Lecture 5 – Directions for dissemination,

implementation and evaluation

Janine Margarita R. Dizon, PhD

Janine.Dizon@mymail.unisa.edu.au

Research SupervisorCenter for Health Research and Movement Science

University of Santo Tomas, Philippines

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Objectives

• Lecture– To present strategies to assess the impact of

disseminating, implementing and evaluating the guidelines into practice

• Practical work– To identify the following which are relevant to the disease

condition identified in the workshop• methods of dissemination and evaluation of the impact of the

contextualised guidelines for a larger roll out in practice• enablers and barriers in guideline dissemination and

implementation

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Evidence into Practice

• The implementation of guidelines is one strategy to get evidence into practice

• “Globalise the evidence, localise the decision” (Eisenberg 2002, Globalize the evidence, localize the decision: evidence-based medicine and international diversity)

Evidence based healthcare

Patient Values

Clinical Expertise

Best research evidence

EBP

Local context

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Who and what are to be involved???

• Hospital director• Hospital departments • Department heads• Medical residents/ Registrars• Allied health practitioners• Patient’s families• Change champions• Hospitals? Clinics? Community?

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Enablers

• Access to hospital departments/ peers• Membership in professional organisations• Good leadership

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Barriers

• Knowledge management barriers• Structural • Organisational• Peer group• Professional• Professional-patient interaction barriers

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• Why is there a need to disseminate and implement guidelines??– So much time has been devoted to

developing guidelines– Not sure if these guidelines are utilised to

underpin practice– Changing ‘usual practice’ takes time– Consider ‘intention-behavior’ gap

Dissemination and implementation

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Dissemination of guidelines

• Consider ‘spreading’ the guidelines in the form of:– Publications– Conferences/ workshops– Trainings– Educational meetings– Journal clubs– Posters in hospitals

• Multi faceted dissemination strategies better than single component strategy

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Implementation of guidelines

• Consider factors that impact guideline implementation– Practical and easy to understand guideline

recommendations– Multifaceted strategies (multiple components) are

more effective– Guideline interventions are considered as complex

interventions (consider local context setting, practice setting and patient and clinician behavior)

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• To assess if the principles of evidence based practice are applied in real life practice– Evidence based guidelines provide information to guide/assist clinicians

in making informed decisions regarding patients• To identify if implementation strategies are effective

– Not all implementation strategies are effective; general and context specific strategies are needed to make sure that guidelines are implemented and utilised in practice

• To achieve better patient outcomes– Evidence based guidelines provide recommendations which are known to

result to effective outcomes, thus expecting better patient outcomes• To achieve efficiency in the health system

– Guidelines provide recommendations for best patient management known to result to effective outcomes, thus improving efficiency in the health system

Evaluation of guideline dissemination and implementation

strategies

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Evaluation methods

• Conduct audit studies– Descriptive audits– Benchmarking audits

• Conduct surveys• Conduct practice visits• Semi-structured interviews• Focus group interviews

The PARM Project

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The dissemination and implementation plan

• One day training– Morning

• Lectures on concepts of underpinning practice with best evidence• Contextualisation of the guidelines• Key recommendations

– Afternoon• Workshop on implementing the key recommendations

• Development of forms to use for documentation• Collaboration with other hospital departments• Posters in the department (patient journey, key recommendations)• Per hospital orientation • Inclusion of the guideline recommendations in the examinations of the trainees

involved

(Refer to implementation protocol)

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The dissemination and implementation plan

• Stroke and low back pain caravan• 2 day training for health professionals for

the purpose of:– Introducing the importance of using evidence to

guide practice– Presenting the key recommendations of the

contextualised guidelines – Training to implement the key

recommendations

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What and who we involvedFactors to consider Target

Setting Rehabilitation Wards and Neurology wards of the training institution Philippine OrthopedicCenter Philippine General Hospital University of Santo Tomas Hospital Veterans Memorial Medical CenterMain islands of the Philippines

(National Capital Region, Luzon, Visayas and Mindanao)Health professionals Medical Internists/Neurologists (Consultants/ interns/ residents)

PhysiatristsPhysical TherapistsOccupational TherapistsNursesMasters students in our Physical Therapy program

Consumers Patients who have been confined because of strokeCaregivers of the patients

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Our Identified enablers

• Access to hospitals• Vision of the professional organisation• Passion and commitment of the group

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Our identified barriers

• Misconception about guidelines• Hierarchy in place• Unavailable records for assessment

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Our experience – Evaluation methods

• Descriptive audit of acute in-patient stroke practices (nationwide audit -43 hospitals)

• Post implementation audit (3 training institutions involved in the implementation project)

• Focus group interviews with health professionals involved– Perspective regarding the implementation– Facilitators and barriers– Recommendations for improvement

(Refer to clinical audit protocol)

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Preliminary findings

• Gaps in practice identified• The forms developed for documentation

are already being used• Health professionals involved perceive the

implementation useful especially in standardising practice

It’s your turn…..