE Measurement for Improvement Team combines expertise in quality improvement,statisticalanalysisandqualitativeresearchwithclinicalexperience.Theteamprovidesanumberofusefultools and resourcesontheirwebsite,aswellastraining and adviceonhowtoanalyseandpresentinformationgatheredfrommonitoringandevaluationprocesses.
To access the tools, resources, training and advice, see the HSE Measurement for Improvement Team website: https://www.hse.ie/eng/about/who/qid/measurementquality/measurementimprovement/measurement-for-improvement-team.html
Additional information and tools for clinical auditareavailableinthefollowingdocuments:• A Practical Guide to Clinical Audit (HSE) https://www.hse.ie/eng/about/who/qid/
measurementquality/clinical-audit/
• Improvement Knowledge and Skills Guide (HSE) https://www.hse.ie/eng/about/who/qid/improvement-knowledge-and-skillsguide/
42 Implementation Guide and Toolkit for National Clinical Guidelines42 Implementation Guide and Toolkit for National Clinical Guidelines
Training and Capacity BuildingOneof themost important factors inbuilding leadership inanorganisationorsetting isbuildingandmaintainingstaffcapacity.Oneaspectof this;coachingandmentoring– iscovered indetailinstage3.Therearealsoseveralotherkeymechanismstobuildstaffcapacityforimplementation[22]:
• Assignment/recruitmentofstaff• Training
Whenplanning for implementation,GuidelineGroups should seek to highlight the staff trainingandcapacity-buildingneedsthatareassociatedwiththeguideline.Whilenotnecessarilyexpectedtodesigntheseproceduresandprocesses,itisimportantthatthesegroupsconsiderhowtheymaybedeveloped.Again, internallyavailableresourcesshouldbeleveraged,wherepossible,andanyadditionalresourcesrequiredshouldbeincludedintheguideline’sBudgetImpactAnalysis.
Assignment/recruitment of staffStaffwhowillbeinvolvedinimplementingclinicalguidelinesshouldhavetheappropriateskillsandknowledgetodoso,ortheabilitytolearnthese.Effectiveassignment/recruitmentofstaffrequiresspecifyingwhattherequiredskillsandabilitiesforthespecificinterventionare;thedevelopmentof methods for identifying these skills and abilities in practitioners; and criteria for selectingpractitionerswiththoseskillsandabilities.Theseaspectsshouldbe included in jobdescriptions,staffinductionandcontinuousprofessionaldevelopment.
TrainingStaffshouldbefacilitatedtodeveloptheirknowledge,experienceandskillsofspecificinterventionsthrough effective and timely training. Training programmes should provide knowledge relatedto the theory and underlying principles and values of the intervention; introduce the keycomponentsofpractices;andprovideopportunitiestopracticenewskillsandreceivefeedbackina safe, supportiveenvironment. The content and formatof trainingmay varydependingon theinterventionandshouldbedevelopedwiththeneedsofstaffandpatientsinmind.
Sustainability PlanningGuidelines aimed at improvinghealthcare need to be sustainedfor improved outcomes to bemaintained. Essentially, sustainabilitymeans that one year or longer afterimplementation, at a minimum, thesituation has not reverted to theold way of working, or old level ofperformance.
Forinterventionscontainedwithinguidelinestobesustainable,theyshouldbeabletowithstandchallengesandvariation,evolvealongsideotherchangesandcontinuetoimproveovertime.Thereisatensionbetweenneedingtomaintain‘fidelity’toaspecificinterventionandneedingtoevolveinachanginghealthcarecontext.Changestoimplementationplansmayneedtobemadesothatan intervention can continue to be used in practice andmaintain the benefits for patients andcommunities.
TheUnitedKingdom’sNationalHealthServicedefinessustainability as achieved when ‘not only have theprocess and outcome changed, but the thinking andattitudes behind themare fundamentally altered andthesystemssurroundingthemaretransformedaswell.Inotherwords,thechangehasbecomeanintegratedormainstreamwayofworkingratherthansomething“addedon”’[38,p.6]
43Implementation Guide and Toolkit for National Clinical Guidelines 43Implementation Guide and Toolkit for National Clinical Guidelines
To maximise the potential for sustainability, sustainability planning should commence near thebeginningof theguidelinedevelopmentand implementationprocess.However, it isusefulatallstagesof implementation, and sustainabilityplans shouldbe revisitedat severaldifferentpointssothatsustainabilitycanbemonitoredovertime.Throughcontinuouslyassessingandidentifyingpotentialbarrierstosustainability,strategiescanbeputinplacetoanticipateandaddresspotentialimplementationproblems.
The following tableoutlines somekeyquestions to consider in relation todifferent elementsofsustainability[38,39]:
44 Implementation Guide and Toolkit for National Clinical Guidelines44 Implementation Guide and Toolkit for National Clinical Guidelines
Sustainability Planning ToolTheUnitedKingdom’sNationalHealthServicehasproducedaSustainability:ModelandGuide,whichacts as a diagnostic tool to help plan for sustainability and monitor progress over time, and as a guide offering practical advice on how to maximise success at sustaining change
It identifies a range of factors that influencesustainability,including:• Credibilityofthebenefitsofanintervention• Effectiveness of the system to monitor
progressandmeasurechange• Staff involvement and training to sustain
andsupport• Alignment with organisational strategic
aimsandculture.
Guideline Groups are not necessarily expected to design these systems and processes.Instead, they should aim to signal the importance of these factors, identify needs, cost theimplementation process, and influence high-level decision-makers where possible. This pointmaybeparticularlyrelevantforstakeholdersandimplementersatamorelocallevel.
Click here to access the NHS Sustainability Model and Guide: https://improvement.nhs.uk/resources/Sustainability-model-and-guide/
46 Implementation Guide and Toolkit for National Clinical Guidelines46 Implementation Guide and Toolkit for National Clinical Guidelines
Stage 3: Implementing and OperationalisingIn stage 3 of implementation, guidelines are implemented in clinical and healthcare settings for the first time. Essentially,guidelinesareput intopracticebypractitionersandorganisationalsupportsandfunctionsbegintooperatetohelp implementation.Guidelineswillbesignedoffatthispoint,however, stakeholders cancontinue tobe influential in their implementation throughhighlightingneeds,takingupmembershipofimplementationteams,andactingaschampionsfortheguidelines.
Specificactivitiestobecarriedoutinthisstageare:• Maintainingcommunicationwithstakeholdersandsecuringcontinuedbuy-in• Providing professional development opportunities and support, such as coaching and
Maintaining Communication Ongoing communication between implementation teams, practitioners, champions, publicrepresentatives,andallotherrelevantstakeholdersisanimportantenablerofimplementationforseveralreasons:
Both formal and informal communication are important, with networking and ‘water cooler’conversationshavingasmuchpotentialtochangeindividualbehaviourasformalbroadcasts.Thefollowingstrategiesrelatingtocommunicationcanallcontributetomoreeffectiveimplementation[20]:üAssimilatingnewstaffandmakingthemfeelwelcomeüFosteringpeercollaborationandopenfeedbackandreviewacrosshierarchicallevelsüClearcommunicationofguidelines’purposeandgoalsüUseofchampionstoencouragecohesionbetweenstaffandpositiveinformalcommunication
aboutguidelines.
47Implementation Guide and Toolkit for National Clinical Guidelines 47Implementation Guide and Toolkit for National Clinical Guidelines
Coaching and MentoringEvidence suggests that training aloneis insufficient to change the skills ofprofessionals.Ameta-analysisof research ineducation showed that with training alone,only 5-10% used the new practice; thisincreased to 80-90% when supplementedwithcoaching[40].Accordingly,coachingandmentoring are increasingly being used as amethod of supporting and building capacityamongprofessionals.
Building quick and accurate use of new skills and behaviours in the real world is challenging.Coaching andmentoringoffer additional benefits to traditional training approaches andprovideopportunitiesforstafftoreceivesupportandassistanceinthedevelopmentofskillsalignedwithspecificinterventions.Benefitsinclude[41,42]:
• Helpingstafftoadjusttoandimplementchange• Decreasing frustration by focusing on helping staffmeet performance goals and reducing
Coaching is a formal, typically short-term,arrangementbetweenacoachandanindividualfocused on developing work-related skills orbehaviours.
Mentoringisaformalorinformalarrangement,whichtypicallyinvolvesanongoingrelationshipof support for significant transitions inknowledge,thinkingandskills[42]
48 Implementation Guide and Toolkit for National Clinical Guidelines48 Implementation Guide and Toolkit for National Clinical Guidelines
NetworksNetworks seek todeepenknowledgeandexpertiseof theirmembersand thegroupasawholeby interacting with each other on an ongoing basis. Networks among groupings of individuals,organisations and/or agencies can take many forms and serve different purposes. Two suchexamplesinclude:
• Knowledge Networks – These lead to accumulation, augmentation and exchange of tacitknowledgeandimprovedskillsrequiredforimplementingspecificinterventions
• Communities of Practice – These aim to solve specific problems by forming self-selected,informalgroupslinkedbysharedexperience,passionsorgoals.
Ongoing Monitoring of OutcomesBased on the planning formonitoring and evaluationconducted during stage 2, implementation teamsshould look to engage in ongoing monitoring ofimplementation outcomes, service outcomes andclientoutcomes.
At this point, Guideline Groups are likely to haveidentifiedoutcomes, KPIs andauditmeasures aspartof guideline development. Using this informationand revisiting documents developed during stages1 and 2, (such as the logic model, implementationplan, enablers and barriers assessment, and themonitoring and evaluation plan) implementationteamscanthereforeseekoutandobtainanyemerginginformationabouttheseoutcomes.
At this stageof implementation,monitoring is formative innature– it providesan indicationofwhether guidelines are functioning andbeing implementedasplanned, an indicationofwhat isworkingwellornotwell,andhowchangescanbemadetoinformimprovement.
Itisalsoimportanttogetanearlysenseofanychangesinserviceoutcomesandclientoutcomes– if the changesarepositive, these canbeused togenerate increasedbuy-in and support frompatients,public,healthcarestaff,managementandpolicy-makers.
Resources to support ongoing monitoring of outcomes• AguidebookproducedbytheNationalResourceCentreintheUSfor‘Strengthening Non-
profits: A Capacity Builder’s Library’ aimstohelpstakeholdersunderstand the concepts, uses and limitations of measuring outcomes.Whilethisresourceisnotdesignedspecificallyforhealthcaresettings,itprovidesusefulinformationforstakeholdersinvolvedinmonitoringguidelines.
To access ‘Strengthening Non-profits: A Capacity Builder’s Library’, click here: http://www.strengtheningnonprofits.org/resources/guidebooks/MeasuringOutcomes.pdf
49Implementation Guide and Toolkit for National Clinical Guidelines 49Implementation Guide and Toolkit for National Clinical Guidelines
Data-Based Decision MakingGuideline Groups should use processes for collectingandanalysingdifferenttypesofdatatoguidedecisionstowards improvement of clinical guideline processesandoutcomesonanongoingbasis.Thisdatacancomefrommultiple sources, including both standard auditproceduresandspecificeffortstomonitorandevaluateimplementationofclinicalguidelines.
Data should also be used to support effective feedback loops across multiple system levels.“Without effective feedback loops within and across levels of an organizational system, effective innovations are often changed to fit the existing systems, as opposed to existing systems changing to support effective innovations” [43, p.8] Continuous quality improvement relies on gatheringandassessingfeedbackandcommunicationbetweenvariousstakeholders intheimplementationprocess.Thishelpstoconnectpolicytopracticeandpromotereflectionthatcanleadtobarriersbeing identifiedandaddressedonacontinuousbasis.Therefore,systemsshouldbeput inplacethatensurestakeholderexperiencesarebeing fedbacktoguidelinegroupsanddecision-makersandplayaroleintheirdata-baseddecision-makingprocesses.Itwouldalsobehelpfulforguidelinegroups to consider if, and how, this feedback could be usefully shared throughout the Irishhealthcaresystemandbeyond.
Adapting Implementation Plans for Local SettingsImplementationrequiresmanagementofmany interactingelements in the internalandexternalenvironments. This means that all implementation plans contain a degree of tension betweenmaintainingfidelitytoanintervention’sdesignandneedingtoconsiderandadaptimplementationplanstolocalcontextandconditions.Inreality,duetonaturalvariationinrealworldcontexts,itisalmostimpossibletoapplyanimplementationplanwith100%fidelity.
The Dynamic Sustainability Framework [45] challenges the notion that interventions can bedesigned and tested in a single form that will be applicable across all healthcare settings andpopulationsovertime.Itarguesthatthecharacteristicsofsettingsinwhichinterventionsarebeingdelivered are constantly evolving, including human and capital resources, information systems,organisational culture, climateand structure, andprocesses for trainingand supervisionof staff.Thesuccessofsustaininganinterventionisthereforedependentonitsongoingfitwithinasetting.
50 Implementation Guide and Toolkit for National Clinical Guidelines50 Implementation Guide and Toolkit for National Clinical Guidelines
Ongoing adaptation of implementation plans with a primary focus on fit between guidelinesandpractice settingsmay thereforebe required. Thiswill then lead to ongoing improvement inhealthcareservicedeliveryandoutcomes.Dynamicsustainabilitycanthereforebethoughtofastheprocessofmanagingandsupportingtheevolutionofguidelinesovertimewithinachangingcontext.
Researchershavearguedthattherearetwoseparatecategoriesofimplementationactivities[20]: Core components –theseareessentialand indispensableelementsof the implementation
Adaptable periphery –theseareelementsoftheimplementationplanwhichmaybetailoredto local settings.Guideline groupsmaybe able tomakeevidence-baseddecisions onhowbesttoadaptelementsoftheirimplementationplantothecontext,withoutunderminingtheintegrityoftheintervention.
Evidence-basedhealthcare/Evidence-basedPractice(EBP)iscomprisedofthreefactors:bestavailableevidence, clinical expertise and patient values. Accordingly, specific clinical recommendationsmay not be appropriate in all cases and it may be necessary to deviate from the guideline. In theseindividualcases,thehealthcarepractitionerrecordsthisdecisioninthepatient’schart.
52 Implementation Guide and Toolkit for National Clinical Guidelines52 Implementation Guide and Toolkit for National Clinical Guidelines
Stage 4: Full ImplementationIn stage 4 of implementation, guidelines are fully operational and integrated, used consistently, and embedded in structures. Thismeans that skills and activities are sustained throughout thehealth system,policies andprocedures are fully in place to support changes, andoutcomes areready to be evaluated. Themajority of the specific implementation tasks will be completed atthispoint,meaningthatthe importanttasks forstakeholderswillbetoshowthatguidelinesareworkingandtolookathowprocessesandoutcomescanbecontinuouslyimproved.
EvaluationUpon reaching full implementation, guidelines should be fully operational and integrated intoroutinepractice, i.e.thestandardwayinwhichservicescarryouttheirwork.Thismeansthatallimplementationoutcomes,serviceoutcomesandclientoutcomesarereadytobeevaluated.Thisdiffersfromongoingmonitoringasitislargelysummativeinnature,providingevidenceofwhetherguidelinesarehavingthedesiredimpactonoutcomes.
Clientoutcomes,serviceoutcomesand implementationoutcomesshouldallbeevaluated.Someservice-focused stakeholders may show most interest in whether guidelines are achieving theresultstheyanticipateanddesire.However, it iscriticalthattimeandresourcesarededicatedtogatheringandanalysingdataonallaspectsof the implementationprocess inorder tomake thenecessaryadjustments tomeet local, contextual conditionsand inorder tounderstandhowthequalityofimplementationaffectsoutcomes[43]
• Returning to theMonitoring and Evaluation of Implementation Planning Tool (Tool 5) to review implementation outcomesmay be useful at this point. This tool was createdbytheCentreforEffectiveServicestohelpGuidelineGroupstothinkaboutandplan for monitoring and evaluation of the implementation process.Whilethistoolshouldinitiallybeusedatanearlystageofguidelinedevelopmenttoensurethatmonitoringandevaluationareembeddedintotheimplementationprocess,itisbeneficialtoreturntothetoolwhenevaluatingimplementationatlaterstagesofimplementation.
To access the Monitoring and Evaluation of Implementation: Planning Tool, click here or see Tool 5.
• The HSE Websiteprovides information, toolsand resources thatencourage theaccuratecollection,analysisandreportingofmonitoring,evaluationandclinicalauditdata:https://www.hse.ie/eng/about/who/qid/measurementquality/
53Implementation Guide and Toolkit for National Clinical Guidelines 53Implementation Guide and Toolkit for National Clinical Guidelines
Continuous Improvement CyclesReflectingonemergingevidenceonoutcomesandimplementationprovidesopportunitiestolearnfromexperience and inform future implementation. If guidelines are not being implemented asintendedorarebeingusedasintendedbutnotproducingdesiredoutcomes,improvementcyclescanbeusedtosupportcontinuedimprovementandchange.Thiswillhavethebenefitof:üEnablingGuidelineGroupstoengageboththemselvesandleadershipinusingdatatosupport
implementationcapacity,fidelity,andpatientoutcomes.üEnsuring decisions are data-based, purposeful and planned, rather than opportunistic and
To access the HSE ‘Model for Improvement: Guidance Note on Key Concepts’, which contains useful information on using the PDSA method, click here: https://www.hse.ie/eng/about/who/qid/nationalsafetyprogrammes/pressureulcerszero/model-for-improvement-guidance-document.pdf
The HSE has also published ‘Improving our Services - A users guide to managing change in the Health Service Executive’ https://www.hse.ie/eng/staff/resources/hrstrategiesreports/improving-our-services,-a-guide-to-managing-change-in-the-the-hse---oct-2008.pdf
Itisimportanttorecognisethatbyundertakingcontinuousimprovementcycles,GuidelineGroupsandotherstakeholderswillnotbeabletosolveallchallenges.Implementationisalengthyprocessthatshouldnotberushed,andcontinuedsupportisneededfromleadership,management,orotherkeypartnersinthehealthsystemtoaddressbarrierstoimplementation.Ongoingcommunication,therefore, continues to be necessary at this stage of implementation, so thatmanagement andpolicymakersareequippedwiththeinformationandconfidenceneededtochangethesystemsothatdesiredoutcomescanbeachieved.
Implementation Research: In2018, theCentre for Implementationand ImprovementScience inKings College London published the Implementation Science Research Development (ImpRes) Tool. This tool provides a step-by-step approach to designing implementation research. ImpResencourages research teams todesign robust implementation researchby clearly articulating theimplementationaims that the research seeks toaddress,understanding theactivitiesassociatedwitheachimplementationstage,andselectinganappropriatestudydesign.http://www.kingsimprovementscience.org/ImpRes
54 Implementation Guide and Toolkit for National Clinical Guidelines
Glossary
56 Implementation Guide and Toolkit for National Clinical Guidelines
GlossaryNote: Many of the terms included in this glossary have been adapted from the National Implementation Research Network (NIRN) online glossary: https://nirn.fpg.unc.edu/learn-implementation/glossary.
Clinical Guidelines: systematically developed statements, based on a thorough evaluation oftheevidence, toassistpractitionerandserviceusers’decisionsaboutappropriatehealthcare forspecificclinicalcircumstancesacrosstheentireclinicalsystem.
Community:agroupofpeoplelivinginaparticularareaorhavingcharacteristicsincommon(e.g.,city, neighborhood, organisation, service agency, business, professional association); the largersocio-political-culturalcontextinwhichanimplementationprogrammeisintendedtooperate.
Context: the set of circumstances or unique factors that surround a particular implementationeffort.Thiscanrefertoboththewider,systemiccontext,aswellasthespecificsettinginwhichaspecificinterventionwillbeimplemented.
Core Components: essential and indispensable elements of implementation, which cannot bechangedwithoutunderminingtheintervention.Allcorecomponentsmustbedeliveredwithtotalfidelity.
Evaluation: a planned investigation of a project, programme, or policy used to answer specificquestions,oftenrelatedtodesign,implementation,andresults(causeandeffect).
Framework: a structure, overview, outline, system or plan consisting of various descriptivecategories, e.g. concepts, constructs or variables, and the relations between them that arepresumed to account for a phenomenon. Frameworks do not provide explanations; they onlydescribeempiricalphenomenabyfittingthemintoasetofcategories.
Implementation: the carrying out of specific planned, intentional activities undertakenwith theaimofmakingevidence-informedpoliciesandpracticesworkbetterforpeople.Itcanbethoughtofasthe‘how’aswellasthe‘what’.
Implementation Team: a group of stakeholders that oversees and attends tomoving guidelinesthrough the stages of implementation. They actively use strategies and supports to facilitateimplementation.
Leadership: theactionof leadingagroupofpeople,or theability todo this. Thisdoesnot justapplytoleadingawholeorganisationorsystem–leadershipcantakemultipleformsandcanoccuratanylevelofanorganisationorsystem.
Logic Model: agraphicaldepictionofanintervention’sTheoryofChange,describingconnectionsbetween the intervention’s context, inputs, outputs, and outcomes. It also provides some
58 Implementation Guide and Toolkit for National Clinical Guidelines
information on evidence underpinning the intervention and the monitoring and evaluationprocessesattachedtoit.
Monitoring: the routineandsystematiccollectionof informationagainstaplan. Itmakesuseofexistingdataandinformationaboutinputs,outputs,outcomes,oraboutoutsidefactorsaffectingtheorganisationorproject,toinformimprovement.
Needs Assessment: aprocesswhich clarifies theextent towhichneeds, aswell as barriers andfacilitatorstomeetthoseneeds,areaccuratelyknownandprioritisedbyanorganisationorgroupofpeople.
Stakeholders: anyone who is affected by or is involved in the development and delivery ofguidelines,includingpatients,public,clinicians,managers,professionalbodies,unions,educators,andpolicy-makers.
Theory: a set of analytical principles or statements designed to structure our observation,understandingandexplanationoftheworld.A‘goodtheory’providesaclearexplanationofhowandwhyspecificrelationshipsleadtospecificevents.
References
60 Implementation Guide and Toolkit for National Clinical Guidelines
References[1] National Clinical Effectiveness Committee (2015). Standards for Clinical Practice Guidance.
Available from: http://health.gov.ie/wp-content/uploads/2015/11/NCEC-Standards-for-Clinical-Practice-Guidance.-Nov-2015.pdf
[2] Greenhalgh,T.(2018).How to implement evidence-based healthcare. WestSussex,UK:Wiley,4
[3] Kryworuchko, J., Stacey, D., Bai, N., & Graham, I. D. (2009). Twelve years of clinicalpractice guideline development, dissemination and evaluation in Canada (1994 to 2005).Implementation Science, 4(1),pp.49-59.Availablefrom:https://doi.org/10.1186/1748-5908-4-49
[4] Haines, A., Kuruvilla, S.,& Borchert,M. (2004). Bridging the implementation gap betweenknowledgeandactionforhealth.Bulletin of the World Health Organization, 82(10),pp.724-731.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2623035/
[5] Mickan,S.,Burls,A.,&Glasziou,P. (2011).Patternsof ‘leakage’ in theutilisationofclinicalguidelines: a systematic review. Postgraduate Medical Journal. Available from: http://epublications.bond.edu.au/hsm_pubs/302
[6] Gagliardi, A. R., Brouwers, M. C., Palda, V. A., Lemieux-Charles, L., & Grimshaw, J. M.
(2011). How canwe improve guideline use? A conceptual framework of implementability.Implementation Science, 6(1),pp.26-36.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3072935/
[7] Greenhalgh,T.,Howick, J.,&Maskrey,N. (2014).Evidencebasedmedicine:amovement in
crisis? British Medical Journal, 348, g3725. Available from: https://doi.org/10.1136/bmj.g3725
[8] Gagliardi,A.R.,&Brouwers,M.C.(2015).Doguidelinesofferimplementationadvicetotargetusers? A systematic review of guideline applicability. BMJ open, 5(2), e007047. Availablefrom:http://bmjopen.bmj.com/content/5/2/e007047
forguideline implementationplanning: reviewandsynthesisofguidelinedevelopmentandimplementation advice. Implementation Science, 10(1), p. 19. Available from: https://doi.org/10.1186/s13012-015-0205-5
[10] Liang, L., Abi Safi, J., Gagliardi, A. R., &members of theGuidelines International NetworkImplementationWorkingGroup.(2017).Numberandtypeofguidelineimplementationtoolsvariesbyguideline,clinicalcondition,countryoforigin,andtypeofdeveloperorganization:contentanalysisofguidelines.Implementation Science,12(1),p.136.Availablefrom:http://doi.org/10.1186/s13012-017-0668-7
[11] Michie, S., & Lester, K. (2005). Words matter: increasing the implementation of clinical
guidelines.Quality and Safety in Health Care, 14(5), pp. 367-370. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1744083/pdf/v014p00367.pdf
J., on behalf of the AGREE Next Steps Consortium. (2010). AGREE II: Advancing guidelinedevelopment,reportingandevaluationinhealthcare.Canadian Medical Association Journal, 182,pp.839-842.Availablefrom:http://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf
[14] Burke, K., Morris, K. & McGarrigle, L. (2012). An introductory guide to implementation.
Available from: http://effectiveservices.org/downloads/Guide_to_implementation_concepts_and_frameworks_Final.pdf
[15] Fixsen, D.L., & Blasé, K.A. (2009). NIRN Implementation Brief Number 1 Available from:http://files.eric.ed.gov/fulltext/ED507422.pdf
[16] Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion ofinnovations inserviceorganizations:systematicreviewandrecommendations.The Milbank Quarterly, 82(4), pp. 581-629. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690184/
[17] Tabak, R. G., Khoong, E. C., Chambers, D. A., & Brownson, R. C. (2012). Bridging research
and practice:models for dissemination and implementation research.American Journal of Preventive Medicine, 43(3),pp.337-350.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3592983/
[18] Powell,B.(2017).Global Implementation Conference Academy Workshop(June2017).
[19] Nilsen, P. (2015). Making sense of implementation theories, models and frameworks.Implementation Science, 10(1), p. 53. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4406164/
[21] Rycroft-Malone, J. (2004). The PARIHS framework — A framework for guiding the
implementation of evidence-based practice. Journal of Nursing Care Quality, 19(4), pp.297-304. Available from: http://www.effectiveservices.org/downloads/The_PARIHS_Framework-A_framework_for_guiding_the_implementation_of_evidence_based_practice.pdf
62 Implementation Guide and Toolkit for National Clinical Guidelines
[23] Powell,B.J.,Proctor,E.K.,Smith,J.L.,Kirchner,J.E.,Damschroder,L.J.,Chinman,M.J., ...&Waltz, T. J. (2015). A refined compilation of implementation strategies: results from theExpertRecommendationsfor ImplementingChange(ERIC)project. Implementation Science, 10(1),p.21.Availablefrom:https://doi.org/10.1186/s13012-015-0209-1
N. (2010). Tailored interventions to overcome identified barriers to change: effects onprofessional practice and health care outcomes. Cochrane Database Systematic Review (3): CD005470. Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005470.pub2/full
[25] Centre for Effective Services (2017). Stakeholder Engagement Tool. Available from: http://
effectiveservices.org/resources/article/stakeholder-engagement-tool [26] National Clinical Effectiveness Committee (2018). Public Involvement Framework. Available
[27] Kochevar, L. K., & Yano, E. M. (2006). Understanding health care organization needs andcontext.Journal of general internal medicine,21(S2),pp.25-29.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2557132/
[28] Proctor,E.,Silmere,H.,Raghvan,R.,Hovmand,P.,Aarons,G.,Bunger,A.,Griffey,R.,Hensley,M. (2010). Outcomes for implementation research: Conceptual distinctions, measurementchallenges,andresearchagenda.Administration and Policy in Mental Health, 38(2),pp.65-76.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068522/
Straus, S.E., & the MOVE ON Team (2014). Mapping barriers and intervention activities to behaviour change theory for Mobilization of Vulnerable Elders in Ontario (MOVE ON), a multi-site implementation intervention in acute care hospitals. Implementation Science, 9(1), p. 160. Availablefrom: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4225038/
[30] Shea,C.M., Jacobs,S.R.,Esserman,D.A.,Bruce,K.,&Weiner,B. J. (2014).Organizationalreadiness for implementing change: A psychometric assessment of a new measure. Implementation Science, 9(1),7.Availablefrom:https://doi.org/10.1186/1748-5908-9-7
[31] Weiner,B.J.,Lewis,M.A.,&Linnan,L.A.(2009).Usingorganizationtheorytounderstandthedeterminants of effective implementation of worksite health promotion programs.Health Education and Research, 24(2),pp.292-305.Availablefrom:https://academic.oup.com/her/article/24/2/292/572832
[32] Dymnicki, A., Wandersman, A., Osher, D., Grigorescu, V., Huang, L. (2014). Office of the
Assistant Secretary for Planning and Evaluation (ASPE) Issue Brief Available from: https://aspe.hhs.gov/system/files/pdf/77076/ib_Readiness.pdf
[33] Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model ofevidence-basedpracticeimplementationinpublicservicesectors.Administration and Policy in Mental Health and Mental Health Services Research, 38(1), pp. 4-23. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025110/
[35] Gifford, W. A., Davies, B., Edwards, N., & Graham, I. D. (2006). Leadership strategies to
influence the use of clinical practice guidelines. Canadian Journal of Nursing Leadership, 19(4),pp.72-88.Availablefrom:https://www.ncbi.nlm.nih.gov/pubmed/17265675
[36] Health Information and Quality Authority (2012). National Standards for Safer Better
Healthcare. Available from: https://www.hiqa.ie/system/files/Safer-Better-Healthcare-Standards.pdf
[37] HealthServiceExecutive(2017).A Practical Guide to Clinical Audit. Available from:https://www.hse.ie/eng/about/Who/QID/MeasurementQuality/Clinical-Audit/practticalguideclaudit.html
[38] NHS Institute for Innovation and Improvement (2005). Sustainability: Model and Guide. Availablefrom:https://improvement.nhs.uk/resources/Sustainability-model-and-guide/
sustainability of intervention effects in public health evidence: identifying key elements toprovide guidance. Journal of Public Health, 36(2), pp. 347-351. Available from: https://academic.oup.com/jpubhealth/article/36/2/347/2901777
[41] Aarons, G. A., Sommerfeld, D. H., Hecht, D. B., Silovsky, J. F., & Chaffin,M. J. (2009). Theimpactofevidence-basedpracticeimplementationandfidelitymonitoringonstaffturnover:evidenceforaprotectiveeffect.Journal of Consulting and Clinical Psychology, 77(2),p.270.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742697/
[42] Morgan, M. and Rochford, S. (2017) Coaching and Mentoring for Frontline Practitioners.
Centre for Effective Services, Dublin. Available from: http://www.effectiveservices.org/downloads/CoachMentor_LitReview_Final_14.03.17.pdf
[44] Barwick, M.A. (2011). Checklist to Assess Organizational Readiness (CARI) for EIP Implementation. Available from: http://www.effectiveservices.org/resources/article/checklist-to-assess-organisation-readiness
[45] Chambers,D.,A.,Glasgow,R.E.,&Stange,K.C.(2013).Thedynamicsustainabilityframework:Addressing the paradox of sustainment amid ongoing change. Implementation Science, 8(117),1-11.Availablefrom:https://doi.org/10.1186/1748-5908-8-117
National Patient Safety Office Learning Zone (including videos and slides from the Centre forEffectiveServices’2-DayIntroductiontoImplementationScienceTraining)https://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/
Bauer,M.S.,Damschroder,L.,Hagerdorn,H.,Smith,J.,&Kilbourne,A.M.(2015).Anintroductionto implementation science for thenon-specialist.BMC Psychology, 3,pp.32-43.Retrieved from:https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-015-0089-9
Ogden, T., & Fixsen, D. L. (2014). Implementation science: A brief overview and a lookahead. Zeitschrift fȕr Psychologie, 222, 4-11. Retrieved from: https://www.researchgate.net/publication/259962369_Implementation_Science_A_Brief_Overview_and_a_Look_Ahead
Peters, D. H., Tran, N.T., Adam, T. (2013). Implementation research in health: A practical guide.Geneva: World Health Organization. Retrieved from: http://who.int/alliance-hpsr/alliancehpsr_irpguide.pdf
Rabin,B.A.,Brownson,R.C.,Haire-Joshu,D.,Kreuter,M.W.,&Weaver,N.L.(2008).Aglossaryfordisseminationand implementationresearch inhealth.Journal of Public Health Management and Practice, 14(2),117-123.Retrievedfrom:http://chipcontent.chip.uconn.edu/chipweb/documents/DI/Rabin_etal_2008.pdf
68 Implementation Guide and Toolkit for National Clinical Guidelines
Appendix A – Summary of Implementation Science Frameworks
1. Active Implementation FrameworkDescriptionAssociated with the National Implementation Research Network (NIRN) in the US, the ActiveImplementationFrameworkemergedfromasynthesisoftheimplementationliterature.1
2. Consolidated Framework for Implementation Research (CFIR)
DescriptionThis framework combines common elements from multiple implementation theories, offeringconsistent terminology. It places anemphasis on adapting interventions tofit the settingwherethey will be implemented, and continuous improvement of implementation throughout theprocess.2
69Implementation Guide and Toolkit for National Clinical Guidelines
3. Promoting Action on Implementation Research in Health (PARiHS)DescriptionThisframeworkisdesignedtoaidinimplementingresearchintopractice.Itfocusesonorganisationalchange, rather than individual change, noting that organisations with transformational leaders,elementsoflearningorganisations,andevaluationmechanismshavethemostsuccess.3
70 Implementation Guide and Toolkit for National Clinical Guidelines
5. Normalisation Process TheoryDescriptionThis theory and its associated tools primarily target researchers who are designing complexinterventions.Ratherthanfocusingontheprocessforimplementation,asmanyotherframeworksdo, it aims to ensure that there is good potential for implementation due to the design of theintervention.Thetoolsencouragethecreationof interventionswhicharecapableofwidespreadimplementationandcaneasilybenormalisedintoroutinepractice.4
The Behaviour Change Wheel5 shows how these conditions may be affected by certaininterventions,andhowpolicydecisionsmayimpactontheseinterventions.Thisallowsyouto:
71Implementation Guide and Toolkit for National Clinical Guidelines
7. IHI Framework for Leadership for ImprovementDescriptionDevelopedbytheInstituteforHealthcareImprovement(IHI),thisframeworkorganisesleadershipprocessesthatfocustheorganisationandseniorleadersonimprovement6
[2] Damschroder,L.J.,Aron,D.C.,Keith,R.E.,Kirsh,S.R.,Alexander,J.A.,&Lowery,J.C.(2009).Fostering implementation of health services research findings into practice: A consolidatedframeworkforadvancingimplementationscience.Implementation Science, 4(1),p.50.
[3] Rycroft-Malone,J.(2004).ThePARiHSFramework–Aframeworkforguidingtheimplementationofevidence-basedpractice.Journal of Nursing Care Quality, 19(4),pp.297-304.
[4] Murray, E., Treweek, S., Pope, C.,MacFarlane, A., Ballini, L., Dowrick, C., Finch, T., Kennedy,A.,Mair,F.,O’Donnell,C.,NioOng,B.,Rapley,T.,Rogers,A.,&May,C.(2010).Normalisationprocess theory: A framework for developing, evaluating and implementing complexinterventions.BMC Medicine, 8(63),pp.1-11.
[5] Michie, S., van Stralan M., West R. (2011). The behaviour change wheel: A new method forcharacterisinganddesigningbehaviourchangeinterventions.Implementation Science, 6(1),p.42.
[6] Reinertsen, J.L., Bisognano,M., & Pugh,M.D. (2008). Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (SecondEdition). IHI InnovationSerieswhitepaper.Cambridge,MA:InstituteforHealthcareImprovement.Availableonwww.IHI.org
Pleaseratethefollowingaspectsofimplementationreadinessin accordance with your guideline(ticktheappropriatebox):
High Med Low
Need
Fit
Resource Availability
Evidence
Intervention Readiness
Capacity to Implement
Adapted from the National Implementation Research Network (NIRN) Hexagon Tool by theCentre for Effective Services, with permission from NIRN. Original version available at: https://implementation.fpg.unc.edu/sites/implementation.fpg.unc.edu/files/resources/NIRN-HexagonDiscussionandAnalysisTool2018_FINAL.pdf
Guidance for completing each specific section of the logicmodel is provided in the text of theImplementationGuide.ThefollowingtipsandhintsshouldalsohelpGuidelineGroupstofill inalogicmodelfortheirguideline:
• Whilealogicmodelshouldbereadfromlefttorightoncecompleted,itismostlydeveloped from right to left, beginning with outcomes (after completing the situation analysis) andworkingbackthroughactivities/outputsandinputs.
• Thoughitisoftendifficulttobeprecise,being as concrete as possible,intermsoffiguresandtargetslisted,isbetterforplanning,implementation,accountabilityandevaluationpurposes.
• Outcomes inserted into a logic model can be clearly grouped bywhethertheyarerelatedtoimplementationoutcomes,serviceoutcomesorclientoutcomes
• List any anticipated inputs and discuss any issues arising. If you are intending to workin partnership, for example, what would you need to consider in terms of planning orimplementation?
• Workalreadydoneonthe Hexagon Tool and outcomes can form the basis for development of a logic model
74 Implementation Guide and Toolkit for National Clinical Guidelines
Mon
itorin
g an
d Ev
alua
tion
Situ
ation
Ana
lysi
sIn
puts
Activ
ities
/Out
puts
(wha
t we
do)
Shor
t-ter
m O
utco
mes
(res
ults
/cha
nges
)
Implem
entatio
nOutcomes
ServiceOutcomes
ClientOutcomes
Evid
ence
Long
-term
Out
com
es(r
esul
ts/c
hang
es)
Implem
entatio
nOutcomes
ServiceOutcomes
ClientOutcomes
Logi
c M
odel
Tem
plat
e –
Nati
onal
Clin
ical
Gui
delin
es
75Implementation Guide and Toolkit for National Clinical Guidelines
Tool 3 – Implementation Enablers and Barriers: Assessment Tool
Introduction to the Implementation Enablers and Barriers Assessment ToolA wide range of factors influence whether implementation is successful. Assessing andunderstanding these factors can help to identify barriers and facilitators to change and informimplementationplanning.Thisassessmenttoolprovidesanoverviewofkeyfactorsthatinfluenceimplementationandassistspeopleinassessingthese.Italsohelpswithidentifyingopportunitiestostrengthenimplementation.
The factors influencing implementation are organised around the four areas presented in thegraphic:
Thistoolbuildsontwotheoreticalframeworks:• The Consolidated Framework for Implementation Research(CFIR)(Damschroderet al.,2009)[1]
and• The Behaviour Change Wheel(Michieet al.,2011)[2]
76 Implementation Guide and Toolkit for National Clinical Guidelines
Thistoolcanbecompletedforindividual recommendationswithinNationalClinicalGuidelines,orforaguideline/project as a whole. Itcanalsobeusedtoassessenablersandbarriersatvarious levels,suchasatanationallevelorinaparticularhealthcaresetting.
In completing this tool, you should focus on factors that aremost relevant and salient to yourguideline and its stage of implementation. For example, youmaywish to focus on factors thatwillbemostfruitfultoaddress.Werecommendthatyouchoosebetweenfivetosevenfactorstoassessandatleastonefactorfromeachofthefourareas.Usethetablebelowtoselectthefactorsyouarefocusingonbyticking(ü)intherelevantboxes
FACTORS INFLUENCING IMPLEMENTATION Tick (ü)
1. Intervention characteristics
a) Interventionsource
b) Evidencestrengthandquality
c) Relativeadvantage
d) Trialability
e) Complexity
f) Designquality
g) Cost
2. Outer setting
a) Patientneedsandresources
b) Cosmopolitanism(networksandrelationships)
c) Peerpressure
d) Externalpoliciesandincentives
3. Inner Setting
a) Structuralcharacteristics
b) Networksandcommunications
c) Culture
d) Implementationclimate
e) ReadinessforImplementation
4. Characteristics of Individuals
a) Capacity-physicalandpsychological
b) Motivation
77Implementation Guide and Toolkit for National Clinical Guidelines1.
INTE
RVEN
TIO
N C
HARA
CTER
ISTI
CS
An in
terv
entio
n is
defi
ned
as a
ny c
hang
e to
pol
icy
or p
racti
ce. I
t cou
ld re
fer t
o a
Nati
onal
Clin
ical
Gui
delin
e an
d/or
indi
vidu
al
reco
mm
enda
tions
with
in th
em.
A ra
nge
of in
terv
entio
n att
ribut
es c
an in
fluen
ce th
e su
cces
s of i
mpl
emen
tatio
n.
A) IN
TERV
ENTI
ON
SO
URC
ETh
e pe
rcei
ved
legi
timac
y an
d cr
edib
ility
of t
he s
ourc
e (e
.g. a
cade
mic
col
lege
, HSE
clin
ical
pro
gram
me
or a
dvoc
acy
grou
p) o
f the
inte
rven
tion,
in
clud
ing
whe
ther
the
inte
rven
tion
is de
velo
ped
exte
rnal
ly o
r int
erna
lly.
If th
is is
an
exis
ting
inte
rven
tion,
who
dev
elop
ed
it; w
ho is
the
spon
sor;
who
is re
spon
sibl
e fo
r up
date
and
impl
emen
tatio
n?
To w
hat e
xten
t is t
he
inte
rven
tion
cons
ider
ed to
be
app
ropr
iate
? (ti
ck re
spon
se)
□High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g thi
s? (I
f uns
ure,
w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
78 Implementation Guide and Toolkit for National Clinical GuidelinesB)
EVI
DEN
CE S
TREN
GTH
AND
QUA
LITY
The
qual
ity a
nd v
alid
ity o
f the
evi
denc
e in
dica
ting
that
the
inte
rven
tion
will
hav
e th
e de
sired
out
com
es.
Wha
t sup
porti
ng e
vide
nce
show
s the
inte
rven
tion
will
wor
k?
How
do
stak
ehol
ders
pe
rcei
ve th
e st
reng
th o
f th
e ev
iden
ce b
ase
for t
he
inte
rven
tion?
(ti
ck re
spon
se)
□High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g thi
s? (I
f uns
ure,
w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
C) R
ELAT
IVE
ADVA
NTA
GE
The
adva
ntag
e of
impl
emen
ting
the
inte
rven
tion
vers
us a
n al
tern
ative
solu
tion.
Wha
t adv
anta
ges d
oes t
he in
terv
entio
n ha
ve
com
pare
d to
alte
rnati
ves?
To
wha
t ext
ent i
s the
in
terv
entio
n co
nsid
ered
to
be
bett
er th
an c
urre
nt
and/
or a
ltern
ative
pr
actic
es?
(tick
resp
onse
) □
High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g thi
s? (I
f uns
ure,
w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
79Implementation Guide and Toolkit for National Clinical GuidelinesD)
TRI
ALAB
ILIT
YTh
e ab
ility
to te
st th
e in
terv
entio
n on
a sm
all s
cale
in a
setti
ng, a
nd to
be
able
to re
vers
e co
urse
(und
o im
plem
enta
tion)
if w
arra
nted
.
Has t
he in
terv
entio
n be
en p
ilote
d or
are
ther
e pl
ans t
o pi
lot t
he in
terv
entio
n pr
ior t
o fu
ll-sc
ale
impl
emen
tatio
n?
To w
hat e
xten
t is i
t po
ssib
le to
tria
l/pi
lot t
he
inte
rven
tion
prio
r to
full-
scal
e im
plem
enta
tion?
(tick
resp
onse
) □
High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g thi
s? (I
f uns
ure,
w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
E) C
OM
PLEX
ITY
The
com
plex
ity o
f th
e in
terv
entio
n, r
eflec
ted
by d
urati
on, s
cope
, rad
ical
ness
, disr
uptiv
enes
s, c
entr
ality
, and
intr
icac
y an
d nu
mbe
r of
ste
ps
requ
ired
to im
plem
ent.
How
com
plic
ated
is th
e in
terv
entio
n?W
hat i
s the
leve
l of c
hang
e re
quire
d to
impl
emen
t the
in
terv
entio
n an
d re
plac
e ex
istin
g pr
actic
es?
(tick
resp
onse
) □
High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g thi
s? (I
f uns
ure,
w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
80 Implementation Guide and Toolkit for National Clinical GuidelinesF)
DES
IGN
QUA
LITY
AN
D PA
CKAG
ING
Qua
lity
of th
e m
ater
ials
and
supp
orts
ava
ilabl
e to
hel
p im
plem
ent a
nd u
se th
e in
terv
entio
n.
Wha
t res
ourc
es, t
ools
and
supp
orts
are
ava
ilabl
e to
hel
p im
plem
ent a
nd u
se th
e in
terv
entio
n?
How
do
you
rate
the
qual
ity o
f the
reso
urce
s de
velo
ped
to su
ppor
t im
plem
enta
tion
of th
e in
terv
entio
n?(ti
ck re
spon
se)
□High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g thi
s? (I
f uns
ure,
w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
G) C
OST
Cost
s of t
he in
terv
entio
n an
d co
sts a
ssoc
iate
d w
ith im
plem
entin
g th
e in
terv
entio
n in
clud
ing
inve
stm
ent,
supp
ly, a
nd o
ppor
tuni
ty c
osts
.
Wha
t cat
egor
ies o
f cos
ts w
ill b
e in
curr
ed in
im
plem
entin
g th
e in
terv
entio
n? (e
.g. s
taffi
ng,
equi
pmen
t, IT
)
Wha
t lev
el o
f cos
ts w
ill b
e in
curr
ed in
impl
emen
ting
the
inte
rven
tion?
(tick
resp
onse
) □
High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g thi
s? (I
f uns
ure,
w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
81Implementation Guide and Toolkit for National Clinical Guidelines2.
OU
TER
SETT
ING
Th
e w
ider
eco
nom
ic, p
oliti
cal,
soci
al a
nd c
ultu
ral c
onte
xt in
fluen
ces i
mpl
emen
tatio
n.
A) P
ATIE
NT/
CLIE
NT
NEE
DS A
ND
RESO
URC
ESTh
e ex
tent
to w
hich
pati
ent n
eeds
, as w
ell a
s bar
riers
and
faci
litat
ors t
o m
eet t
hose
nee
ds, a
re a
ccur
atel
y kn
own
and
prio
ritise
d.
Howwerethene
edsa
ndpreferencesofp
atien
ts/
clientsc
onsid
ered
whe
nde
ciding
toim
plem
entthe
interven
tion?
To w
hat e
xten
t will
the
inte
rven
tion
mee
t the
ne
eds a
nd p
refe
renc
es o
f pa
tient
s/cl
ient
s?
(tick
resp
onse
) □
High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g th
is?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
B) C
OSM
OPO
LITA
NIS
M (E
XTER
NAL
NET
WO
RKS
AND
RELA
TIO
NSH
IPS)
The
qual
ity a
nd e
xten
t of r
elati
onsh
ips a
nd n
etw
orks
with
oth
er e
xter
nal o
rgan
isatio
ns (s
ocia
l cap
ital).
Wha
tkindofin
form
ation
excha
nge/ne
tworking
do
staff
havewith
otherso
utsid
etheirsetti
ng?
Wha
t is t
he le
vel o
f in
form
ation
exc
hang
e/ne
twor
king
staff
hav
e w
ith
othe
rs o
utsi
de o
f the
ir se
tting
/org
anis
ation
? (ti
ck re
spon
se)
□High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g th
is?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
82 Implementation Guide and Toolkit for National Clinical GuidelinesC)
PEE
R PR
ESSU
RECo
mpe
titive
pre
ssur
e to
impl
emen
t an
inte
rven
tion,
mai
nly
from
oth
er p
rofe
ssio
nals/
serv
ices
/org
anisa
tions
who
hav
e al
read
y im
plem
ente
d th
e in
terv
entio
n. T
his c
an a
id a
dopti
on o
f int
erve
ntion
s.
Areothe
rservices/professio
nalsim
plem
entin
gthe
interven
tionorsimilarp
racti
ces?
To w
hat e
xten
t are
oth
er
serv
ices
/pro
fess
iona
ls
impl
emen
ting
the
inte
rven
tion?
(tick
resp
onse
) □
High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g th
is?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
D) E
XTER
NAL
PO
LICI
ES A
ND
INCE
NTI
VES
Exte
rnal
pol
icie
s and
ince
ntive
s tha
t spr
ead
inte
rven
tions
, inc
ludi
ng g
over
nmen
t pol
icy
and
regu
latio
ns, e
xter
nal m
anda
tes,
reco
mm
enda
tions
an
d gu
idel
ines
, col
labo
rativ
es, a
nd p
ublic
or b
ench
mar
k re
porti
ng.
Arethereexternalpolicies,re
gulatio
nsor
guidelineswhichcou
ldim
pede
orc
onflictwith
im
plem
entatio
nofth
einterven
tion?
To w
hat e
xten
t are
ex
tern
al p
olic
ies a
nd
ince
ntive
s sup
porti
ng th
e im
plem
enta
tion
of th
e in
terv
entio
n?
(tick
resp
onse
) □
High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g th
is?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
83Implementation Guide and Toolkit for National Clinical Guidelines3.
INN
ER S
ETTI
NG
The
orga
nisa
tiona
l str
uctu
re, c
ultu
re a
nd c
limat
e pl
ay a
n im
port
ant r
ole
in su
cces
sful
impl
emen
tatio
n.
A) S
TRU
CTU
RAL
CHAR
ACTE
RIST
ICS
The
age
and
size
of th
e or
gani
satio
n, le
vel o
f sta
ff tu
rnov
er, g
eogr
aphi
c sp
read
, phy
sical
layo
ut e
tc.
Wha
t kin
d of
infr
astr
uctu
re c
hang
es a
re n
eede
d to
acc
omm
odat
e th
e in
terv
entio
n (e
.g. c
hang
es to
po
licie
s, in
form
ation
and
reco
rd sy
stem
s)?
To w
hat e
xten
t is t
he
leve
l of i
nfra
stru
ctur
e re
quire
d to
impl
emen
t the
in
terv
entio
n in
pla
ce?
(ti
ck re
spon
se)
□High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g th
is?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
B) N
ETW
ORK
S AN
D CO
MM
UN
ICAT
ION
STh
e na
ture
and
qua
lity
of so
cial
net
wor
ks, a
nd fo
rmal
and
info
rmal
com
mun
icati
ons w
ithin
an
orga
nisa
tion.
How
do
staff
find
out
abo
ut n
ew in
itiati
ves,
ac
com
plis
hmen
ts, b
est p
racti
ce e
tc.?
How
do
you
rate
the
qual
ity o
f com
mun
icati
on
in th
e or
gani
satio
n?
(tick
resp
onse
) □
High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g th
is?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
84 Implementation Guide and Toolkit for National Clinical GuidelinesC)
CU
LTU
REN
orm
s, v
alue
s, a
nd b
asic
ass
umpti
ons o
f an
orga
nisa
tion.
How
do
you
thin
k th
e or
gani
satio
n’s c
ultu
re w
ill
affec
t the
impl
emen
tatio
n of
the
inte
rven
tion?
To
wha
t ext
ent a
re n
ew
idea
s em
brac
ed a
nd u
sed
to m
ake
impr
ovem
ents
?(ti
ck re
spon
se)
□High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g th
is?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
D) IM
PLEM
ENTA
TIO
N C
LIM
ATE
The
abso
rptiv
e ca
paci
ty fo
r cha
nge,
shar
ed re
cepti
vity
of i
nvol
ved
indi
vidu
als t
o an
inte
rven
tion,
and
the
exte
nt to
whi
ch u
se o
f tha
t int
erve
ntion
w
ill b
e re
war
ded,
supp
orte
d, a
nd e
xpec
ted
with
in th
eir o
rgan
isatio
n.
How
wel
l doe
s the
inte
rven
tion
fit w
ith e
xisti
ng
wor
k pr
oces
ses a
nd p
racti
ces?
To
wha
t ext
ent i
s the
or
gani
satio
n re
cepti
ve
to im
plem
entin
g th
e in
terv
entio
n?
(tick
resp
onse
) □
High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g th
is?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
85Implementation Guide and Toolkit for National Clinical GuidelinesE)
REA
DIN
ESS
FOR
IMPL
EMEN
TATI
ON
– L
eade
rshi
p en
gage
men
t; av
aila
ble
reso
urce
s; a
cces
s to
know
ledg
e an
d in
form
ation
Tang
ible
and
imm
edia
te in
dica
tors
of o
rgan
isatio
nal c
omm
itmen
t to
its d
ecisi
on to
impl
emen
t an
inte
rven
tion.
It in
volv
es:
i) le
ader
ship
eng
agem
ent,
i.e. c
omm
itmen
t, in
volv
emen
t and
acc
ount
abili
ty o
f lea
ders
;ii)
ava
ilabl
e re
sour
ces,
i.e.
reso
urce
s ded
icat
ed to
impl
emen
tatio
n (e
.g. f
or tr
aini
ng);
and
iii) a
cces
s to
know
ledg
e an
d in
form
ation
, i.e
. acc
ess t
o in
form
ation
and
kno
wle
dge
abou
t how
to im
plem
ent t
he in
terv
entio
n.
Do y
ou h
ave
the
nece
ssar
y re
sour
ces a
nd su
ppor
ts
requ
ired
to im
plem
ent t
he in
terv
entio
n?
To w
hat e
xten
t doe
s the
or
gani
satio
n en
dors
e or
su
ppor
t im
plem
enta
tion
of
the
inte
rven
tion?
(ti
ck re
spon
se)
□High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g th
is?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
86 Implementation Guide and Toolkit for National Clinical Guidelines4.
CHA
RACT
ERIS
TICS
OF
INDI
VIDU
ALS
The
char
acte
ristic
s of i
ndiv
idua
ls, in
clud
ing
thei
r cap
acity
and
moti
vatio
n, in
fluen
ce ch
ange
s in
beha
viou
r req
uire
d to
impl
emen
t int
erve
ntion
s.
A) C
APAC
ITY
– PH
YSIC
AL A
ND
PSYC
HOLO
GIC
ALTh
e ph
ysic
al a
nd p
sych
olog
ical
cap
acity
of i
ndiv
idua
ls to
del
iver
the
inte
rven
tion,
incl
udin
g ph
ysic
al st
reng
th, k
now
ledg
e, sk
ills a
nd st
amin
a.
Who
(i.e
. wha
t gro
ups)
are
nee
ded
to d
eliv
er th
e in
terv
entio
n?
To w
hat e
xten
t do
indi
vidu
als h
ave
the
capa
city
(phy
sica
l and
ps
ycho
logi
cal)
to e
nact
the
chan
ges r
equi
red?
(ti
ck re
spon
se)
□High
□Med
ium
□Low
Wha
t are
the
next
step
s for
stre
ngth
enin
g th
is?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
B) M
OTI
VATI
ON
Brai
n pr
oces
ses t
hat e
nerg
ise a
nd d
irect
beh
avio
ur, i
nclu
ding
kno
wle
dge,
bel
iefs
, and
con
fiden
ce.
How
do
indi
vidu
als f
eel a
bout
impl
emen
ting
the
inte
rven
tion?
To
wha
t ext
ent a
re st
aff
moti
vate
d to
ena
ct th
e ch
ange
s req
uire
d?
(tick
resp
onse
) □
High
□Med
ium
□Low
Wha
t ar
e th
e ne
xt s
teps
for
str
engt
heni
ng t
his?
(If
unsu
re, w
hat a
dditi
onal
info
rmati
on d
o yo
u ne
ed?)
87Implementation Guide and Toolkit for National Clinical Guidelines
Guidance and Definitions for Implementation Enablers and Barriers Assessment Tool
1. Intervention Characteristics The characteristics of the intervention being implemented.
4. Characteristics of Individuals Knowledge, beliefs and skills that individuals need in order to carry out the implementation process. May also refer to a team or unit
Fostering implementation of health services research findings into practice: a consolidatedframework for advancing implementation science. Implementation Science, 4(1), pp. 50-64.Availablefrom:https://doi.org/10.1186/1748-5908-4-50
[2] Michie, S., van Stralan M., West R. (2011). The behaviour change wheel: A new methodfor characterising and designing behaviour change interventions. Implementation Science, 6(1), p.42. Available from: https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42
89Implementation Guide and Toolkit for National Clinical Guidelines
Tool 4 – Implementation Planning Tool Implementation is a key requirement for Guideline Groups and completed published guidelinesmustincludeanimplementationplan.Groupsshouldfilloutthetemplateprovidedonthefollowingpage, listingspecificactionsthatarerequiredfor implementation,andlinkingthemto:guidelinerecommendations(anumberofrecommendationscanbegroupedtogether,whereappropriate);who is ultimately responsible for leading the action; the expected timeframe for completion;and themeasure/indicator that will be used to verify that the recommendation has been fullyimplemented.Thesearedescribedingreaterdetailbelow.
Explanatory notes for implementation plan • Guideline recommendation/number:Thisreferstothespecificguidelinerecommendation(s)
which the action/intervention aims to achieve. One action may address several recommendations, e.g. training programme or additional staff. Ensure all guidelinerecommendationsareincludedintheimplementationplan.
• Barriers and enablers: Identify the barriers and enablers for implementing this recommendation.Completingthe ‘ImplementationEnablersandBarriers:AssessmentTool’inTool3will helpyou to complete this section.Note that somebarriersandenablerswillbecommontomultiplerecommendations.Considercapability,opportunityandmotivation,whichinfluencebehaviour.
• Action/intervention/task to implement recommendation: This is the specific high-levelaction,interventionortaskwhichisneededtoimplementtheguidelinerecommendation(s).Determinetheactions,interventionsortasksthatareeffectiveandbestsuitedtoaddresstheidentifiedneedsandbarriers.Theactions, interventionsortasksshouldspecifythechangerequiredtocurrentpractice,i.e.whoneedstodowhatdifferentlyforthisrecommendationtobeimplementedeffectively.
• Lead responsibility for delivery of the action/intervention/task:Manyactions,interventionsor tasks are carriedout bymultidisciplinary teams andmultiple stakeholders. This columnshouldbeusedtospecifytheleadgroup/unit/organisationresponsibleforimplementingtheaction/intervention/task.EnsuringthatthesestakeholdersareonyourGuidelineGroupfromthebeginningwillhelptoensurethattheguidelinerecommendationsareimplementable.
• Timeframe for completion: Specifythetimeframeyouexpectforfullimplementationofthisaction,interventionortaskwithinthethreeyearsfollowingpublication.Foradditionaldetail,thequarter(Q1,Q2,Q3,orQ4)canalsobeadded.Itisusefultospreadtheseoutoverthe3years.Someinterventionsmaybedependentonadditionalfundingandcanbedenotedassuch.Theguidelineisupdatedafter3years,withanewimplementationplan.
• Expected outcome and verification:Specifytheexpectedoutcomeandhowyouwillverifyormeasureit,i.e.howwillyouknowwhentherecommendationhasbeenfullyimplemented?Howwillyouknowiftheexpectedoutcomehasbeenachieved?Useexistingdata/measurementsourceswhereavailable.
• Allowing adequate and appropriate time for planning how clinical guidelines will be implemented is a crucial implementation enabler,enablingthosewhoaredrivingthechangetomapouttheimplementationprocessandprovideacourseofactiontoaddressanypotentialchallenges.
90 Implementation Guide and Toolkit for National Clinical GuidelinesIm
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92 Implementation Guide and Toolkit for National Clinical Guidelines
Tool 5 – Monitoring and Evaluating Implementation: Planning ToolIntroductionThistoolhasbeenproducedbytheCentreforEffectiveServices,basedonProctoretal.’s(2011)taxonomy of implementation outcomes and the Reach Efficacy Adoption ImplementationMaintenance (RE-AIM) framework (Glasgow, Vogt & Boles, 1999). It has been produced tohelp those involved in developing and implementingNational ClinicalGuidelines toplan for themonitoringandevaluationofimplementationoftheirguideline.
It relatesspecificallytotheeight implementationoutcomeareasrelevanttothe implementationofNationalClinicalGuidelinesthatarelistedbelow.Foreachoutcomearea,thelevelsofanalysisare listed, some questions regarding monitoring and evaluation, and potential data collectionmethods are listed. It is important to remember that many of the outcomes below are inter-related. Further, someof these outcomes aremore relevant for early stages of implementation(e.g. appropriateness) and others are more relevant for later stages of implementation (e.g.sustainability).