A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines

Abstract

Theories from social and behavioural science can make an important contribution to the process of developing a conceptual framework for improving use of clinical practice guidelines and clinician performance. A conceptual framework for guideline dissemination and implementation is presented which draws on relevant concepts from diVusion of innovation theory, the transtheoretical model of behaviour change, health education theory, social influence theory, and social ecology, as well as evidence from systematic literature reviews on the eVectiveness of various behaviour change strategies. The framework emphasises the need for preimplementation assessment of (a) readiness of clinicians to adopt guidelines into practice, (b) barriers to change as experienced by clinicians, and (c) the level at which interventions should be targeted. It also incorporates the need for multifaceted interventions, identifies the type of barriers which will be addressed by each strategy, and develops the concept of progression through stages of guideline adoption by clinicians, with the use of appropriately targeted support strategies.The potential value of the model is that it may enable those involved in the process of guideline dissemination and implementation to direct strategies to target groups more eVectively. Clearly, the eVectiveness and utility of the model in facilitating guideline dissemination and implementation requires validation by further empirical research. Until such research is available, it provides a theoretical framework that may assist in the selection of appropriate guideline dissemination and implementation strategies. (Quality in Health Care 1999;8:177-183) Keywords: guidelines; behaviour change theory; conceptual framework Until recently, there has been little research on the relative merits of dissemination and implementation strategies used to encourage adoption of clinical practice guidelines. However, evidence now exists that use of an appropriate range of strategies, beyond simple information provision through publication in journals or general mailings, can significantly increase rates of guideline adoption by clinicians.

Health Professionals’ Attitudes towards Electronic Psychosocial Assessments in Youth Mental Healthcare

“…Although the current research does not provide overly positive views about the current willingness of clinicians to incorporate these new technologies in practice, it does provide useful information in developing implementation guidelines in helping to change these attitudes [23]. For example, it suggests that attitudes toward shared decision-making may need to also be addressed, that clinicians should not feel forced to change their clinical practice [51], and, that the attitudes of some champion clinicians in a service could be used to help alter the views of their colleagues [26] thereby improving organizational "readiness for change" [25].…”

“…Further, although participants in the current study may not currently hold strong positive beliefs about the e-tool, they still provided useful reasons as to why the e-tool could be beneficial. These reasons, specifically, that it could allow disclosure to occur in a stepped process, normalize questions, give youth greater input into their help-seeking, help clinicians formulate early treatment plans, and focus the time in sessions, could be highlighted within implementation guidelines to further increase the value of this change in practice [23].…”

“…In their five step framework for effective change in clinical practice, Moulding, Silagy and Weller [23] suggested that the first step must involve an assessment of the practitioner's readiness to change, which involves understanding their attitudes and beliefs about their current practice model, and the suggested change [24]; specifically, whether they believe the change is needed, important, beneficial or worthwhile [25]. It is also important to understand how the attitudes of colleagues play a major role in influencing the attitudes of individual practitioners, as predicted according to social influence theory [23] [26]. Therefore, when assessing the attitudes of practitioners working in collaboration with others at a specific location, it is necessary to determine the "shared sense of readiness" [25].…”

Effectiveness and efficiency of guideline dissemination and implementation strategies

“…If such a guideline is unavailable, the resources required to develop a robust guideline de novo are substantial. Mittman and colleagues, 35 Grimshaw and Eccles 36 and Moulding and colleagues 37 ). However, the empirical basis for these rationales is not strong.…”

Managing access block

“…There is no doubt that in all areas of medical practice, clinicians are most affected by other influential colleagues who are experts in the field (Moulding 1999). …”