Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
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]
September 2018. © Department of Health, September 2018.
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)
Contents
Development of the Guide ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2
How to use this Guide .. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3
Implementation of Clinical Guidelines . ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5
Introduction to Implementation Science... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 8 WhatisImplementationScience? 8 ImplementationFrameworks 9 ImplementationStages 10 AssessingImplementationStage 12 EnablersandBarriers 12 ContextforImplementation 13 StrategiesforImplementation 14
Stage 1: Exploring and Preparing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 16
Stage 2: Planning and Resourcing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 28
Stage 3: Implementing and Operationalising . ... ... ... ... ... ... ... ... ... ... ... ... ... .. 46
Stage 4: Full Implementation . ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 52
Glossary ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 56
References ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 60
Additional Implementation Websites and Resources... ... ... ... ... ... ... ... ... ... ... .. 66
Appendix A ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 68
Tool 1 – The Hexagon Tool. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 72
Tool 2 – Logic Model ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 73
Tool 3 – Implementation Enablers and Barriers: Assessment Tool... ... ... ... ... ... ... .. 75
Tool 4 – Implementation Planning Tool ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 89
Tool 5 – Monitoring and Evaluating Implementation: Planning Tool ... ... ... ... ... ... .. 92
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.
AuthorsTheguidewasproducedbytheCentreforEffectiveServices(CES). www.effectiveservices.org TheauthorsareDrAislingSheehan,MrChrisMinchandMsKatieBurke.
AcknowledgementsThe Clinical EffectivenessUnitwould like to thank the following peoplewho contributed to thedevelopmentoftheGuideinvariousways,includingtheprovisionofworkedexamplesoftoolsandprovidingfeedbackonearlierdraftsofthisGuide:
• MsMaryBeddingandMsChristinaDoyle,SepsisGuidelineDevelopmentGroup,HSE• MsBrídBoyce,NationalQualityImprovementDivision,HSE• MsCatherineDuffyandDrEveO’TooleonbehalfoftheNationalCancerControlProgramme
(NCCP),HSE• Dr Helena Gibbons,Ms LouiseMurphy and Dr Niamh Kilgallen, Ovarian Cancer Guideline
DevelopmentGroup,NCCP,HSE• DrPatrickGlackin,AreaDirectorofNursingandMidwiferyPlanningandDevelopment,HSE
West• MsCaralynHorne,PortfolioLead-ProgrammeManagementOffice,MidlandsLouthMeath
CHOArea8,HSE• MsMaryCMorrissey,ResearchandDevelopment,StrategicPlanningandTransformation,HSE• MsClareO’Neill,Risk&IncidentMonitoring,SupportandLearningOfficer,Quality&Service
UserSafety,HSENationalCommunityOperations• DrKarenPower,ChildbirthGuidelineDevelopmentGroup.
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:
• Logicmodel(onepage)• Implementationplan(actions,timeframe,personsresponsible,expectedoutcomes)
Templatesandworkedexamplesfortheseareincludedinthisguide.
4 Implementation Guide and Toolkit for National Clinical Guidelines
ThisImplementationGuideprovidesreaderswith:üContextforthe importanceof ImplementationScience insuccessfully implementingclinical
guidelinesüAnoutlineofImplementationSciencetheoryandanintroductiontokeyconceptsüKeyelementscommontoimplementationframeworksüApackageofinformation,toolsandresourcestofacilitatediscussions,thinking,andplanning
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.
Clinical Guidelinesare‘systematicallydevelopedstatements,basedonathoroughevaluationoftheevidence,toassistpractitionerandserviceusers’decisionsaboutappropriatehealthcareforspecificclinicalcircumstancesacrosstheentireclinicalsystem’[1]
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]
Theimportanceofdedicatingtimeandresourcestoimplementationofclinicalguidelinesisbeingincreasinglyrecognised,andtheNCEChasincludedconsiderationofimplementationissuesaspartofprioritisationandqualityassuranceprocessesforNationalClinicalGuidelines.
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
clinicians)?
Implementationinvolvesthecarryingoutofspecificplanned,intentionalactivitiesundertakenwiththeaimofmakingevidence-informedpoliciesandpracticesworkbetterforpeople.Itcanbethoughtofasthe‘how’aswellasthe‘what’.
6 Implementation Guide and Toolkit for National Clinical Guidelines
• DidtheGuidelineDevelopmentGroupincludeindividualsfromalltherelevantprofessionalgroups,methodological experts and intended users, for example healthcare professionals,hospitalmanagersetc.?
• Isthereadegreeofurgencyforimplementationoftheclinicalguideline?• Whatisthelikelihoodoftheclinicalguidelineimplementationstrategybeingsuccessful?• Howaccessiblewilltheclinicalguidelinebe?
KeyaspectsofimplementationwhichareassessedduringtheNCECqualityassuranceprocessformpartofthe‘Applicability’domainoftheAppraisalofGuidelinesforResearchandEvaluation(AGREEII)tool[13],namely:
• Theguidelinedescribesfacilitatorsandbarrierstoitsapplication• The guideline provides advice and/or tools on how the recommendations can be put into
practice• Thepotentialresourceimplicationsofapplyingtherecommendationshavebeenconsidered• Theguidelinepresentsmonitoringand/orauditingcriteria.
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/
Introduction to Implementation Science
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 Scienceistheformalstudyofmethodsandfactorsthatinfluencehowsuccessfullyspecificinterventionsareincorporatedintoservicesettings,leadingtoimprovedoutcomes.
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
andwillnotguaranteethesuccessofclinicalguidelines.Thereareamyriadoffactorsaffectingimplementationsuccess,andsometimesitmaynotbepossibleorfeasibletoaddressthemall.
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.
Interventionsareanyevidence-informedpolicy,practice,serviceorprogrammebeingimplemented,beitachangetoanexistingpolicy,practice,serviceorprogramme,oranewintervention.
InthisGuide,weuseinterventiontorefertospecificrecommendationscontainedwithinNationalClinicalGuidelines,ClinicalPracticeGuidance(PPPGs)andNationalClinicalAudit.
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.
Thetermstheory, modelandframeworkareoftenusedinterchangeably.
Foradetaileddescriptionoftheseterms,withparticularrelevancetoImplementationScience,seeNilsen,2015 [19]
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.
TheremainderofthissectionwillfocusonsomeofthecoreelementsofImplementationScience.Thesecoreelementsare:
Implementation Stages
Enablers and Barriers
Context for Implementation
Implementation Strategies
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
attention.• Implementation takes time;estimatesvaryfrom2-4yearsto7-10years,dependingonscale
andcomplexity.Rushingthroughstagesorworkingaparticularlylargenumberofhoursinashorttimedoesnotadequatelycompensateforthisneed.
• Thestagesarenot linear.Manyoftheactivitiesoverlap,andyoumayneedtore-visitorbringforwardtasksfromotherstages asnecessary.
• Therearearange of toolsavailabletohelpGuidelineGroupsnavigateeachstage.ThesearesignpostedthroughouttheremainderofthisGuide.
11Implementation Guide and Toolkit for National Clinical Guidelines
The four-stage model below is one way to visualise the implementation process of clinical guidelines:
Stage 2: Planning & Resourcing
Herethefoundationislaidforeffectiveimplementation.
Key activities at this stageinclude:• Assessingimplementation
readiness• Assessingenablersand
barriersforimplementation• Developingan
implementationplan• Establishingimplementation
team(s)andinfrastructureforimplementation
• Developingleadershipforimplementation
• Designingmonitoring,evaluationandfeedbacksystems
• Determininganddeliveringstafftraining,capacitybuildingandsupportrequirements
• Planningforguidelinesustainability
Stage 4: Full Implementation
Theguidelineisfullyoperationalandintegrated,usedconsistently,andsupportedbystructuresandresources.
Key activities at this stageinclude:• Evaluatingimplementation
outcomes,serviceoutcomesandclientoutcomes
• Engagingincontinuousimprovementcyclestoenhancequality
Stage 1: Exploring & Preparing
Here the needs of stakeholders are assessed, the reason/rationale for developing theguidelineisclarified,andthescopeoftheguidelineisdetermined.
Key activities atthisstageinclude:• Stakeholderengagementplanning• Assessingneedsandtheevidencebaseforaguideline• Definingkeyclinicalquestionstobeaddressed• Assessingthefit,feasibilityandimplementabilityofpotentialrecommendations• Specifyingoutcomeswhichtheguidelineseekstoachieve• DevelopingaTheoryofChangeandLogicModel
Stage 3: Implementing & Operationalising
Heretheguidelineisimplementedforthefirsttime.
Keyactivitiesatthisstageinclude:• Maintainingongoingcommunication,explainingwhytheguidelineisnecessaryand
securingcontinuedbuy-in• Providingongoingprofessionaldevelopmentopportunitiesandsupportforstaff
implementingguidelines• Ongoingmonitoringofimplementationoutcomes,serviceoutcomesandclientoutcomes• Usingdataandfeedbackmechanismstoinformongoingimprovements• Adaptingimplementationplansforlocalsettings,whereappropriate
1. Exploring & Preparing
4. Full Implementation
2. Planning & Resourcing
3. Implementing & Operationalising
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’
Implementation Enablers Stages of Implementation1
Exploring&Preparing
2 Planning&Resourcing
3 Implementing&Operationalising
4 Full
ImplementationStakeholderconsultationandbuy-inLeadershipResourcesImplementationplanImplementationteamStaffcapacityOrganisationalsupportSupportiveorganisationalcultureCommunicationMonitoringandevaluationDatainformedimprovementcycles
ImplementationEnablersbyStageofImplementation[14]
Researchhasalsopointedtoanumberoffactorswhichhindertheimplementationprocess.Theseareknownas implementation ‘barriers’. These includealignmentproblemswith funding cycles,resistancetochangeandvestedinterests.Takingstepstoavoidorovercomethesebarriers,wherepossible,atanearlystageofimplementationisveryimportantforsuccessfulimplementation.
13Implementation Guide and Toolkit for National Clinical Guidelines
Context for ImplementationImplementationScience indicatesthe importanceofthecontext inwhich interventionsare implementedand used [19]. Examples of factors that influencecontextinclude:
• Providers’perceptionsofanintervention• Patients’needs• Relationships,networksandcommunications• Structuralcharacteristicsoftheenvironment• Localandnationalpolicies• Culture.
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.
Assuch,itisimportanttotakecontextintoaccountanddesignguidelinessothattheycanleveragefavourablecontextualfactorsandovercomeunfavourableones.Thiscanbedifficult,ascontextualfactorsareoftenchangeableandtransient.
However,contextcanalsobe influencedandmalleabletochange [21]. Implementationenablerssuchasasympatheticculture;strongleadership;staffsupportsuchascoachingandmentoring;andwell-designedfeedbackandevaluationmechanisms,canallhelptoinfluencecontextinapositiveway.
Contextcanbedescribedas‘thesetofcircumstancesoruniquefactorsthatsurroundaparticularimplementationeffort’.Thiscanrefertoboththewider,systemiccontext,aswellasthespecificsettinginwhichaspecificinterventionwillbeimplemented[20]
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:
Top-Down Implementation Strategies Bottom-Up Implementation StrategiesA linearapproachwherestrategiesare ledfromacentralsource.
Adecentralised approachwhere strategiesareinitiatedbystakeholdersatcommunity/locallevel.
Examples:• Distributeeducationalmaterials• Conductongoingtraining• Mandatechange
Examples:• Captureandsharelocalknowledge• Organise clinician implementation
teammeetings
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.
Unfortunately,thereiscurrentlylittleevidenceonhowtosystematicallychoosestrategies[24],soanelementoftrialanderrorshouldbeexpectedandtolerated.
ClickheretoaccesstheExpertRecommendationsforImplementingChangelistof73 implementation strategies [23,pp.8-10]
Stage 1: Exploring and Preparing
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:
• Stakeholderengagementplanning• Assessingneedsandtheevidencebase• Assessingthefit,feasibilityandimplementabilityofpotentialrecommendations• Specifyingoutcomeswhichtheguidelineseekstoachieve• DevelopingaTheoryofChangeandLogicModel.
Itisworthrememberingthatwhiletheseactivitiesaremostsuitableduringstage1,theymaystillbeusefulforGuidelineGroupsatotherstagesofimplementation.
Thekeytoolsthatcanbeusedduringthisfirststageofimplementationare:• Stakeholderengagementtool• Hexagontoolforassessingthereadinesstoimplement• Logicmodeltemplate.
Stakeholder Engagement PlanningIn the development, implementation and evaluation ofguidelines,theinvolvementofstakeholders:
• Helpscreateawareness• Generatesbuy-in• Identifiesandacknowledgesanyresistance• Aidsintheassessmentofneed,fit,feasibility,capacity
andreadiness.
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.
Stakeholdersareanyonewhoisaffectedbyorisinvolvedinthedevelopmentofanddeliveryofguidelines/projects.Theyincludepatients,public,clinicians,managers,professionalbodies,unions,educatorsandpolicymakers.
17Implementation Guide and Toolkit for National Clinical Guidelines
Collaborate Two-wayengagementwithjointlearning,decision-makingandactions;
partnerintheprocess
Involve Two-wayengagementwithlimitstotheirresponsibility;
theyarepartoftheprocess.
Consult Morelimitedpartoftheprocess–involved,butroleislimited–stakeholdersareasked
questionsandtheyrespond
Inform Usingpullcommunication(informationismadeavailableandonusisonstakeholdertofind
it)orpushcommunication(informationisactivelybroadcastedtostakeholders)
Levels of Stakeholder Engagement. From Centre for Effective Services, 2017 [25]
Effor
tN
umbers
Itisalsoimportanttorecognisethat,whenimplementingguidelines,groupsofstakeholdersmaybeverydiverse,dependingonspecificlocalcontexts.ThismeansthatGuidelineGroupsmayfocusonhigh-levelstakeholders,anddetailedstakeholderengagementplanningmaybemoreeffectiveatalocallevel.
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:
• Dignityandrespect• Support• Transparencyandopenness• Learningandresponsiveness• Inclusivity,fairnessanddiversity• Sustainability• Collaborationandpartnership.
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].
Thebasicquestionstobeansweredbyaneedsassessmentare[27]:• Whatarethegaps?• Whatiscausingthem?• Whatcanwedotofixit?
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.
TheHexagonToolisalsoaveryusefulwayforGuidelineGroupstobeginconsideringoutcomesandcanbeconsideredasanintroductoryexerciseindevelopingalogicmodel.
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
serviceorclientoutcomeswhichmayfollow(becauseaninterventionisunlikelytobeeffectiveunlessimplementedwell).
Thediagrambelowpresentsataxonomyofimplementationoutcomes,serviceoutcomesandclientoutcomes.Thisisfollowedbyfurtherdetailsonimplementationoutcomes.
Implementation Outcomes
AcceptabilityAdoption
AppropriatenessCosts
FeasibilityFidelity
PenetrationSustainability
ServiceOutcomes
EfficiencySafety
EffectivenessEquity
Patient-centerednessTimeliness
ClientOutcomes
SatisfactionFunction
Symptomatology
Taxonomy of Outcomes. From Proctor et al., 2010 [28]
Outcomesareintendedorunintendedchangesthatoccurasaresultofimplementinginterventions.Thesechangescanoccuratthelevelofindividuals,groups,organisationsorpopulation,andcanoccurintheshort-,medium-orlong-term.
20 Implementation Guide and Toolkit for National Clinical Guidelines
Implementation Outcome
Description Other terms
Acceptability Theperceptionamongstakeholdersthataninterventionisagreeable,palatableorsatisfactory.
Content;comfort;credibility
Adoption Theinitialdecisiontoemployanintervention. Uptake;utilisation;intentiontotry
Appropriateness Theperceivedfit,relevanceorcompatibilityofanintervention.
Perceivedfit;compatibility;suitability;practicability
Feasibility Theextenttowhichaninterventionmaybecarriedoutwithinagivensetting.
Actualfit;suitabilityforeverydayuse;practicability
Fidelity Thedegreetowhichaninterventionwasdeliveredasdescribed.
Deliveredasintended;adherence;integrity;qualityofdelivery
Cost Thecostimpactoftheimplementationactivities;bothduetothecostofdeliveringanintervention,andthecomplexityoftheimplementation.
Cost-effectiveness;cost-benefit;marginalcost
Penetration Theintegrationofaninterventionintoaservicesettinganditssub-systems.
Institutionalisation;spread;serviceaccess
Sustainability Theextenttowhichaninterventionisinstitutionalisedwithinaservice’songoingoperations.
Maintenance;continuation;durability;incorporation;integration
Tips for identifying desired outcomes: • A range of outcomes relating to implementation, service delivery and clients should be
considered.• Identifywhichoutcomesareachievableintheshort-term,andwhicharemoremedium-or
long-termoutcomes.• Forclinicalguidelines,wellthought-outandarticulatedoutcomesareusefully includedina
logicmodel,formingoneofthefirststepsinalogicmodel’sdevelopment.Beforegoingstraighttothelogicmodel,theHexagon Tool(Tool1)helpstostartthinkingaboutdesiredoutcomes.
• 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
Standardisationofcharts
Teamwork
E-learningprogrammemandatory
Chartsarestandardisednationally.
Enhancedteamworkacrosshealthcareteams.
E-learningprogrammeincorporatedintomandatorytrainingrequirements.
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.
Input X Output Y Outcome Z
Theoverall TheoryofChangecanbe simplybrokendown intoa seriesof ‘if-then’ relationships,wherebyeachstep/relationship shouldbe informedbyexistingevidenceabouthowneedsariseandhowchangeisachievedinprevioussteps/relationships.
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
Theseriesof‘if-then’relationshipsandoutcomesthatexpresstheprogramme’stheoryofchangeformtheunderlyingbasisofaLogic Model.ThelogicmodelfurtherdescribesandelaboratesontheTheoryofChange,allowingstakeholderstosystematicallyworkthroughconnectionsbetweentheessentialcomponentsofguidelines,usuallyonasinglepage.
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.
However,toomanychanges,especiallyifthesearereactive,canunderminethevalueofthelogicmodel.Therefore,alogicmodel,particularlyifverycomplex,isbestseenasahigh-levelstatementwhichrequiresaseparate,andmoredetailed,implementationplan(tobedevelopedinstage2).
Monitoring and Evaluation
Situation Analysis Inputs Activities/
OutputsShort-term Outcomes
Evidence
Long-term Outcomes
Thebasicoutlineofalogicmodelisshownabove.ItshouldbecompletedbyGuidelineGroupsinthefollowingsequenceofsteps:
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)
• Keepsfocusonsharedgoals• Improvesevaluationandwhat
variablesgetmeasured
23Implementation Guide and Toolkit for National Clinical Guidelines
• Whatdoweneedtoimprove?• Whatarethesocio-economicinfluences?
2. Outcomes:Asdescribedabove, those responsible fordevelopmentand implementationofguidelinesshouldaskwhatspecificchangesaredesiredintheshort-,medium-andlong-term.Thesecanincludechangesinknowledge,behaviour,practice,decision-making,policies,socialaction,condition,statusetc.Long-termoutcomesarethedesiredend-result,andshort-termoutcomesmayormaynotbecumulativestepsorcontributionstothelong-termoutcomes.
3. Outputs/Activities:Thesearekeyareasofworkthatwillhelptoachievethedesiredoutcomes.Theyincludespecifictargets(e.g.,numbersofpeopletrainedorqualified,resources,reports,newprocessesandstructures),aswellasclearstatementsabout:• Whatwillbedone?(typesofactivities)• Whowillbereached?(clients,providers,beneficiaries,otheragencies)• Whereitwillhappen?• Whenandhowoftenhowitwillhappen?• Howitwillhappen?
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.
Morethanothersectionsofthelogicmodel,themonitoringandevaluationsectionshouldbehigh-level,withspecificconcernsaboutdataandmethodologydealtwithindetailduringplanningforMonitoringandEvaluation,whichiscoveredinmoredetailinlatersectionsofthisGuide.
6. Evidence: Thisshouldunderpinallaspectsof the logicmodeland involves takingdataandevidencefromresearch,audit,experience,policy,consultation,andongoingmonitoringandevaluationprocessesto:• Informunderstandingofproblems
24 Implementation Guide and Toolkit for National Clinical Guidelines
• Identifydesiredoutcomes,andhowtheymaybeeffectivelyachieved• Devisingwaysofmonitoringandevaluatingprogress.
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:
1. Multiple logic models,witheachpertainingtoadifferentelementoftheintervention.Thismaybeparticularlyhelpfulinthecaseofclinicalguidelines,whichoftencontainamultitudeofdifferentrecommendationsthatarenotalwayseasytogrouptogether.
2. Nested Logic Models,witheachbeingapplicableatdifferent levelsofservicedelivery(e.g.national,hospital,service).Thismayhelptoincreaseclarityateachlevel,aswellasallowingguidelinegroupstotailorandadaptthelevelofdetailincludedineachlogicmodel.
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
Mon
itorin
g an
d Ev
alua
tion
•Th
eAn
nualSep
sisRep
ortw
illre
view
HIPEda
tato
assessfrequ
encyand
cha
racteristi
csofsep
sispresentati
ons,and
sepsisassociated
morbidityand
mortalityinIrelan
d.•
SepsisAu
dits,K
eyPerform
anceIn
dicators,and
balan
cing
mea
sures.
Logi
c M
odel
for N
ation
al C
linic
al G
uide
line
– Se
psis
Man
agem
ent
Situ
ation
Ana
lysi
s•Sepsisisalead
ingglob
alhea
lth&
finan
cialburde
n•Irish
dataon
sepsis(201
6):
o14
,804
casesofsep
sis
oIn-hospitalm
ortalityrate18.5%
oCriticalcareho
spita
lmortality
rate31.3%
o67
%in
crea
sein
docum
ented
sepsiscasess
ince201
5o
50%ofb
eddaysu
sedby
patie
ntsw
ithinfecti
on/sep
sis
diagno
siso
Sepsiscontrib
utesto
25%
ofa
llho
spita
ldeaths
•Allsep
sispati
entssh
ouldbe
provided
with
thebe
stopp
ortunity
tosu
rvivesepsis
•Prob
lemsw
ithaccuracyofHIPE
recordingofse
psiscases
•New
internati
onaldefi
nitio
nof
sepsis;Sep
sis-3
•Va
riatio
ninpracti
ce•Clinicaldecision
supp
orttoo
ls(CDS
T)–upd
ateofexisting
Sep
sis
Form
sand
new
Sep
sisFormsfor
paed
iatrics,obs,G
Ps,residen
tial
care
•Nee
dforS
epsis
Predicti
onM
odel
Inpu
ts•Gu
idelineDe
velopm
ent&
Im
plem
entatio
nGrou
p•SepsisStee
ringCo
mmittee
•HS
E:QID
•HS
E:NAS
/HPO
/ICT
•Nati
onalSep
sisTe
am•SepsisAD
ONfo
reachHo
spita
lGrou
p•SepsisCo
mmittee
s–Local&
Hospita
lGroup
Level
•Ho
spita
lman
agem
ent
•Labo
ratory&Nati
onalM
edical
Labo
ratoryIn
form
ation
System
(Med
LIS)
•Med
ical&Nursin
glead
inevery
hospita
l•Alliedhe
althcareprofessiona
ls•SepsisCh
ampion
sinPrim
aryCa
re
•Re
siden
tialcarestaff
•Und
ergrad
uatecolleges–
nursin
gan
dmed
ical
•Stati
stician
•An
nualSep
sisSum
mit
•An
nualSep
sisRep
ort
•Sepsispo
rtalonHS
Eweb
site
•CD
STs
•Lactatepo
int-o
f-care(POCT
)de
vices
•Do
H–NCE
C/HR
B-CICE
R
Activ
ities
/Out
puts
•Co
mmun
icati
on&eng
agem
ent
with
keystakeh
olde
rs•
Dissem
inati
onand
commun
icati
onofn
ewse
psis
defin
ition
s&re
commen
datio
ns•
Developm
ento
fsep
sisedu
catio
nprog
rammes(a
dult,pae
ds,o
bs,
GP)
•Ro
utine
sepsisscreen
ingfor‘at
risk’and
suspectedsepsiscases
•De
liveryofapp
ropriate
treatm
enta
ndtimelyescalatio
nofcare(ifre
quire
d)•
Deliveryofedu
catio
nprog
rammes
oAv
ailableon
HSELand
as
eLea
rningprog
ramme
oGrou
pAD
ONsa
vailableto
provideed
ucati
onatlocallevel
oEd
ucati
onre
sourcesa
vailable
onSep
sisW
ebsite
•De
velopm
ento
fCDS
Tforp
aeds,
obs,GPsand
resid
entia
l•
Developm
ento
fpati
ent
inform
ation
leafl
ets&
postersfo
rweb
site
•Bu
sinessc
aseforp
aediatric
AD
ON
•De
velopm
ento
fsep
sisaud
ittoolsa
ndsc
hedu
leofa
udit
•Nati
onalaud
itsperform
edby
SepsisAD
ONs
•Bi-ann
ualSep
sisSteering
Committee
mee
tings
•SepsisAD
ONsliaising
betwee
nlocalsite
s&Nati
onalSep
sis
Team
•De
velopm
ento
fmon
thlyKPIsfor
seps
is•
Educati
onofH
IPEcode
rs
Out
com
esSh
ort-t
erm
out
com
esIm
plem
enta
tion
Out
com
es•
Sepsisgu
idelinewidely
dissem
inated
&in
usein
all
clinicalareas/areasofcare
•Allstaffun
derstand
thene
w
sepsisde
finition
sand
its
man
agem
ent
•Pathwayso
fcarearefeasible
•Prog
rammeofedu
catio
nestablish
edfo
rund
ergrad
uate
andqu
alified
staff
•Ed
ucati
onprogram
mede
emed
man
datoryata
nati
onallevel
Serv
ice
Out
com
es•
Useofa
ppropriateCDS
Ttoaid
timelydiagno
sisand
treatm
ent
•CD
STwidelyavailableinall
clinicalareasto
aiddiagn
osis&
treatm
ent
•Sepsisde
finition
swidelyused
&
documen
tedbyallstaff
•Increa
sedaccuracyofcod
ingfor
allsep
siscases
•Be
tterc
ommun
icati
onacrossa
llhe
althcarete
ams&
professiona
ls•
Decrea
sedaverageLeng
thof
Stay(LOS)fo
rpati
entswith
se
psis
•Im
proved
recogn
ition
and
treatm
entforpati
entsin
all
clinicalse
tting
s•
Discha
rgefollo
w-upprovided
for
patie
ntsw
ithse
pticshock
Clie
nt O
utco
mes
•De
crea
sedmortality&m
orbidity
associated
with
sepsis
•De
crea
sedincide
nceofse
psis
andsepti
cshock
•Re
ducti
onofa
dverseoutcomes
Long
-term
out
com
esIm
plem
enta
tion
Out
com
es•
Nati
onalado
ption
ofg
uide
line
with
fide
lity
•Useofthe
nati
onalguide
lines
isem
bedd
edacrossa
llservice
area
s•
Allspe
cialtie
sarere
presen
tedon
theNati
onalSep
sisTe
am•
Paed
iatricADO
Nin
post
•NOCA
nati
onalaud
itofIC
U
patie
ntsw
ithse
pticshock&
databa
sein
place
Serv
ice
Out
com
es•
Decrea
sedaverageLO
Sforsep
sis
patie
nts
•Safera
ndequ
itablesepsiscare
fora
llpa
tientsw
ithse
psis
•Im
proved
accuracyofre
cording
ofse
psiscases
Clie
nt O
utco
mes
•De
crea
sedmortality/morbidity
associated
with
sepsis
•Im
proved
qua
lityoflifefo
rpa
tientsfollowingsepsis
•Im
proved
pati
enta
ndfa
mily
satisfacti
onwith
carereceived
Evid
ence
: Systemati
creview
oflite
ratureonde
tecti
onand
man
agem
ento
fsep
sis;Interna
tiona
lguide
lines;T
hirdIn
ternati
onalCon
sensusDefi
nitio
nsfo
rSep
sisand
Sep
ticSho
ck(JAM
A20
16);Su
rvivingSepsisCa
mpa
ign:
Internati
onalGuide
lines
forM
anagem
ento
fSep
sisand
Sep
ticSho
ck:2
016;Expertreview;B
udgetimpa
ctana
lysis
;Ann
ualSep
sisRep
orts;H
IPEda
ta.
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
developinfrastructureforimplementation• Developingleadershipforimplementation• Monitoringandevaluationplanning• Trainingandcapacitybuilding• Sustainabilityplanning.
Itisworthrememberingthatwhiletheseactivitiesaremostsuitableduringstage2,theymaystillbeusefulforGuidelineGroupsatotherstagesofimplementation.
Thekeytoolsthatshouldbeusedduringthissecondstageofimplementationare:• Implementationenablersandbarriersassessmenttool(Tool3)• Implementationplantemplate(Tool4)• MonitoringandevaluationofimplementingNationalClinicalGuidelines–PlanningTool(Tool
5).
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.
• Leadership engagement– leaderscancreatereadinessbyconsultingallstakeholders inthedecision-makingprocess,bygivingcleardirectiononthechange,andbyacknowledgingandvalidatinganyconcerns.
• Securingaccess to resourcesneededtoimplementguidelines–theimplementationplanmustbecosted,andaBudgetImpactAssessmentcarriedout,tobesubmittedthroughtheserviceplanningprocess.
Implementation Readinessreferstotheextenttowhichorganisationsandindividualsareboth‘willing’to,and‘capable’of,implementinganyspecificintervention[32]
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
developing,evaluatingand implementingcomplex interventions’,whichoutlines fourcomponentsofreadiness,andalistofquestionsforimplementersthatarerelevanttoeachcomponent:
http://www.lenus.ie/hse/handle/10147/142753
• The Checklist to Assess Organizational Readiness (CARI) created by Barwick (2011)addresseseightdifferentfactorsrelatingtoreadinessinorganisations:
http://www.effectiveservices.org/resources/article/checklist-to-assess-organisation-readiness
• Other resources and measures for assessing implementation readinessareavailableandlistedontheCaliforniaEvidence-BasedClearinghousewebsite:
http://www.cebc4cw.org/implementing-programs/tools/measures/
30 Implementation Guide and Toolkit for National Clinical Guidelines30 Implementation Guide and Toolkit for National Clinical Guidelines
Assessing Enablers and Barriers
Implementation Enablers
Stakeholder consultation and buy-in
Involvingclinicians,thepublic,patients,administratorsandpolicymakers,amongothers,asearlyaspossibleandthroughoutthedevelopmentandimplementationprocesshasseveralbenefits:ithelpscreateawareness;itgeneratescontinuedbuy-in;itidentifiesandacknowledgesanyresistance;anditaidsintheassessmentofneed,fit,feasibility,capacityandreadiness.TheNCECPublicInvolvementFramework[26]includestoolstoassistinvolvingthepublicinclinicaleffectivenessprocesses.
Leadership Havingatleastonechampionimprovesthelikelihoodofimplementationsuccess[22].Championsareearlyadoptersofchange,providingvisionandsupporttoindividualstaffandtheorganisationasawhole.
Resources Itisimportanttohaveanaccuratecalculation(aspartofaBudgetImpactAnalysis)ofthecostsandcosteffectivenessofdesigning,implementinganddeliveringaguideline.Oncecosthasbeendetermined,securingappropriateresources,wherenecessary,throughtheserviceplanningprocessisrequiredforsuccessfulimplementation.ToolstoassistwithBudgetImpactAssessmentandEconomicEvaluationareavailableontheNCECwebsite:http://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/ncec-processes-and-templates/
Implementation teams
Implementationteamsoverseeandattendtomovingguidelinesthroughthestagesofimplementation.Theseteamsmakeuseofactivestrategiestodrivesuccessfulimplementationandshouldbemadeupofmembersfromarangeofdisciplinarybackgroundswithspecificexpertiseinrelevantinterventionsorinimplementingchange.TheremaybesignificantoverlapinmembershipbetweentheoriginalGuidelineDevelopmentGroupandtheImplementationTeam(s).Inadditiontoanationalimplementationteam,furtherimplementationteamsmayalsobeestablishedtodriveimplementationinspecificsettings.
Implementation plan
Allowingtimeforplanninghowguidelineswillbeimplementediscrucialinensuringsuccessfuloutcomes.Byinvolvingmultiplestakeholdersinplanningatanearlystageoftheimplementationprocess,potentialhurdlescanbemoreeasilyanticipatedandovercome.Italsoincreasesaccountabilityamongrelevantstakeholders.Animplementationplanincludesthespecificactionstoimplementtheguidelinerecommendations,detailsofwhoisresponsible,timelinesfordeliveryandoutcomemeasurements.
Staff capacity Thosewhoareresponsiblefortheimplementationofaspecificinterventionmusthavethecapacitytodeliverit.Therefore,developingandkeepingthiscapacityispivotalinensuringdesiredoutcomesareachieved.Staffcapacitycanbeattainedthrough:carefullyallocatingstaff;deliveringqualitytraining;andprovidingongoingsupport,suchascoachingandmentoring.
31Implementation Guide and Toolkit for National Clinical Guidelines 31Implementation Guide and Toolkit for National Clinical Guidelines
Implementation Enablers
Organisational support
Supportiveorganisationalstructures,systems,policiesandproceduresthatalignwithandsupportguidelinesareimportantforsuccessfulimplementation.Examplesinclude:proceduresforinternalgovernanceanddecision-making;andhumanresourcestomanageresistancetochange.
Supportive organisational culture
Organisationalcultureincludesthenorms,valuesandbeliefsthatexistandgovernbehaviourwithinanorganisation.Itisnecessarytocreateasupportiveculturesothatspecificinterventionscansuccessfullybecomeembeddedintheorganisationthrough:championscommunicatingastrongvisionforchange;supportingpositiverolemodels;andongoingtrainingandsupport.
Communication Ongoingandopencommunicationwithandbetweenstaffiscrucialinsuccessfulimplementationforseveralreasons:ithelpsmotivatestaffandovercomeresistance;providesamechanismforfeedbackanddealingwithconcerns;andhelpstobuildtrustandmorale.
Monitoring and evaluation
Collectingandinterpretinginformationaboutimplementationandotherkeyoutcomesisessentialindeterminingwhetherguidelinesarebeingsuccessfullyimplemented.Thisinformationhelpstoinformfutureactionsandincreaseefficiency.
Learning from experience
Theuseofdataandinformationtoimprovebothspecificinterventionsandtheguidelineimplementationprocessisvitalforimplementationsuccess.Doingthiseffectivelyhelpstoidentify‘quickwins’,buildcredibilityandsupport,andenablescontinuousimprovementcycles.
Implementation Barriers
External environment
Theexternalenvironment canreduceimplementationsuccessifexistingstructuresarenotinlinewithguidelines.Forexample,shortpolicyandfundingcyclesmayinterferewiththeimplementationprocessbymakingitmoredifficulttosecurelong-termengagementandbuy-in.
Resistance to change
Resistancetochange fromthosedeliveringspecificinterventionscanundermineimplementationeffortsandreducetheprobabilityofsuccess.Resistanceiscommonlygeneratedif:stakeholdersfeeltheyhavenotbeenconsulted;changesareimplementedbeforestakeholdersareready;implementationisperceivedasoccurringthroughcoercionorcontrolfromleadership;theorganisationalcultureisnotalignedwiththeguideline;orappropriategovernancestructurestosupportguidelineimplementationarenotputinplace.
Vested interests Vestedinterestsofstaff,managers,lobbygroups,andotherprofessionalbodiesmayinterferewiththeimplementationprocessiftheyareincongruentwiththeguidelines.Thiscanoccurthroughstakeholdersblockingtheimplementationprocessoralteringitinanew,lessproductivedirection.
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:
• Assessmentofimplementationreadiness• Developmentofaone-pagelogicmodel,includingsituationanalysis,inputs,activities/outputs
andoutcomes• Assessmentofenablersandbarriers• Identificationof specificbehaviour changeor change in currentpractice required (i.e.who
needstodowhatdifferentlyinorderforthisrecommendationtobeimplemented?)• Clearlydocumentingbaseline/currentstatusandanyassumptionsbeingmade• IncludinganyadditionalresourcesrequiredintheBudgetImpactAssessment.
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
timeframeforcompletion;andsomedetailonexpectedoutcomesandhowtheywillbeverifiedormeasured.Itcanalsoincludeimplementationenablersandbarriers,someofwhichwillbecommontomultiplerecommendations.
Guideline recommendation or number(s)
Implementation enablers/barriers/gaps
Action/intervention/task to implement recommendation
Lead responsibility for delivery of the action
Timeframe for completion
Expected outcome and verification Year 1 Year 2 Year 3
ImplementationPlanningTools• TheabovetemplateiscontainedinanImplementation Planning Tool (Tool 4) Completed
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
• Thefollowingpagescontainaworked exampleofanimplementationplancompletedbytheOvarianCancerGuidelineDevelopmentGroup.
• 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]
34 Implementation Guide and Toolkit for National Clinical Guidelines34 Implementation Guide and Toolkit for National Clinical GuidelinesIm
plem
enta
tion
Plan
– O
varia
n Ca
ncer
Gui
delin
e
Guideline
recommen
datio
nor
numbe
r(s)
Implem
entatio
nen
ablers/
barriers/gap
sAc
tion/interven
tion/taskto
im
plem
entrecom
men
datio
nLead
respon
sibilityfo
rde
liveryofth
eactio
nTimeframefor
completi
onExpe
cted
outcomean
dverifi
catio
n
Year1
Year2
Year3
Reco
mm
enda
tion
#1Inpati
entswith
suspectedovarian
carcinom
a,a
combina
tionof
tran
sabd
ominal
andtran
svaginal
ultrasou
ndsh
ould
beperform
edand
interpretedusingthe
IOTA
simplerules
incon
junctio
nwith
clinicalassessm
ent.
Enab
ler:
Nati
onalCan
cerS
trategy
Recommen
datio
n#1
4(Cap
italPlan).
Barr
ier:
Accessto
tran
svaginal
ultrasou
ndequ
ipmen
t.
•Assessth
eavailabilityof
ultrasou
ndequ
ipmen
t,includ
ingsterilisatio
neq
uipm
ent.
•Assesswaitin
gtim
esfo
rte
sts
HSEClinical
Prog
rammefor
Radiolog
y
XO
utco
me:
Allw
omen
with
suspectedovariancancerwill
havetimelyaccessto
tran
svaginalultrasou
nd,
carriedou
tbyexpe
rienced
personn
el.
Tran
svaginalultrasou
ndwillprovide
greater
sensitivityfo
rdiagn
osingovariancancer.
Verifi
catio
n:Co
mpleted
assessm
ento
fequ
ipmen
tand
waitin
gtim
es.
Securere
sources/fund
ing*fo
r•
Equipm
ent:Ad
ditio
nal
ultrasou
ndequ
ipmen
t+
replacem
ent/m
ainten
ance.
(Thisa
ction
willbeba
sedon
theresultsofthe
equ
ipmen
tassessmen
t)
NCC
P&Hospital
Grou
psX
Verifi
catio
n:Eq
uipm
entinplace.
Accessto
diagn
ostic
s.
Enab
ler:
Nati
onalCan
cerS
trategy,
Recommen
datio
n#1
0,16
&50
(radiolog
ytraining
,consultantstaffi
ng,w
orkforce
plan
ning
).
Barr
ier:
Limite
davailabilityof
approp
riatelytraine
dstaff
.
Assessth
ecurren
tnum
ber
ofpersonn
elwith
specialist
training
inso
nograp
hy.
HSEClinical
Prog
rammefor
Radiolog
y
XVe
rifica
tion:
Completed
workforceassessm
ent.
Securere
sources/fund
ing*fo
r•
Training
:Spe
cialisttraining
ofra
diolog
ystaff
.•
Staffi
ng:P
ersonn
elwith
specialisttrainingin
sono
grap
hy.
(Thisa
ction
willbeba
sedon
theresultsofthe
workforce
assessmen
t).
NCC
P&Hospital
Grou
ps&HSEClin
ical
Prog
rammefor
Radiolog
y
XVe
rifica
tion:
Staff
inplace.
Training
provide
d/staff
training
records.
*Fun
ding
requ
irem
ents
incl
uded
in B
udge
t Im
pact
Ass
essm
ent,
for s
ubm
issio
n in
the
HSE
finan
cial
esti
mat
es/s
ervi
ce p
lann
ing
proc
ess
35Implementation Guide and Toolkit for National Clinical Guidelines 35Implementation Guide and Toolkit for National Clinical GuidelinesGu
ideline
recommen
datio
nor
numbe
r(s)
Implem
entatio
nen
ablers/
barriers/gap
sAc
tion/interven
tion/taskto
im
plem
entrecom
men
datio
nLead
respon
sibilityfo
rde
liveryofth
eactio
nTimeframefor
completi
onExpe
cted
outcomean
dverifi
catio
n
Year1
Year2
Year3
Reco
mm
enda
tion
#2CT
thorax,abd
omen
an
dpe
lviswith
oral
andintraven
ous
contrastis
recommen
dedfor
thestagingofovaria
ncancer.
Reco
mm
enda
tion
#4Forp
atien
tswith
ahigh
suspicionof
relapseofovaria
ncancereith
erclin
ically
orbiochem
ically,CT
thorax,abd
omen
and
pe
lvisisrecommen
ded
asth
efirstline
im
agingtest.
Enab
ler:
Nati
onalCan
cerS
trategy
Recommen
datio
n#1
4(Cap
italPlan).
Barr
ier:
Accessto
Com
puterised
Tomog
raph
y(CT).
•Assessth
eaccessto
CT.
•Assessth
ewaitin
gtim
esfo
rCT
HSEClinical
Prog
rammefor
Radiolog
y
XO
utco
me:
Allp
atien
tswith
ovaria
ncancerwillhavetim
ely
accessto
CT.
Allp
atien
tswith
ahighsuspicionofre
lapseof
ovariancancerwillhavetim
elyaccessto
CT.
Verifi
catio
n:Co
mpleted
assessm
ento
fCTeq
uipm
enta
nd
waitin
gtim
es.
Securere
sources/fund
ing*fo
r•
Equipm
ent:Ad
ditio
nalC
Ts.
Thisactio
nwillbeba
sedon
theresultsofthe
equ
ipmen
tas
sess
men
t
NCC
P&Hospital
Grou
ps&HSEClin
ical
Prog
rammefor
Radiolog
y
XVe
rifica
tion:
Equipm
entinplace.
Accessto
diagn
ostic
s.
Reco
mm
enda
tion
#3IftheCT
is
inde
term
inate,
patie
ntss
hould
bedisc
ussedata
multid
isciplin
aryteam
mee
ting.
Enab
ler:
Nati
onalCan
cerS
trategy
Recommen
datio
n#1
3multid
isciplin
aryteam
mee
ting.
Barr
ier:
Availabilityofim
agingfor
discussio
natm
ultid
isciplin
ary
team
mee
ting.
Prep
arati
onofa
Stand
ard
Ope
ratin
gProced
ure(SOP)fo
rovariancancerm
ultid
isciplin
ary
team
mee
ting.
NCC
P&Hospital
Grou
psX
Out
com
e:
Patie
ntsd
iagn
osed
with
ovaria
ncancer
willhavetheirc
aseform
allydisc
ussedata
multid
isciplin
aryteam
mee
ting.
Verifi
catio
n:KP
I12Ca
ncerStrategy:Ensurethatpati
ents
haveth
eirc
asediscussedatam
ultid
isciplin
ary
team
mee
ting.
SOPisde
velope
dan
davailable.
*Fun
ding
requ
irem
ents
incl
uded
in B
udge
t Im
pact
Ass
essm
ent,
for s
ubm
issio
n in
the
HSE
finan
cial
esti
mat
es/s
ervi
ce p
lann
ing
proc
ess.
For
full
impl
emen
tatio
n pl
an, s
ee p
ublis
hed
guid
elin
e.
36 Implementation Guide and Toolkit for National Clinical Guidelines36 Implementation Guide and Toolkit for National Clinical GuidelinesG
over
nanc
e an
d Im
plem
enta
tion
Team
Gov
erna
nce:Governa
nceofth
egu
idelineisprovided
byamultid
isciplin
aryStee
ringGrou
pchairedbyth
eDirectorofthe
NCC
P.M
embe
rshipinclud
esre
presen
tativ
esfrom
allrelevant
disciplin
esand
thechairsofe
achCa
ncerGuide
lineGrou
p.The
group
mee
tsqua
rterlyto
assessp
rogress,provide
oversightand
lead
ershipto
guide
linegrou
ps,add
ressanyque
riesa
ndto
en
sureth
egu
idelinede
velopm
enta
ndim
plem
entatio
nprocessu
sesa
neviden
ce-based
app
roach.
TheSu
rgicalGyn
aecologyOncolog
yClinicalLea
dsgroup
wasestab
lishe
din201
2toensurethatth
esevencentresd
esigna
tedforS
urgicalG
ynae
cologyOncolog
ybu
ildonrobu
stlo
calclin
ical
governan
cearran
gemen
ts,toop
erateasacoh
esivena
tiona
lclin
icalnetworkforc
linicalaud
it,sh
aringofgoo
dpractic
ean
dprob
lemso
lving.
Impl
emen
tatio
n Te
am:A
Steering/Im
plem
entatio
ncommittee
hasbee
nsetu
pbyth
eNCC
Pan
dtheHS
Etoguide
theim
plem
entatio
nofth
isGu
ideline.The
Steering/Im
plem
entatio
nGrou
pinclud
esallrelevantstakeh
olde
rsin
clud
ing–pa
tholog
ists,ra
diolog
ists,gyn
aecologyoncolog
ists,palliativ
ecare,h
ospitalm
anagers,nursin
g,IC
T,inform
atics,lab
oratoryscienti
sts,pati
ents
andarepresen
tativ
efrom
theNCC
P.Im
plem
entatio
nwillbesupp
ortedbyth
eorganisatio
nsth
atarere
presen
tedon
theGu
idelineGrou
p,whichin
clud
etheFaculty
ofR
adiologists,Royal
CollegeofS
urgeon
sinIre
land
,The
FacultyofP
atho
logistsR
oyalCollegeofP
hysic
iansIrelan
d,Nati
onalLea
dClinicianforH
ered
itaryCan
cera
ndPati
entA
dvocateGrou
ps.
Diss
emin
ation
and
com
mun
icati
on p
lan
TheGu
idelinewillbecirculated
and
diss
eminated
throug
htheprofessio
naln
etworkswho
partic
ipated
indevelop
ingan
dreview
ingthisgu
ideline(HSEClin
icalProgram
mesin
Surgery/
Radiolog
y/Patholog
y/Palliati
veCare,RCS
I,Faculty
ofS
urgery/Rad
iology/Patho
logy,H
SEPati
entF
orum
,IrishCa
ncerSociety,C
ancerC
areWeste
tc.).The
guide
linewillalso
beavailablevia
theNCE
Can
dNCC
Pweb
sites.
Adissem
inati
onstrategyhasbee
nprep
ared
and
theGu
idelinewillbeoffi
ciallylaun
ched
and
circ
ulated
toallrelevantfa
cultiesand
collegesfordiss
eminati
onto
theirm
embe
rs.The
NCC
Pwillco-ordina
tewith
HSECom
mun
icati
onstodistrib
ute,sh
arean
ddissem
inatethroug
hthemed
ia(H
SEBroad
cast,H
ealth
Matt
ers,and
Twitter).The
implem
entatio
nofth
eGu
idelinewill
alsobesupp
ortedbycom
mun
icati
on,trainingan
ded
ucati
on.
Impl
emen
tatio
n to
ols:
The
follo
wingim
plem
entatio
ntoolsa
reavailableon
theNCC
Pweb
siteathttps://w
ww.hse.ie
/eng
/services/list/5/cancer/nccp/
•GP
Referralguide
linean
dreferralfo
rm:
oOvaria
ncancerGPRe
ferralGuide
lineforsym
ptom
aticwom
eno
Ovaria
ncancerGPRe
ferralfo
rmfo
rsym
ptom
aticwom
en•
Book
let-NCC
P(201
8)Sexua
lwellbeing
afte
rbreasto
rpelviccancertreatm
ents-agu
ideforw
omen
•Algo
rithm
sforclin
iciansavailableinth
egu
ideline:
oStagingalgo
rithm
forp
atien
tswith
suspectedovariancancer
oStagingalgo
rithm
forp
atien
tswith
suspectedrecurren
ceofo
varia
ncancer
•Cliniciangu
idan
cedocum
ent-Hea
lthServiceExecutiv
eGu
idan
cefo
rdecon
taminati
onofsem
i-criti
calu
ltrasou
ndprobe
s;se
mi-invasivean
dno
n-invasiv
eultrasou
ndprobe
s(https://
www.hse.ie
/eng
/abo
ut/w
ho/qid/nati
onalsafetyprog
rammes/decon
taminati
on/ultrasou
nd-probe
-decon
taminati
on-guida
nce-feb-17
.pdf)
•HS
Epo
licytoguide
staff
-Nati
onalCon
sentPolicy20
17https://w
ww.hse.ie
/eng
/abo
ut/w
ho/qid/other-qua
lity-im
provem
ent-p
rogram
mes/con
sent/
•Patie
ntinform
ation
oncancergen
eticshttps://w
ww.can
cergen
etics.ie
/•
Training
and
resourcesinEviden
cebased
Practi
ce
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:
• Diversity–doestheteamhaveanappropriatebalanceofperspectives,trainingandexpertise,experience,relationshipsandpriorities?
• Decision-making authority – the implementation team should containmemberswho havetheirowndecision-makingauthorityorhavedirectaccess todecision-makingauthority, sothatdecisionscanbemadeinatimelymanner
• Knowledge –theimplementationteamshouldcontainmemberswhohaveexpertknowledgeofspecificinterventionscontainedwithinguidelines,datause,implementation,andsystemschange.
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
implementation üEnsurefidelitytointerventionscontained
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]
Researchlinkingleadershipandthequalityofhealthcareindicatesaneedforacollectivenetworkofleaders,includingpractitionersatalllevels,distributedthroughoutthehealthcaresystems[34] andpublicinvolvement.Thismayrequiredistributionanddecentralisationofleadershippowertowhereverexpertise,capabilityandmotivationsitinthesystem.
Creatinganorganisationalculturewhereleadersflourishhasbenefitsforbothstaffandtheleadersthemselves:
• If leaders and implementers create positive, supportive environments for all practitioners,thosepractitionersthencreatecaring,supportiveenvironmentsforpatients
• Wherethereisacultureofcollectiveleadership,practitionersarelikelytointervenetosolveproblems,toensurequalityofcareandtopromoteresponsible,safeinnovation.
The following table provides examples of different leadership activities which can supportimplementation[35]:
Relations-oriented behaviours
Change-oriented behaviours Task-oriented behaviours
• Communicatewithpractitionersaboutclinicalissues
• Recogniseeffortstochange• Providereminders• Encourageandsupport
collaborationwithspecialistsandinter-professionals
• Supportchangevisiblyandsymbolically
• Demonstratecommitmenttochange
• Reinforcevisionandgoalsofchange
• Understanddifficultieswithchange
• Advocateforchangeinternallyandexternally
• Advocateforadditionalresourcesorreorganisationofexistingresourcesinternallyandexternally
• Conductregularleadershipmeetings
• Clarifyrolesandresponsibilities
• Monitorperformanceandoutcomes
• Modifycare-plansanddocumentation
• Procureresources,education,trainingandpoliciestoreflectchange
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.
• Monitoringistheroutineandsystematiccollectionofinformationagainstaplan.Itmakesuseofexistingdataandinformationaboutinputs,outputsandoutcomes,oraboutoutsidefactorsaffectingtheorganisationorproject,toinformimprovement.
• Evaluationisaplannedinvestigationofaproject,programme,orpolicyusedtoanswerspecificquestions,oftenrelatedtodesign,implementation,andresults(causeandeffect).
• 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
internationalstandards,orclinicalguidelines• evaluationandaction– reflecting theoutcomeofaudit andwhere indicated, changing
practiceaccordingly(sometimesreferredtoas‘closingtheloop’).
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.
40 Implementation Guide and Toolkit for National Clinical Guidelines40 Implementation Guide and Toolkit for National Clinical Guidelines
Planning for Monitoring and Evaluation – Prompts and Questions
1. What is the purpose(s) of our evaluation? Why do we want to do it?
• Isitabouteffectiveness,efficiency,economy,relevance,implementation,processand/orimpact?
• Isitaboutpopulationchangeorperformanceaccountability?
2. What is the evaluation question(s)? What will we monitor and evaluate?
• Whatisthetheoryofchangeunderpinningtheguidelinesorspecificinterventionstobeevaluated?
• Fromthelogicmodelfortheguideline,whatwillbeprioritisedformonitoringandevaluation?
3. Who will use the learning from the evaluation? How can we involve them from the start?
• Whatindicatorswillweusetoaddressdifferentaudiences?
• Whatmethodswillweuseintheevaluationtoinvolvekeystakeholders?
4. What resources and expertise do we have for our evaluation? What resources do we have/will we need, including outside support?
• Whatisthebudgetfortheevaluation?• What areourexperiencesofevaluation?• What areourskillsandwhatarethegapsthatneed
tobefilled?
5. What is our plan for operationalising the evaluation (tasks, responsibilities, timescales etc.)? How will we do it? When will we do it?
• Whowillmanageandcoordinatetheevaluation?• Howlongwillittake?Dowehaveascheduleof
activities?
6. What are the main challenges? Who will do it, and do they have the right skills?
• Whatstaffwillbeinvolvedandwhattrainingisrequired?
• Howwillwesecureactiveparticipation,engagement,motivation?
7. What is our plan to disseminate and use our learning from the evaluation? What will we do with the information we get?
• Whowillwriteupthefindingsandhelpwithinterpretation?
• What otherstrategiesareneededtodisseminateandsharelearningwithdifferentstakeholders?
• Howwillthefindingsbeusedtoinformqualityimprovements?
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
monitoringandevaluationcommences,andthattheaddedburdenofcollectingandrecordingdataisfeasibleandmanageable.Todeterminewhichstakeholdersshouldbeinvolvedinthemonitoringandevaluationofclinicalguidelines,itisimportanttoestablish[37]:
1. Whoisinvolvedinthedeliveryofthecareorservice?2. Whoisinreceiptof,usesorbenefitsfromthecareorservice?3. Whohastheauthoritytosupportimplementationofanyidentifiedchanges?
IndicatorsItisalsoimportanttoconsiderwhatindicatorscanbefeasiblyandaccuratelyusedtomonitorandevaluateimplementationoutcomes.Toensurethateffortstocollectdataarestreamlinedandthatthedataisrelevant,theseindicatorsshouldbeaction-focused, important, measurable and simple.
Action-Focused Mustbeusedtoinformfuture
actions
Measurable Collectingandanalyzingthe
informationmustbepossiblewithmethodsandresourcesavailable
Important Aswithoutcomes,onlymeasure
whatmatters
Simple Thelanguagemustbeaccessible,
clearandconcise
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]:
Key elements of Sustainability
Questions
Planning for sustainability
• Issustainabilityplanninganactivecomponentofallstagesofimplementation?
• Canexistingservicesintegrateaspecifiedintervention?
Credibility of the evidence
• Arebenefitstoserviceusers,staffandorganisationsvisible?• Isthereevidencethatthistypeofchangehasbeenachieved
elsewhere?
Seeking commitment and support
• Whatleaders/managerssupporttheimplementationofguidelines?• Aretheguidelinescongruentwithotherpolicyobjectives/contextsat
thetime/future?
Engagement and partnerships
• Isthereevidencethatappropriateandinfluentialstakeholders,includingthepublic,areaccepting/supportiveofguidelines?
Programme champions
• Aretherelocal‘champions’topromotethevalueofguidelinesandisinterestlikelytobeongoing?
Fit with organisation • Areguidelinescontributingtotheoverallorganisationalaims?• Is‘fit’assessedinanongoingmanner?
Building capacity – organisational and community
• Arestaffinvolvedintheimplementationofguidelines?• Isthereacapacity-buildinginfrastructuretoensuretheskills
necessarytocontinueimplementationwillexist/remain?
Infrastructure for sustainability
• Havecrucialelementsofguidelinesbeenembeddedintopoliciesandprocedures?
• Arenewrequirementsbuiltintojobdescriptions?
Adaptability • Dostructuresandpoliciesallowsomeflexibilityandevolution,asrequired,tomaintainandimproveoutcomes?
Evaluation • Areoutcomesmeasuredtodeterminecontinuedbenefit?• Isevidenceusedtodevelopandimproveguidelines?• Aretherefeedbackmechanismsinplacetocommunicateresultsand
initiateaction?
Funding • Isfundingavailabletosupportimplementationtoalevelthateffectsaremaintained(orincreased)?
• Whatexistingresourcescanbeleveragedorreorganisedtosupportimplementation?
Policy/economic environment
• Whatchangesareoccurringinthepolicyandeconomicenvironmentthatmayhaveanimpactonguidelineimplementation?
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
theprocess• Seniorandclinical leadershipengagement
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/
Stage 3: Implementing and Operationalising
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
mentoring• Ongoingmonitoringofimplementationoutcomes,serviceoutcomesandclientoutcomes• Usingdataandfeedbackmechanismstoinformongoingimprovements• Adaptingimplementationplansforlocalsettingswhereappropriate.
Itisworthrememberingthatwhiletheactivitieshighlightedaremostsuitableduringstage3,theymaystillbeusefulforGuidelineGroupsatotherstagesofimplementation.
Maintaining Communication Ongoing communication between implementation teams, practitioners, champions, publicrepresentatives,andallotherrelevantstakeholdersisanimportantenablerofimplementationforseveralreasons:
• Communicatingavisionforchangehelpstomotivatestaffandovercomeresistancetochange• Communicationprovidesanimportantmechanismforobtainingfeedback• Opencommunicationhelpstobuildtrustandteamworkbetweenvariousstakeholders,teams
andorganisationsresponsibleforimplementation.
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
burnout• Motivatingandhelpingstafftobuildfluencyandaccuracywitheffectiveskills• Providingtimetoproblem-solve,rehearse,andgetfeedbackabouthowtousepractices• Strengthenstaffcapacitytointegratenewpracticesandtolearnfromexperience• Ensuringimplementationfidelity• Increasingself-confidenceandenhancingprofessionalnetworks.
Coaching and Mentoring Tools and Resources• ForanevidencereviewproducedbyCentreforEffectiveServicesonwhat works in coaching
and mentoring, clickhere: http://effectiveservices.org/resources/article/coaching-and-mentoring-an-access-
evidence-report
• Foraone-pageinfographicproducedbytheCentreforEffectiveServicesthathighlightsthedifferences between coaching and mentoring, clickhere:
http://effectiveservices.org/resources/article/coaching-and-mentoring-table
• TheNCECwebsitehas resources and advice for Guideline Groups, includingvideosfromstakeholderswhohaveexperienceoftheguidelinedevelopmentprocess:
http://health.gov.ie/national-patient-safety-office/ncec/
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
Benefits of ongoing monitoring of outcomes:
• Increaseaccountability• Identifyanddeliver‘earlywins’• Learnaboutactivitiesand
results• Promotereflection• Identifystrengthsand
weaknesses• Ultimately,informfutureactions
andimprovepractice
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.
Somequestionsrelatedtoimplementationthatthisdatacanprovideanswerstoinclude:• Aretheprojectedoutcomeslaidoutintheimplementationplanbeingmet?• Aretheindicatorshighlightedintheimplementationplanprovidingusefulinformation?• Areguidelinesbeingimplementedwithfidelity?• Haveanyrisksemerged?
Formeaningfuldecisionsandactionstoariseoutofthismonitoringprocess:üDatarelatingtoguidelinesmustbecollectedüDatamustbemeasured,analysedandreportedaccuratelyüAppropriatereportingandreviewmechanismsmustbeinplacetodeterminewhetherdesired
outcomesarebeingachievedüDecisionsforactionmustbeclearlyinformedandlinkedtothedataandotherevidence.
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.
Data-Based Decision Making: usingprocessesforcollectingandanalysingdifferenttypesofdatatoguidedecisionstowardsimprovementofprocessesandoutcomesonanongoingbasis.
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
plan,whichcannotbechangedwithoutunderminingeffectiveness.Allcorecomponentsmustbedeliveredwithtotalfidelity.
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.
GuidelineGroupsmayworkwithhealthcareprofessionalsandotherrelevantstakeholdersinlocalsettingstohelpdefinewhichelementsofanimplementationplanmaybeappropriatetoadaptforlocalsettings.Clinicaljudgementinanysuchdecisionsmustbeclearlydocumented.
Best available evidence
Clinicalexpertise
Patientvalues
EBP
Evidence-basedPractice
Stage 4:Full Implementation
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.
Specificactivitiesforimplementingclinicalguidelinesatthisstageinclude:• Evaluatingimplementationoutcomes,serviceoutcomesandclientoutcomes• Engagingincontinuousimprovementcyclestoproducemoreefficientandeffectiveguidelines
EvaluationUpon reaching full implementation, guidelines should be fully operational and integrated intoroutinepractice, i.e.thestandardwayinwhichservicescarryouttheirwork.Thismeansthatallimplementationoutcomes,serviceoutcomesandclientoutcomesarereadytobeevaluated.Thisdiffersfromongoingmonitoringasitislargelysummativeinnature,providingevidenceofwhetherguidelinesarehavingthedesiredimpactonoutcomes.
Appropriatereportingandreviewmechanisms,suchasKPIsandaudit,shouldhavebeenplannedatearlierstagesofimplementation,and,atthispoint,mustbefullyinplacetodeterminewhetherdesiredoutcomesarebeingmet.Havingaccuratedata todemonstratewhether theguideline isbeingimplementedandintendedoutcomesarebeingproducedisofparamountimportance.
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
reactionary.
Continuous Improvement CyclesAcommonlyusedmethodisthePlan-Do-Study-ActCycle(PDSA),whichhasfourphases:
1. Plan: use data to identify barriers andchallengesandspecifytheplantoaddressthem, as well as measures to monitorprogress
2. Do: carry out the plan to addresschallenges
3. Study: use measures identified duringthe planning phase to assess and trackprogress
4. Act:makechangestothenextiterationoftheplantoimproveimplementation.
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.
Adaptable Periphery: elementsofanimplementationplanwhichmaybetailoredtolocalsettingswithoutunderminingtheintegrityoftheinterventionitself.
Barriers: factorswhichhindertheimplementationprocessandreducetheprobabilityofsuccessfulimplementation.
Capacity: the ability or power to do, understand or absorb something. This can apply to anindividual,ateam,anorganisationorawholesystem.
Clinical/healthcare Audit: aprocesstoimprovepatientcareandoutcomesinvolvingadocumented,structuredandsystematicreviewandevaluation,againstclinicalstandards,orclinicalguidelines,and,wherenecessary,actionstoimproveclinicalcare.
Clinical Guidelines: systematically developed statements, based on a thorough evaluation oftheevidence, toassistpractitionerandserviceusers’decisionsaboutappropriatehealthcare forspecificclinicalcircumstancesacrosstheentireclinicalsystem.
Coaching: aformal,typicallyshort-term,arrangementbetweenacoachandanindividualfocusedondevelopingwork-relatedskillsorbehaviours.
Community:agroupofpeoplelivinginaparticularareaorhavingcharacteristicsincommon(e.g.,city, neighborhood, organisation, service agency, business, professional association); the largersocio-political-culturalcontextinwhichanimplementationprogrammeisintendedtooperate.
Consultation: theactionorprocessofformallydiscussingsomethingwithastakeholder–generallyaskingthestakeholderarelevantquestionandreceivingananswertothatquestion.
Context: the set of circumstances or unique factors that surround a particular implementationeffort.Thiscanrefertoboththewider,systemiccontext,aswellasthespecificsettinginwhichaspecificinterventionwillbeimplemented.
Continuous Improvement Cycles: ongoing useofemergingdataandevidenceonoutcomesandimplementationofguidelines,andusingthatinformationtolearnfromexperience,informfutureimplementationandimproveoutcomes.Progressis,therefore,achievedinanincrementalmannerovertime.
Core Components: essential and indispensable elements of implementation, which cannot bechangedwithoutunderminingtheintervention.Allcorecomponentsmustbedeliveredwithtotalfidelity.
Data-Based Decision Making: usingprocessesforcollectingandanalysingdifferenttypesofdatatoguidedecisionstowardsimprovementprocessesandoutcomesonanongoingbasis.
57Implementation Guide and Toolkit for National Clinical Guidelines
Diffusion:theprocessbywhichaninnovationiscommunicatedthroughcertainchannelsovertimeamongthemembersofasocialsystem.Thespreadofideasisgenerallyapassiveprocess,followinganunpredictable,unprogrammed,emergentandself-organisingpath.
Dissemination: an active, negotiated and influenced means of distributing information aboutguidelines.
Enablers: factorswhichincreasetheprobabilityofsuccessfulimplementation.
Evaluation: a planned investigation of a project, programme, or policy used to answer specificquestions,oftenrelatedtodesign,implementation,andresults(causeandeffect).
Evidence-Based Interventions:practices,programmes,policies, strategiesorotheractivities thathavebeenempiricallyshownthroughresearchandevaluationprocessestoimproveoutcomestosomedegree.
Fidelity:deliveringanevidence-basedinterventionexactlyassetoutandintendedbythosewhodevelopedit.
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 Plan: alistofkeyactivities, responsibilities,assumptions,resourcerequirements,risksandotherinformationrequiredtoachievethedesiredoutcomesfromguidelines.
Implementation Readiness: theextenttowhichorganisationsandindividualsareboth‘willing’to,and‘capable’of,implementinganyspecificintervention.
Implementation Science:theformalstudyofmethodsandfactorsthatinfluencehowsuccessfullyspecificinterventionsareincorporatedintoservicesettings,leadingtoimprovedoutcomes.
Implementation Team: a group of stakeholders that oversees and attends tomoving guidelinesthrough the stages of implementation. They actively use strategies and supports to facilitateimplementation.
Intervention: anyevidence-informedpolicy, practice, serviceorprogrammebeing implemented,beitachangetoanexistingpolicy,practice,serviceorprogramme,oranewintervention.
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.
Mentoring: aformalor informalarrangementwhichtypically involvesanongoingrelationshipofsupportforsignificanttransitionsinknowledge,thinkingandskills.
Model: adeliberatesimplificationofaphenomenonoraspecificaspectofaphenomenon.Modelsareintendedtobedescriptiveandneednotbecompletelyaccuraterepresentationsofrealitytohavevalue.
Monitoring: the routineandsystematiccollectionof informationagainstaplan. Itmakesuseofexistingdataandinformationaboutinputs,outputs,outcomes,oraboutoutsidefactorsaffectingtheorganisationorproject,toinformimprovement.
Needs Assessment: aprocesswhich clarifies theextent towhichneeds, aswell as barriers andfacilitatorstomeetthoseneeds,areaccuratelyknownandprioritisedbyanorganisationorgroupofpeople.
Outcomes: intendedorunintendedchangesthatoccurasaresultofimplementinginterventions.Thesechangescanoccuratthe levelof individuals,groups,organisationsorpopulation,andcanoccurintheshort-,medium-orlong-term.
Organisational Culture: thenorms,valuesandbeliefs thatexistandgovernbehaviourwithinanorganisation.
Resources: astockorsupplyofmoney,materials,staff,andotherassetsthatcanbedrawnonbyapersonororganisationinordertoeffectivelyimplementguidelines.
Stakeholders: anyone who is affected by or is involved in the development and delivery ofguidelines,includingpatients,public,clinicians,managers,professionalbodies,unions,educators,andpolicy-makers.
Sustainability: guidelinescanbeconsideredtobesustainablewhen notonlyhavetheprocessandoutcomechanged,butthethinkingandattitudesbehindthemarefundamentallyalteredandthesystemssurroundingthemaretransformedaswell. Inotherwords,theinterventionhasbecomeanintegratedormainstreamwayofworkingratherthansomething‘addedon’.
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
[9] Gagliardi,A.R.,Marshall,C.,Huckson,S.,James,R.,&Moore,V.(2015).Developingachecklist
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
61Implementation Guide and Toolkit for National Clinical Guidelines
[12] National Clinical Effectiveness Committee (2015). National Clinical Guideline Proposal Template.Available from:http://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/ncec-processes-and-templates/
[13] BrouwersM.,KhoM.E.,BrowmanG.P.,CluzeauF.,FederG.,FerversB.,HannaS.,Makarski
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/
[20] Damschroder,L.J.,Aron,D.C.,Keith,R.E.,Kirsh,S.R.,Alexander,J.A.,&Lowery,J.C.(2009).Fostering implementationofhealth services researchfindings intopractice: a consolidatedframework foradvancing implementationscience. Implementation Science, 4(1),pp.50-64.Availablefrom:https://doi.org/10.1186/1748-5908-4-50
[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
[22] Fixsen,D.L.,Naoom,S.F.,Blasé,K.A.,&Friedman,R.M.(2005).Implementationresearch:
a synthesis of the literature.Available from:http://nirn.fpg.unc.edu/sites/nirn.fpg.unc.edu/files/resources/NIRN-MonographFull-01-2005.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
[24] Baker,R.,Camosso-Stefinovic,J.,Gillies,C.,Shaw,E.J.,Cheater,F.,Flottorp,S.,&Robertson,
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
from:http://health.gov.ie/national-patient-safety-office/ncec/public-involvement-framework/
[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/
[29] Moore, J.E., Mascarenhas, A., Marquez, C., Almaawiy, U., Waihin Chan, D’Souza, J, Liu, B.,
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/
63Implementation Guide and Toolkit for National Clinical Guidelines
[34] West,M.,Eckert,R.,Steward,K.,&Pasmore,B.(2014).Developingcollectiveleadershipforhealth care. London:TheKing’s Fund.Available from: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/developing-collective-leadership-kingsfund-may14.pdf
[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/
[39] Whelan,J.,Love,P.,Pettman,T.,Doyle,J.,Booth,S.,Smith,E.,&Waters,E.(2014).Predicting
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
[40] Joyce,B.R.,&Showers,B.(2002).Studentachievementthroughstaffdevelopment(3rded.).
Alexandria,VA:AssociationforSupervision&CurriculumDeve(ASCD).
[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
[43] Metz,A.,Naoom,S.F.Halle,T.,&Bartley,L.(2015).Anintegratedstage-basedframeworkfor
implementationofearlychildhoodprogramsandsystems.OPREResearchBrief48.Availablefrom:http://www.acf.hhs.gov/sites/default/files/opre/es_cceepra_stage_based_framework_brief_508.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
64 Implementation Guide and Toolkit for National Clinical Guidelines
Additional Implementation Websites and Resources
66 Implementation Guide and Toolkit for National Clinical Guidelines
Additional Implementation Websites and Resources
CentreforEffectiveServicesimplementationresourceshttp://www.effectiveservices.org/resources/tag/implementation
Disseminationandimplementationmodelsinhealthresearchandpractice–interactivewebsitehttp://www.dissemination-implementation.org/
EuropeanImplementationCollaborative(EIC)implementationresourceshttp://www.implementation.eu/resources
GuidelinesInternationalNetwork(GIN)http://www.g-i-n.net/home
KingsCollegeLondon–CentreforImplementationSciencehttps://www.kcl.ac.uk/ioppn/depts/hspr/research/cis/index.aspx
NationalImplementationResearchNetwork(NIRN)(US)resourcehubhttp://implementation.fpg.unc.edu/
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/
ScottishIntercollegiateGuidelinesNetwork(SIGN)http://www.sign.ac.uk/
TrinityCollegeDublinPostgraduateCertificateinImplementationSciencehttps://www.tcd.ie/medicine/public_health_primary_care/postgraduate/cis/index.php
UniversityCollegeLondon,CentreforBehaviourChangehttp://www.ucl.ac.uk/behaviour-change
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
67Implementation Guide and Toolkit for National Clinical Guidelines
Appendix A – Summary of Implementation Science Frameworks
Tool 1. The Hexagon Tool
Tool 2. Logic Model
Tool 3. Implementation Enablers and Barriers: Assessment Tool
Tool 4. Implementation Planning Tool
Tool 5. Monitoring and Evaluating Implementation: Planning Tool
CopiesoftheindividualtoolsarealsoavailabletodownloadfromtheNCECwebsitehttps://health.gov.ie/national-patient-safety-office/ncec/
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
Key FeaturesFramedaroundfour‘keyingredients’foractiveimplementation:
1. It takes time–stagesofimplementation
2. It takes a village–implementationteams
3. It takes support–competency,organisationalandleadershipsupports
4. It takes communication–feedbackloops
LinkActiveImplementationHub:http://implementation.fpg.unc.edu/
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
Key FeaturesFivemajordomains:
1. Interventioncharacteristics2. Outersetting3. Innersetting4. Individualcharacteristicsoftheimplementers5. Theprocessofimplementation
Eachisbrokendownintocomponentparts,enablingdetailedanalysis.
Linkhttp://www.cfirguide.org/
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
Key FeaturesThreefactorsdetermineresearchuse:
• RobustEvidence–research;clinicalexperience;patientpreferences;localinformation• ReceptiveContext–culture;leadership;evaluation• FacilitationofChange–respect;credibility;empathy;clarity;flexible;consistent
Allthreeareequallyimportant,meaningthatthecontextinwhichevidenceisbeingused,andthewayitisintroduced,hasasmuchtodowithimplementationasthequalityoftheevidence.
LinkSummaryoftheframework:http://www.nccmt.ca/resources/search/85
4. RE-AIM (Reach Effectiveness Adoption Implementation Maintenance)DescriptionThisisacomprehensiveframeworkdesignedforevaluationofpublichealth,healthpromotionandcommunity-basedinterventions.Itallowsforpolicy,environmentalandindividuallevelcomponentstobeevaluatedwithmeasuressuitedtotheirsetting,goalsandpurpose.
Key FeaturesTheframeworkismadeoffivemajorelementsforevaluatingimplementation:
• Reach• Effectiveness• Adoption• Implementation• Maintenance
Linkhttp://re-aim.org/
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
Key FeaturesThereisadynamicrelationshipbetweenfourmajorelements:
• Coherence–meaningandsense-makingbyparticipants• Cognitive Participation–commitmentandengagementbyparticipants• Collective Action–theworkparticipantsdotomaketheinterventionfunction• Reflexive Monitoring–participantsappraisetheintervention
LinkToolsavailableat:http://www.normalizationprocess.org/
6. COM-BDescriptionA model of behaviour changeusedtoidentify whatisneededtoattain thedesiredbehaviourat individual,practitioneror organisationallevel.
Key FeaturesThismodelpositsthatbehaviouroccursasan interactionbetweenthreeconditions:
• Capability–Psychologicalorphysicalability toenactbehaviour
• Motivation–Reflectiveandautomatic mechanismsthatactivateorinhibitbehaviour
• Opportunity–Physicalandsocial environmentthatenablesthebehaviour
The Behaviour Change Wheel5 shows how these conditions may be affected by certaininterventions,andhowpolicydecisionsmayimpactontheseinterventions.Thisallowsyouto:
• Identifybehavioursthatneedtochange• Understandthesebehaviours• Considerarangeofeffectivestrategies
Linkhttp://www.behaviourchangewheel.com/
71Implementation Guide and Toolkit for National Clinical Guidelines
7. IHI Framework for Leadership for ImprovementDescriptionDevelopedbytheInstituteforHealthcareImprovement(IHI),thisframeworkorganisesleadershipprocessesthatfocustheorganisationandseniorleadersonimprovement6
Key FeaturesPrimaryuses:
• Providesanorganisingstructuretounderstandhowtheactivitiesofhealthcareleaderscontributestotransformationandimprovement
• Assessmentandimprovementoforganisations• Guidethedesignofleadershipdevelopmentprogrammes
IHI Framework for Leadership for Improvement
Link http://www.ihi.org/resources/Pages/Tools/IHIFrameworkforLeadershipforImprovement.aspx
References[1] Fixsen, D.L., Naoom, S.F., Blasé, K.A., Friedman, R.M., Wallace, F. (2005). Implementation
Research:Asynthesisoftheliterature(FMHI#231).Tampa,FL:UniversityofSouthFlorida,LouisdelaParteFloridaMentalHealthInstitute,TheNationalImplementationResearchNetwork.
[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
3. Bulld Will•PlanforImprovement•SetAims/AllocateResources•MeasureSystemPerformance•ProvideEncouragement•MakeFinancialLinkages•LearnSubjectMatter•WorkontheLargerSystem
4. Generate Ideas•ReadandScanWidely,LearnfromOtherIndustriesandDisciplines
•BenchmarktoFindIdeas•ListentoCustomers•InvestInResearchandDevelopment
•ManageKnowledge•UnderstandOrganizationasaSystem
5. Execute Change•UseModelforImprovementforDesignandRedesign
•ReviewandGuldeKeyInitiatives
•SpreadIdeas•CommunicateResults•SustainImprovedLevelsofPerformance
1. Set Direction: Mission, Vision, and StrategyMake the status quo uncomfortable Make the future attractive
2. Establish the Foundation•ReframeOperatingValues•BuildImprovementCapability
•PreparePersonally•ChooseandAligntheSenior
Team
•BuildRelationships•DevelopFutureLeaders
²PUSH ²PULL
72 Implementation Guide and Toolkit for National Clinical Guidelines
Tool 1 – The Hexagon Tool
•Identifytheneedsofserviceusersandcommunitiesthroughconsultation,researchandanalysisofdata
•Assesswhatinterventionsarelikelytoaddresstheidentifiedneeds
•Identifyifthesettinghasthenecessarycapacitytoabsorbandsustaintheintervention(e.g.staffwithrequiredqualifications,leadership,finance,andstructures)
•Assessthelevelofbuy-infortheintervention
•Examineiftheinterventionisclearlydefinedandhasbeenusedinmultiplesettings
•Establishwhethertheexpertiseintheinterventionisavailableandaccessible
•Assessiftheinterventionfitswithcurrentinitiatives,structuresandvalues
•Examineitsfitwithlocalandnationalpoliciesandpriorities
•Identifynecessaryresources:– Technology/datasystems– Staffing– Training,coachingand
supervision– Physicalinfrastructure– Administrativeandsystem
supports•Assesswhatadditionalresourcesarerequiredforimplementation
•Consultandassesstheevidenceinrelationtotheinterventiononwhatworks,inwhatcontexts,andwithwhom
•Assesstheevidenceonimplementationandcost
Need
Evidence
Intervention Readiness
Capacity to Implement
Resource Availability
Fit
Intervention:
TheHexagonToolcanbeusedasaplanningtooltoevaluatepotentialevidence-basedguidelinerecommendationsduringtheExploration Stageofimplementation.
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
ThistoolisavailableonNCECwebsite:https://health.gov.ie/national-patient-safety-office/ncec/
73Implementation Guide and Toolkit for National Clinical Guidelines
Tool 2 – Logic Model
Monitoring and Evaluation
Situation Analysis Inputs Activities/
OutputsShort-term Outcomes
Evidence
Long-term Outcomes
Thebasicoutlineofalogicmodelisshownaboveandablank,editableversionisprovidedonthefollowingpage.ItshouldbecompletedbyGuidelineGroupsinthefollowingsequenceofsteps:
1. SituationAnalysis2. Short-TermandLong-TermOutcomes3. Activities/Outputs4. Inputs5. MonitoringandEvaluation6. EvidenceunderpinningallaspectsoftheLogicModel
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
ThistoolisavailableonNCECwebsite:https://health.gov.ie/national-patient-safety-office/ncec/
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]
1. Intervention Characteristics• Sourceofintervention• Evidencestrengthandquality• Relativeadvantage• Trialability• Complexity• Designquality• Cost
2. Outer setting• Patientneedsandresources• Cosmopolitanism(external
networksandrelationships)• Peerpressure• Externalpoliciesandincentives
3. Inner Setting• Structuralcharacteristics• Networksandcommunications• Culture• Implementationclimate• Readinessforimplementation
4. Characteristics of Individuals• Capacity-physicaland
psychological• Motivation
Implementation Influences (enablers
& barriers)
ThistoolisavailableonNCECwebsite:https://health.gov.ie/national-patient-safety-office/ncec/
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.
Intervention source Legitimacyandcredibilityoftheinterventionsource
Evidence strength and quality
Qualityandvalidityoftheevidenceindicatingthattheinterventionwillachievedesiredoutcomes
Relative advantage Interventionhasmoreadvantagethananotheralternative
Trialability Abilitytotesttheinterventiononasmallscaleintheorganisationandtobeabletoreversecourse(undoimplementation)ifwarranted
Complexity Difficultyofimplementation,reflectedbyduration,scope,radicalness,disruptiveness,centrality,numberofstepsrequiredtoimplement
Design quality and packaging
Excellenceinhowtheinterventionisbundled,presentedandassembled,includingwhatonlinesupportsareavailable
Cost Costsoftheinterventionitselfandcostsassociatedwithimplementingtheintervention,includinginvestment,supplyandopportunitycosts
2. Outer SettingThe economic, political, social and cultural context within which an organisation resides.
Patient needs and resources
Extenttowhichpatientneeds,aswellasbarriersandfacilitatorstomeetthoseneeds,areaccuratelyknownandprioritised
Cosmopolitanism Thequalityandextentofrelationshipsandnetworkswithotherexternalorganisations(socialcapital)
Peer pressure Competitivepressuretoimplementanintervention,mainlyfromoutsideprofessionals/services/organisationswhohavealreadyimplementedtheintervention
External policies and incentives
Externalstrategiestospreadinterventions,includingpolicyandregulations,externalmandates,recommendationsandguidelines,collaboratives,publicorbenchmarkingreporting
3. Inner Setting Structural, political and cultural context through which an implementation process will proceed
Structural characteristics
Socialarchitecture,age,maturity,size,staffturnoverofanorganisation
Networks and communications
Natureandqualityofsocialnetworks,andformalandinformalcommunicationswithinanorganisation(e.g.teamwork)
Culture Norms,valuesandbasicassumptionsofanorganisation
88 Implementation Guide and Toolkit for National Clinical Guidelines
Implementation climate
Tension[perceivedneed]forchangeCompatibility–innovationfitwithexistingsystemsRelativeprioritywithintheorganisationOrganisationalincentivesandrewardsGoalscommunicated,andfeedbacktakenLearningclimateoftryingnewmethods,reflecting,learning
Readiness for implementation
LeadershipengagementAvailableresourcesforimplementationAccesstoinformationandknowledgeabouthowtoimplementtheintervention
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
Knowledge and beliefs about the intervention
Individualbeliefsthattheinterventionwillbesuccessfulintheirsetting,givenexistingevidenceandplans
Self-efficacy Individualbeliefintheirown,andtheircolleagues’,abilitytoimplementtheinnovation
Individual stage of change
Thephaseanindividualisin,accordingtoRogers’/Prochaska’sStagesofChange,theyprogresstowardsskilled,enthusiasticandsustaineduseoftheintervention
Individual identification with organisation
Howindividualsperceivetheorganisation,theirrelationshipwithitandthedegreeofcommitmenttotheorganisation
Other personal attributes
Includingtoleranceofambiguity,intellectualability,motivation,values,competence,andlearningstyle
References[1] 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 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.
ThistoolisavailableonNCECwebsite:https://health.gov.ie/national-patient-safety-office/ncec/
90 Implementation Guide and Toolkit for National Clinical GuidelinesIm
plem
enta
tion
Plan
(for
incl
usio
n in
the
publ
ishe
d gu
idel
ine)
Gui
delin
e re
com
men
datio
n or
num
ber(
s)
Impl
emen
tatio
n ba
rrie
rs/
enab
lers
/gap
s
Actio
n/in
terv
entio
n/ta
sk to
im
plem
ent r
ecom
men
datio
n Le
ad
resp
onsi
bilit
y fo
r de
liver
y of
the
actio
n
Tim
efra
me
for
com
pleti
onEx
pect
ed
outc
ome
and
verifi
catio
n Ye
ar
1Ye
ar
2Ye
ar
3
91Implementation Guide and Toolkit for National Clinical GuidelinesIm
plem
enta
tion
of th
e ov
eral
l gui
delin
eWhilethe
implem
entatio
nplan
isspecifictothe
ind
ividua
lrecommen
datio
nsin
the
guideline,som
eactio
nsw
illassistw
ithguide
line
implem
entatio
nasaw
hole.T
hesein
clud
eestablish
ingan
implem
entatio
nteam
;de
veloping
adiss
eminati
onand
com
mun
icati
onplanan
dde
veloping
spe
cificim
plem
entatio
ntoolsan
dresources.In
the
boxesbelow
,pleasegiveahigh-leveld
escriptio
nofhow
the
seacti
onswillbe
incorporated
intoth
eim
plem
entatio
nofyou
rguide
line:
Impl
emen
tatio
n te
am:De
scrib
ethestructurean
dgo
vernan
ceofyourim
plem
entatio
nteam
,ou
tline
processforrisk
iden
tificatio
nan
dman
agem
ent,listyourim
plem
entatio
nteam
mem
bersand
spe
cifym
eetin
gfreq
uency.O
utlin
eplan
nedtraining
and
cap
acity
buildingfor
team
mem
bers.
Diss
emin
ation
and
com
mun
icati
on p
lan:Describeyourcom
mun
icati
onsstrategyand
diss
eminati
onplanford
istrib
uting
,sha
ring,promoti
ng
andap
plying
guide
linerecommen
datio
nse.g.rep
ortin
gsche
dule,p
ublicati
ons/artic
les,presentati
ons,awaren
ess-raising
acti
vitie
s,m
edia,
know
ledg
etran
sfer,collabo
ratio
nan
dne
tworking
.
Impl
emen
tatio
n to
ols:Listthe
sup
porting
too
lsan
dresourcesde
velope
dtosup
portthisgu
ideline/projectan
dwhe
rethe
setoo
lscanbe
accessed
,e.g.m
aterialson
web
site,pati
entinformati
onleafl
ets,training
linked
toCPD
,e-le
arning
,pod
casts,stud
yda
ys,resea
rch,che
cklists,
audittoo
ls,m
onito
ringan
drepo
rting
processes,sem
inars,con
ference,pati
entp
athw
ays,to
olkits,algorith
ms,te
aching
aids,presentati
ons.
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).
Theseimplementationoutcomeareasareseparatefromserviceoutcomes(e.g.efficiency,safety,effectiveness, equity, patient-centredness, timeliness) and client outcomes (e.g. satisfaction,function,symptomatology).TheyarealsoseparatefromserviceandprocessmeasuresrequiredinNCECpublishedguidelines. Implementationoutcomesrelatespecificallyto implementationofaninterventionandarekeyareasforconsiderationintheimplementationprocess.
ThistoolcanbeusedbyGuidelineGroupstoconsiderimportantfactorsinimplementationoftheirguideline,andtocreateactionplansforhowtomonitorandevaluatethesefactors.Thiswilltheninformtheactualcollection,collation,analysisandreportingofdataonimplementation.
Implementation Outcomes
Acceptability
Fidelity
Feasibility
Reach
Implementation Cost
Adoption
Effectiveness
Sustainability
ThistoolisavailableonNCECwebsite:https://health.gov.ie/national-patient-safety-office/ncec/
93Implementation Guide and Toolkit for National Clinical Guidelines1.
Acc
epta
bilit
y
The
perc
eptio
n am
ong
stak
ehol
ders
that
an
inte
rven
tion
is ag
reea
ble,
pal
atab
le o
r sati
sfac
tory
, and
lead
s to
an
impr
oved
gen
eral
ser
vice
ex
perie
nce
Levelo
fAna
lysis
•Individu
alPati
ent/
Serviceuser
•Individu
alProvide
r
Mon
itorin
gan
dEvalua
tionQue
stion
s
•Wha
tlevelofk
nowledg
edo
provide
rshaveab
outthe
con
tentand
com
plexity
ofthe
interven
tion?
•Wha
tareprovide
rs’attitude
stow
ardtheinterven
tion?
•Do
provide
rsra
teth
eeviden
cefo
rthe
interven
tionasstrong
?•
From
thepa
tient/serviceuser’sperspectiv
e,doe
sthe
interven
tionim
proveho
w
patie
nts/serviceuserse
xperienceaservice?
Potenti
alM
etho
ds
•Su
rvey
•Interviews
•Ad
ministrativ
eDa
ta
Actio
n Pl
anni
ng (W
hata
ction
sdo
theGu
idelineGrou
pan
dothe
rstakeho
ldersne
edto
taketo
helpaccuratelyassessacceptab
ility?Ac
tions
shou
ldbeinform
edbylevelo
fana
lysis
,answerstothequ
estio
nsposed
abo
veand
poten
tialm
etho
dsfo
rdatacollecti
on):
94 Implementation Guide and Toolkit for National Clinical Guidelines2.
App
ropr
iate
ness
/Fea
sibi
lity
Th
e ex
tent
to w
hich
the
inte
rven
tion
is co
mpa
tible
, rel
evan
t and
impl
emen
tabl
e w
ithin
a g
iven
con
text
or s
etting
Levelo
fAna
lysis
•Individu
al
Patie
nt/S
ervice
User
•Individu
al
Provider
•Organ
isatio
n/
Setting
Mon
itorin
gan
dEvalua
tionQue
stion
s
•Do
esth
eorganisatio
nha
veth
eresources,staff
and
equ
ipmen
ttoim
plem
entthe
interven
tion?
•Do
staff
havethetim
e,sk
ills,training
and
abilitytoim
plem
entthe
interven
tion?
•Isth
erean
yaspe
ctofthe
interven
tionthatcou
ldm
akeitinap
prop
riatefo
rprovide
rsor
thetargetpop
ulati
on?(e.g.d
ueto
culture,religion,beliefs,value
setc.)
Potenti
alM
etho
ds
•Su
rvey
•Interviews
•FocusG
roup
s
Actio
n Pl
anni
ng (Wha
tactio
nsdotheGu
idelineGrou
pan
dothe
rstakeh
olde
rsnee
dtotaketohelpaccuratelyassessap
prop
riatene
ss/
feasibility?Ac
tionssh
ouldbeinform
edbylevelo
fana
lysis
,answerstothequ
estio
nsposed
abo
veand
poten
tialm
etho
dsfo
rdatacollecti
on):
95Implementation Guide and Toolkit for National Clinical Guidelines3.
Ado
ption
Th
e in
itial
dec
ision
s by
prov
ider
s to
utilis
e th
e in
terv
entio
n in
the
first
pla
ce, a
nd th
en w
here
it is
impl
emen
ted
and
who
is im
plem
entin
g it
Levelo
fAna
lysis
•Organ
isatio
n/
Setting
•Individu
al
Provider
Mon
itorin
gan
dEvalua
tionQue
stion
s
•Who
isth
etargetgroup
and
inwha
tsetti
ngsa
reth
eybeing
targeted
?•
Who
can
helpgatherinform
ation
abo
utth
is?•
Who
willdeliverth
einterven
tion,and
dotheyhavetheskillsa
ndtime?
•Ho
wwillyou
kno
wifstaff
usedtheinterven
tion?
Potenti
alM
etho
ds
•Su
rvey
•Observatio
n•
Interviews
•FocusG
roup
s•
Administrativ
eDa
ta
Actio
n Pl
anni
ng:(Wha
tactio
nsdotheGu
idelineGrou
pan
dothe
rstakeh
olde
rsnee
dtotaketohelpaccuratelyassessad
optio
n?Acti
ons
shou
ldbeinform
edbylevelo
fana
lysis
,answerstothequ
estio
nsposed
abo
veand
poten
tialm
etho
dsfo
rdatacollecti
on):
96 Implementation Guide and Toolkit for National Clinical Guidelines4.
Fid
elity
Th
e de
gree
to w
hich
the
inte
rven
tion
is co
nsist
ently
del
iver
ed a
s it w
as o
rigin
ally
inte
nded
and
des
igne
d to
be
deliv
ered
Levelo
fAna
lysis
•Individu
al
Provider
Mon
itorin
gan
dEvalua
tionQue
stion
s
•Wha
tareth
ekeyelem
entsofthe
interven
tionthatm
ustb
ede
livered
tobesuccessful?
•Wha
tcostsand
resourcesa
ssociatedwith
ada
pting
theinterven
tion(in
clud
ingtim
ean
dbu
rden
,notju
stm
oney)n
eedtobeconsidered
and
includ
edin
theBu
dgetIm
pact
Analysis?
•Ho
wwillyou
assessd
eliveryofth
einterven
tion?
Potenti
alM
etho
ds
•Observatio
n•
Checklists
•Co
nten
tAna
lyses
•FocusG
roup
s•
Self-Re
port
Actio
n Pl
anni
ng(W
hata
ction
sdo
theGu
idelineGrou
pan
dothe
rstakeho
ldersne
edto
taketo
helpaccuratelyassessfid
elity
?Ac
tionssho
uld
beinform
edbylevelo
fana
lysis
,answerstothequ
estio
nsposed
abo
veand
poten
tialm
etho
dsfo
rdatacollecti
on):
97Implementation Guide and Toolkit for National Clinical Guidelines5.
Pen
etra
tion/
Reac
h
The
degr
ee to
whi
ch th
e in
terv
entio
n is
inte
grat
ed in
to a
serv
ice
setti
ng, i
nclu
ding
whe
ther
it e
ffecti
vely
reac
hed
the
targ
et p
opul
ation
Levelo
fAna
lysis
•Individu
al
Patie
nt/S
ervice
User
•Patie
nt/Service
UserP
opulati
on
Mon
itorin
gan
dEvalua
tionQue
stion
s
•Who
isth
etargetgroup
?De
finetheintend
edben
eficiaries/targetpop
ulati
on(s),an
dwha
tsectorsoftha
ttargetp
opulati
onyou
intend
tore
ach.
•Ho
wand
whe
rewillyou
reachthem
?•
Howcon
fiden
tareyou
thatyou
willbeab
leto
dothis?
•Ho
wwillyou
kno
wifth
osewho
areusin
gtheinterven
tionarerepresen
tativ
eofth
eintend
edben
eficiaries/targetpop
ulati
on(s)?(thisc
anbeba
sedon
stakeh
olde
rana
lysis
activ
ities)
•Ho
wwillyou
kno
wifyou
reache
dtheap
prop
riateta
rgetsites?
•Wha
tmetho
dswillyou
useto
attractund
erserved
pop
ulati
onsa
ndfo
cuso
nhe
alth
ineq
uitie
s?
Potenti
alM
etho
ds
•Su
rvey
•Ca
seStudies
•Interviews
•Ad
ministrativ
eDa
ta
Actio
n Pl
anni
ng (Wha
tactio
nsdotheGu
idelineGrou
pan
dothe
rstakeh
olde
rsnee
dtotaketohelpaccuratelyassesspe
netrati
on/rea
ch?
Actio
nssh
ouldbeinform
edbylevelo
fana
lysis
,answerstothequ
estio
nsposed
abo
veand
poten
tialm
etho
dsfo
rdatacollecti
on):
98 Implementation Guide and Toolkit for National Clinical Guidelines6.
Im
plem
enta
tion
Effec
tiven
ess
Th
e de
gree
to w
hich
pre
-defi
ned
outc
omes
are
ach
ieve
d as
a re
sult
of im
plem
entin
g th
e in
terv
entio
n
Levelo
fAna
lysis
•Individu
al
Patie
nt/S
ervice
User
•Patie
nt/S
ervice
UserP
opulati
on•
Organ
isatio
n/
Setting
Mon
itorin
gan
dEvalua
tionQue
stion
s
•Wha
tareth
emostimpo
rtan
toutcomesyou
expecttosee?
•Ho
wwillyou
defi
nesu
ccessinachievingtheseou
tcom
es?
•Ho
wlikelyisitth
atyou
rinitia
tivewillachieveitsk
eyoutcomes?
•Ho
wwillyou
mea
sureth
esechan
ges?
•Who
willth
eou
tcom
esm
atterto
?•
Howwillyou
sharetheseou
tcom
es?
•Wha
tareth
ebiggestthreatsto
seeing
theou
tcom
esyou
wan
t?
•Wha
tuninten
dedconseq
uencesoro
utcomesm
ightth
erebe
?
Potenti
alM
etho
ds
•Su
rvey
•Ca
seStudies
•Interviews
•FocusG
roup
s•
Administrativ
eDa
ta
Actio
n Pl
anni
ng (Wha
tactio
nsdotheGu
idelineGrou
pan
dothe
rstakeh
olde
rsnee
dtotaketohelpaccuratelyassessim
plem
entatio
neff
ectiv
eness?A
ction
sshou
ldbeinform
edbylevelofana
lysis
,an
swerstothe
que
stion
spo
sedab
ovean
dpo
tenti
alm
etho
dsfordata
collecti
on):
99Implementation Guide and Toolkit for National Clinical Guidelines7.
Im
plem
enta
tion
Cost
Th
e re
sour
ces a
nd fu
ndin
g re
quire
d to
impl
emen
t the
inte
rven
tion,
and
the
net c
ost i
mpa
ct o
f im
plem
entin
g an
d de
liver
ing
the
inte
rven
tion
Levelo
fAna
lysis
•Individu
al
Patie
nt/S
ervice
User
•Organ
isatio
n/
setting
Mon
itorin
gan
dEvalua
tionQue
stion
s
•Ho
wm
uchwillitcosttode
livereachrecommen
datio
n?•
Howwillth
ecostsv
aryacrossdifferen
tsetti
ngs?
•Wha
tisthe
coste
ffecti
vene
ssofthe
propo
sedinterven
tion?
•Aretherean
ycostsa
ving
santi
cipa
tedwith
thisinterven
tion?
•
Wha
tareth
etim
escalesforth
eserviceplan
ning
/fun
ding
cycles(toensuretim
ely
subm
issionofyou
rbud
getimpa
ctassessm
enttotheserviceplan
ning
process)?
Potenti
alM
etho
ds
•Ad
ministrativ
eda
ta•
HIPE
data
•HT
A
(Resou
rceson
cond
uctin
gBu
dget
Impa
ctAssessm
ent
andecon
omic
evalua
tionavailableon
th
e NCE
Cweb
site)
Actio
n Pl
anni
ng (W
hata
ction
sdo
theGu
idelineGrou
pan
dothe
rstakeho
ldersne
edto
taketo
helpaccuratelyassessim
plem
entatio
ncost?
Actio
nssh
ouldbeinform
edbylevelo
fana
lysis
,answerstothequ
estio
nsposed
abo
veand
poten
tialm
etho
dsfo
rdatacollecti
on):
100 Implementation Guide and Toolkit for National Clinical Guidelines8.
Mai
nten
ance
/Sus
tain
abili
ty
The
exte
nt to
whi
ch th
e in
terv
entio
n w
ill b
e re
new
ed a
nd in
stitu
tiona
lised
into
the
orga
nisa
tion/
setti
ng’s
ongo
ing
oper
ation
s
Levelo
fAna
lysis
•Organ
isatio
n/
setting
Mon
itorin
gan
dEvalua
tionQue
stion
s
•Wha
twillhap
penoverth
elong
-term
?Co
nsiderfo
rbothindividu
alben
eficiariesa
nd
setting
s.•
Canorganizatio
nssu
staintheinitiati
veoverti
me?Isth
erean
infrastructureofstaffan
dresourcesinplace?
•Ho
wlikelyisyou
rinitia
tivetoprodu
celasting
effe
ctsforin
dividu
alpati
entsand
provide
rs?
•Ho
wwillyou
beab
leto
follo
wyou
rinitia
tivefora
nextend
edperiodoftime?
•Ho
wwillyou
con
tinue
totracksuccess;cha
ngesm
adeovertime;and
provide
ong
oing
feed
back?
•Ho
wwillyou
getth
ewordou
tabo
utyou
rinterventi
onand
lesson
slea
rned
?
Potenti
alM
etho
ds
•Su
rvey
•Ca
seStudies
•Re
cordand
Policy
Review
s•
Interviews
Actio
n Pl
anni
ng (Wha
tactio
nsd
otheGu
idelineGrou
pan
dothe
rstakeh
olde
rsn
eed
totaketoh
elp
accuratelyassessmainten
ance/
sustaina
bility?A
ction
sshou
ldbeinform
edbylevelofana
lysis
,an
swerstothe
que
stion
spo
sedab
ovean
dpo
tenti
alm
etho
dsfordata
collecti
on):
101Implementation Guide and Toolkit for National Clinical GuidelinesRe
leva
nt A
rticl
es/L
inks
Thefollo
wingartic
lesareexam
plesofh
owthe
RE-AIMfram
eworkan
dProctor’sta
xono
myofim
plem
entatio
nou
tcom
eshavebe
enusedan
dad
aptedtom
onito
rand
evaluateim
plem
entatio
nofinterven
tionsin
thehe
althse
ctor:
• Glasgo
w,R.E.,McKay,H
.G.,Piett
e,J.D.,&
Reyno
lds,K.D.(20
01).Th
eRE
-AIM
fram
eworkfore
valuati
nginterven
tions:w
hatcan
itte
llusabo
ut
approa
chesto
chron
icillnessm
anagem
ent?P
atien
t Edu
catio
n an
d Co
unse
lling
,44(2),1
19-127
.Retrie
vedfrom
:http://www.scien
cedirect.
com/scien
ce/article/pii/S
0738
3991
0000
1865
•Glasgo
w,R.E
.,Vo
gt,T
.M.,&Boles,S
.M.(19
99).Evalua
tingthepu
blichea
lthim
pactofhe
althpromoti
onin
terven
tions:the
RE-AIM
fram
ework.American
journa
lofp
ublichea
lth,8
9(9),1
322-13
27.R
etrie
vedfrom
:http://ajph
.aph
apub
licati
ons.org/do
i/pdfplus/10.21
05/
AJPH
.89.9.13
22
• Jeon
g,H.J.,Jo,H.S.,Oh,M
.K.,&Oh,H.W.(20
15).Ap
plying
theRE
-AIM
Framew
orktoevaluatethedissem
inati
onand
implem
entatio
nof
clinicalpracti
ceguide
linesfo
rsexua
llytran
smitted
infecti
ons.Jo
urna
l of K
orea
n M
edic
al S
cien
ce,3
0(7),8
47-852
.Retrie
vedfrom
:https://
https://doi.org/10.33
46/jk
ms.20
15.30.7.84
7
• Proctor,E.,Silm
ere,H.,Ra
ghavan
,R.,Ho
vman
d,P.,A
aron
s,G.,Bu
nger,A
.,...&Hen
sley,M.(20
11).Outcomesfo
rimplem
entatio
nresearch:
concep
tualdisti
nctio
ns,m
easuremen
tchalleng
es,a
ndresea
rchagen
da.A
dmin
istra
tion
and
Polic
y in
Men
tal H
ealth
and
Men
tal H
ealth
Se
rvic
es R
esea
rch,3
8(2),65
-76.R
etrie
ved
from
:htt
p://eff
ectiv
eservices.org/do
wnloa
ds/O
utcomes_for_Implem
entatio
n_Re
search__
Concep
tual_D
istinctio
ns__
mea
suremen
t_challeng
es_a
nd_resea
rch_
agen
da.pdf
102 Implementation Guide and Toolkit for National Clinical Guidelines
www.health.gov.ie